Developing a Codebook to Understand Cultural Comfort and Discomfort in Psychotherapy Trainees

Research Poster Social & Behavioral Sciences 2025 Graduate Exhibition

Presentation by Deeaanj Hinduja

Exhibition Number 83

Abstract

Cultural comfort—a therapist’s ease in discussing clients’ cultural identities—is a critical yet understudied component of multicultural competence, linked to improved clinical outcomes and reduced disparities in care (Bartholomew et al., 2020; Kivilghan et al., 2019; Owen et al., 2017). Despite its importance, training programs lack clarity on how cultural (dis)comfort emerges, limiting efforts to address it. This study investigates manifestations of cultural (dis)comfort among psychotherapy trainees to inform training practices. Participants (N = 65; 71.2% White; 82.6% women) engaged with seven video vignettes featuring clients discussing spiritual/religious concerns, rated their comfort post-task (1–6 Likert scale), and provided open-ended explanations. Mixed-methods analysis categorized responses as low (1–2) or high (5–6) comfort, with mean scores ranging from 3.90 (SD = 1.62) to 5.03 (SD = 1.10). Of 455 responses, 27 reflected low comfort and 253 high comfort. Using an inductive-deductive framework, open-ended rationales were coded to identify themes (e.g., cultural unfamiliarity, identity conflicts) proposed by Pérez-Rojas and González (2024), while allowing novel insights. Results informed the development of a codebook to systematically classify cultural (dis)comfort in therapeutic interactions. This tool aims to enhance supervision and training by clarifying how discomfort manifests (e.g., anxiety, avoidance) and how comfort fosters attunement. By bridging the gap between theory and practice, the codebook offers actionable strategies to mitigate cultural discomfort, improve multicultural responsiveness, and reduce inequities in psychotherapy outcomes. Findings underscore the need for deliberate training on cultural dynamics, equipping trainees to navigate identity-related discussions with confidence and competence.

Importance

This study helps therapists better understand a hidden challenge in mental health care: the discomfort some therapists feel when talking about a client’s cultural identity, such as their religion, race, or ethnicity. Imagine a therapist who hesitates to ask about a client’s spiritual beliefs because they’re unsure how to approach the topic—this discomfort can make the client feel misunderstood or reluctant to open up. Research shows that when therapists are uncomfortable with cultural topics, clients are more likely to drop out of therapy early or feel less supported. By studying trainees’ reactions to simulated client scenarios, this research identifies why therapists might feel uneasy in these moments—like unfamiliarity with a client’s background or worries about saying the wrong thing.

DEI Statement

This study addresses systemic inequities in mental health care by investigating how therapists’ cultural discomfort—rooted in clients’ identities (e.g., race, religion, gender)—contributes to disparities in therapy outcomes. By analyzing trainees’ reactions to diverse client vignettes, the research identifies barriers to inclusive care, such as discomfort about discussing marginalized identities (e.g., LGBTQ+ or religious minorities) or implicit biases. The resulting codebook equips educators to train therapists to recognize and mitigate discomfort, fostering safer spaces for clients to explore culturally salient issues. This work directly tackles DEI by centering the needs of underserved populations, improving access to culturally responsive care, and dismantling barriers that perpetuate cultural insensitivity.