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Therapeutic Utility of Discussing Therapist/Client Intersectionality in

Treatment: When and How?

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Therapeutic Utility of Discussing Therapist/Client
Intersectionality in Treatment: When and How?
MORGAN E. PETTYJOHN*,1
CHI-FANG TSENG*,1
ADRIAN J. BLOW*

To read this article in Spanish, please see the article’s Supporting Information on Wiley Online Library
(https://onlinelibrary.wiley.com/journal/15455300).

The impact of the therapeutic alliance on positive clinical outcomes has been established
in the literature; however, literature is lacking on how the intersection of therapist and cli-
ent identities influences this process. We propose that the relational intersectionality result-
ing from similarities or differences in therapist and client identities has the potential to
impact the bonds, tasks, and goals of treatment (key components of the therapeutic alli-
ance; Bordin, 1979) depending on how it is addressed or avoided in therapy. In this paper,
we present a model containing pragmatic steps therapists can follow to navigate these con-
versations with clients in a way that is therapeutically beneficial and culturally sensitive
and attuned. Additionally, we provide suggestions for using the proposed model to train
new student therapists (or expose experienced therapists) to ideas of intersectionality and
social justice by reflecting on the intersection of their own identities, acknowledging
dynamics of power and oppression, and understanding how this could shape their relation-
ship with clients.

Keywords: Therapeutic Alliance; Intersectionality; Training; Diversity; Clinical

Intervention; Marriage and Family Therapy

Fam Proc 59:313–327, 2020

T he therapeutic alliance (i.e., the relationship between and therapist) has been identi-
fied as a crucial common factor in producing positive clinical outcomes (Miller, Dun-
can, & Hubble, 1997). We propose that therapist transparency in addressing issues of
intersectionality with client identities deepens and strengthens the therapeutic alliance
and, as a result, positively affects treatment outcomes. More specifically, we discuss how
addressing or not addressing the intersection of therapist and client identities can impact
the bonds, tasks, and goals of treatment (Bordin, 1979). Our conversation about intersect-
ing identities is guided by an adaptation of Morgan’s (1996) model of privilege, domina-
tion, and oppression (see Figure 1). Our objective is to highlight how therapists can
approach these conversations in a way that minimizes anxiety, is sensitive to differences,
and is clinically relevant. We emphasize when these types of conversations should happen,
as well as how they should occur.

*Couple and Family Therapy Program, HDFS Department, Michigan State University, East Lansing, MI.
Correspondence concerning this article should be addressed to Morgan E. PettyJohn, Michigan State
University, 552 W. Circle Drive, 13E Human Ecology, East Lansing, MI 48824. E-mail: morganepet-
tyjohn@gmail.com.
1
First author designation.

313
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doi: 10.1111/famp.12471
314 / FAMILY PROCESS

THERAPEUTIC ALLIANCE
In operationalizing the therapeutic alliance, Bordin (1979) proposed that it includes
three key components: the bonds between client and therapist, including the client’s level
of emotional safety and comfort in treatment; the tasks executed through therapy and
whether the client finds these activities beneficial; and the extent to which therapist and
client goals align with one another. Both clients and therapists have unique perceptions of
the therapeutic relationship. Notably, it is client perceptions of the alliance (as opposed to
those of the therapist) that account for the most variance in treatment satisfaction in clini-
cal studies (Sexton & Alexander, 2003).
Expanding on Bordin’s (1979) conceptualization of the therapeutic alliance, we argue
that the intersection of client and therapist identities impacts these mechanisms as well.
Each member of the alliance brings in their own unique identities which intersect
throughout the process of therapy, producing an amalgamation of worldviews, cultures,
and life experiences which may not always align. We argue that therapist and client iden-
tities which differ from one another can serve as a barrier to deeper therapeutic bonds and
can influence clients’ comfort levels with therapeutic tasks and goals. This may be particu-
larly pronounced in cases where the therapist and client are subject to differing degrees of
social marginalization or oppression in relation to their identity. For example, it is well
documented in the literature that people of color have higher levels of mistrust in therapy
(Parra-Cardona et al., 2012). This issue becomes especially complex when the therapist is
working with couples and families where multiple interactions are happening between
therapists’ and clients’ identities in the room. A collective mistrust of therapy by a couple
or a whole family would certainly present a challenge to the expanded therapeutic alliance
in couple and family therapy (Sprenkle & Blow, 2004). Despite potential challenges, we
assert that any intersection of therapist and client(s) identities can result in positive ther-
apy outcomes if the therapist is trained and willing to facilitate a dialogue at the right
time, and in the right way, in order to address notable differences.

INTERSECTIONALITY
Crenshaw first introduced the notion of intersectionality in 1989, arguing that contem-
porary feminist and antiracist scholarship failed to account for the impact of multiple sys-
tems of marginalization. Since its inception, intersectionality has been defined as “an
individual’s exposure to the multiple, simultaneous, and interactive effects of different
types of social organization and their experiences related to prejudice and power or soci-
etal oppression” (Mock, 2008, p. 427).
Intersectionality accounts for various pieces of an individual’s identity. These identities
come together (intersect) to form one’s social location, which determines the power and
privilege an individual is afforded based on one’s relative position in society and history
(Mock, 2008). A basic example of intersectionality can be seen in the experiences of Black,
LGBTQ+ women. The lived experiences of Black women cannot be adequately captured by
either feminist or critical race theories alone, as their social locations in the world are
shaped simultaneously by gender and race in an interactional way (Crenshaw, 1991).
Based on the theory of intersectionality and the history of race relations, Black women
face challenges in navigating Western society which many white women do not because of
the privilege white people are afforded. Further, Black women who identify as lesbian
may possess less social power than Black women who are heterosexual, due to the added
negative stigma that persists toward people in LGBTQ+ populations.
Dr. Kathryn Morgan created a useful lens to conceptualize the complexity of intersect-
ing identities through a model which captures the intersecting dimensions of domination,

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oppression, and privilege. She argues that everyone “occupies a point of specific juxtaposi-
tion on each of these axes and this point is simultaneously a locus of our agency, power,
disempowerment, oppression, and resistance” (Morgan, 1996, p. 106; Figure 1).
Three additional dimensions of power and oppression which have become more relevant
in the United States in recent years (gender identity, citizenship status, and identifying as
Muslim or non-Muslim) have been added to the original model. Morgan added gender iden-
tity to acknowledge that people who identify as cisgender are privileged in relation to people
who identify as transgender, as evidenced by the high rates of violence, discrimination, and
lack of legal protections for individuals who are transgender (Liu & Wilkinson, 2017). In col-
laboration with Morgan, the authors (M.P. and C.T.) supplemented the concepts of citizen-
ship status and identifying as Muslim or non-Muslim as well (K. Morgan, personal
communication, June 9, 2018). Legalized citizens born in the United States occupy a position
of privilege compared to immigrants, as they are immune to threats of detention or deporta-
tion which documented and undocumented immigrants can be subject to (Lewis, Paik, &
Tseng, 2017). It should also be recognized that people who identify as Muslim culturally, or
practice the religion of Islam, face oppression in the United States based on the fact that
Muslims have experienced harsh prejudice, violence, and discrimination across the country,
especially in the years following the September 11 terrorist attacks (Cainkar, 2004).
We want to be clear that the concept and consequences of intersectionality can never be
adequately captured in a diagram, even one as well formulated as Morgan’s. A visual
depiction of intersectionality cannot capture the lived experiences, power differentials, or
structural inequalities which underlie the social positions of all people. Models such as
this are only intended to be a jumping off point to spur deeper self-reflection and generate
conversations between people, which we will expand on later in this paper.

FIGURE 1. Intersecting Axes of Privilege, Domination, and Oppression, Adapted from Morgan (1996)
(K. Morgan, personal communication, June 9, 2018). An earlier version of this diagram was pre-
sented with the solid lines shown in this figure (Morgan, 1996). Dotted lines represent the concepts
authors added to this diagram (with the permission of K. Morgan). The dash line represents a
recently added concept by Morgan (K. Morgan, personal communication, June 9, 2018).

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INTERSECTION OF THERAPIST/CLIENT IDENTITIES AND THE THERAPEUTIC

ALLIANCE
Addison and Coolhart (2015) expand on the idea of intersectionality to highlight how
dynamics of power and oppression are expressed at the relational level in systemic ther-
apy through the intersection of client identities to one another, and to the therapist. Ther-
apeutic relationships consist, at a minimum, of a highly educated trained professional
with knowledge of therapy, interfacing with clients from varying backgrounds who are
seeking help. From the beginning, this establishes a structural hierarchy in the therapy
process, with the therapist being in a position of greater privilege. However, other aspects
of intersectionality affect the therapeutic relationship as well, stemming from differences
in therapist and client social locations. For example, a white therapist is “doubly empow-
ered” by race and professional position with clients of color, while a therapist of color is
empowered by only the therapist position (Watts-Jones, 2010, p. 409). In instances where
the therapist possesses multiple dimensions of marginalized identities (such as a female
therapist of color), working with a client from a more dominant social position (such as a
white male) may lead to the dynamic feeling “flipped” in the room, where the client is per-
ceived to hold greater power despite the therapist’s professional position. Regardless of
who holds greater social privilege in the therapeutic relationship, finding a way to
address, when appropriate, dynamics of power and privilege differences can be crucial to
establishing a positive therapeutic alliance. We will expand on how to determine when
these conversations are appropriate in the following sections.
Alliances become even more complex in couple and family therapy when multiple peo-
ple participate in treatment. Therapists must not only consider the intersection of their
identity with each individual person in the room, but must also consider the interaction of
each client’s identity with other family members as well (Addison & Coolhart, 2015). Ther-
apists who simply ignore differences in privilege can unintentionally reinforce social struc-
tures of power and oppression, both inside the therapy room and within the couple or
family systems they are treating. As Smith and Shin (2008) highlight, “It is precisely the
invisibility of privilege and its inherent nature to remain unacknowledged that gives it its
insidious power” (p. 353).

Bonds, Tasks, and Goals

Acknowledging the influence of client perceptions of the therapeutic relationship on
therapy outcome, Bordin (1979) operationalized the alliance by breaking it down into
three components: the bonds, tasks, and goals. Each of these important aspects of the alli-
ance can be impacted by how therapists approach issues of intersectionality in treatment.
Bonds
Therapeutic bonds are characterized by the trust and attachment that must occur
between therapist and clients to allow for deep, meaningful work to occur in therapy
(Wampold & Imel, 2015). Research indicates that people begin to form their opinions of
the trustworthiness of others seconds after meeting, suggesting the importance of thera-
pists being cognizant of the initial impressions they are giving to clients based on what is
displayed in their office, the clothes they wear, and the topics they choose to address or
not address (Wampold & Imel, 2015). This is especially important in that, as discussed
earlier, clients from marginalized communities may approach therapy with an initial mis-
trust.
Similarities or differences in identities, and how therapists choose to navigate power
structures in the room, can have a significant impact on clients’ sense of safety, how
bonded they feel to the clinician, and how much they trust the therapist. Studies on client

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perceptions of therapy indicate that clients prioritize feeling understood, accepted, and
heard in a space perceived to be safe (Duncan, Miller, Wampold, & Hubble, 2010). Inte-
grating this literature with theories of intersectionality, we believe that clients cannot feel
fully seen, understood, or accepted until certain dimensions of power are worked through,
giving the clients space to discuss any apprehension or discomfort they may be experienc-
ing in relation to the therapist’s identity. Without fostering this safety, it may be increas-
ingly difficult to maintain a positive emotional connection and foster a healthy bond.
Research also indicates that progress in treatment is negatively impacted when thera-
pists make hurtful remarks, take an authoritarian stance in session, do not listen, stay
quiet or unresponsive, notably differ from client in personality, or appear distant and
untrustworthy (Duncan et al., 2010). Therapists who are unaware of different dimensions
of the clients’ identity may be more likely to engage in microaggressions, or at least fail to
be respectful about topics that may be sensitive to the client (Owen et al., 2018). In fact,
the majority (53–81%) of racial or ethnic minority clients surveyed report experiencing at
least one microaggression perpetrated by their therapist, with the majority of these inci-
dences involving therapist avoidance of culturally relevant conversations, or subscribing
to common cultural stereotypes without asking clients about their own unique experiences
(Owen et al., 2017).
Based on this literature, we assert that therapists who avoid or do not bring up notable
differences in privilege may inadvertently come off as more authoritarian, unresponsive,
unwilling to listen, or untrustworthy to clients who feel unsafe or uncomfortable in the
therapy room based on the existing power structure (Duncan et al., 2010; Owen et al.,
2018). This sense of being unsafe or uncomfortable in the therapy room could also occur in
cases where the client holds more social power than the therapist. More socially privileged
clients may be unsure how to navigate this “flipped” power structure, which they may not
have experienced in the “real world.” For example, a white male client meeting with a
female Muslim therapist who wears a hijab may feel apprehensive being open or honest
about his experiences or opinions until this power dynamic is addressed more directly.
Clients may also struggle to feel they can emotionally connect with or be helped by their
therapist if they do not share certain characteristics or experiences. Cabral and Smith
(2011) conducted a meta-analysis of research on racial/ethnic matching and found that cli-
ents have strong preferences for therapists who shared the same race/ethnicity as theirs.
This issue may be especially prominent with identities that can be outwardly identified,
such as gender or race; however, clients may make assumptions about other pieces of the
therapist identity through their office decor, the clothes they wear, or things they bring up
in conversation, without the therapist realizing. Therapists and clients will never come
from the exact same positionality; therefore, it is crucial that therapists provide a safe
space for clients to express any concerns they might have about differences. This will serve
to deepen the bond and increase trust.
Tasks
The tasks within therapy refer to activities used to treat the presenting problem, and
these can impact the alliance based on how well the clients feel the interventions fit with
their presenting issue, style, and needs (Bordin, 1979). As humans, we are limited to our
own life experiences and cultural exposure in how we define problems and how we
approach change; therefore, based on Bordin’s (1979) conceptualization, the goodness of fit
of tasks for clients may be largely determined by the intersectionality of their identities.
Therapists may not have a clear understanding of what meaningful tasks look like with-
out having an explicit conversation about client identity to gain a better idea of what ther-
apy means to them, how they conceptualize their presenting issue, and the path they
deem as relevant toward healing.

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For example, a relative of the author (C.T.) has been suffering from depression. Her rel-
ative grew up in the Chinese culture, which perceived his depression as a disruption in his
Yin/Yang. He sought help from a traditional Chinese medicine doctor, who treated his
depression by using Chinese herbal medicine soups, a culturally relevant healing tool.
Most therapists trained in the Western mental health model would be unaware of this cul-
turally relevant treatment approach and might automatically assume from their own lens
that certain treatment models (such as cognitive-behavioral therapy or family therapy)
would work best for depressed clients, regardless of heritage or background. While we are
not suggesting that American therapists adopt herbal soups as their primary mode of
depression treatment with Chinese clients (given that they are not trained in this
approach), we posit that therapists in this situation who do not ask about client experi-
ences and perspectives may encounter resistance, see lack of progress, or have clients drop
out due to discomfort or lack of confidence with the tasks presented. Opening a discussion
about tasks as they relate to client identity can be as simple as stating “From my Western-
ized therapy training, I believe [treatment approach] would be most helpful to you; how-
ever, I’d value understanding your perspective on what could be helpful, in case your
experiences differ from mine.” Though therapists may not be able to change treatment to
involve all tasks that clients assert to be most beneficial, having a conversation on the
topic provides therapists with an opportunity to present their perspective, speak from
their clinical training, provide a rationale for tasks offered, and hopefully gain buy-in from
the client. This also allows clients to feel heard, validated, and understood and, through
this, believe that their identity is valued in the therapy room.
Goals
The goals of therapy should be established through mutual collaboration of therapist
and clients in a way that fosters a positive alliance (Bordin, 1979). Similar to the tasks of
treatment, client goals in therapy are largely impacted by how they grew up, things they
have experienced in life, and how they view their problems. The lens through which people
perceive and process the world shapes the outcomes they see as most important. There-
fore, therapists and clients who have dissimilar intersectional identities may propose dif-
fering goals for treatment.
An example of this could be a heterosexual therapist treating a gay client for distress
related to coming out to his family of origin. Arguably, many systemically trained family
therapists might set their own goal of working to strengthen the attachment bonds
between the client and his family in order to gain their support and acceptance. This cli-
ent, however, (having a much more thorough understanding of their own family dynamics
and beliefs about the LGBTQ+ community) may instead want to focus on detaching from
his parents, hiding his sexual orientation, and strengthening bonds with his family of
choice. While this goal may seem in conflict with certain family therapy theories, a conver-
sation with the client will shed more light on why he prefers this goal as he brings a
unique understanding of his family’s cultural and religious beliefs. Without opening a dia-
logue about the intersectionality of the therapist and client’s identities, it would be diffi-
cult for either party to understand the other’s perspective and work toward establishing
goals that feel comfortable for the client. Ideally, a safe therapy environment would lead
to an honest conversation about these different possible goals and would allow the client
to feel even more certain about what he would like to accomplish in therapy.

APPROACHING THERAPEUTIC CONVERSATIONS ON INTERSECTIONALITY

We next outline a model of how therapists can approach conversations about intersec-
tionality in therapy (see Figure 2). In the following sections, each component of the model

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PETTYJOHN, TSENG, & BLOW / 319

FIGURE 2. A model for approaching conversations about intersectionality in therapy.

will be discussed to address processes which contribute to the quality of the therapeutic
alliance.

Assessing Intersectionality of Clients’ Identities

We suggest that therapists develop an in-depth demographics form which asks about
dimensions of Morgan’s (1996) adapted model (Figure 1) which are clinically relevant to
their practice. Utilizing this type of demographic assessment gives the therapist an oppor-
tunity to prepare themselves before meeting with clients by reviewing literature on identi-
ties they may be less familiar with and checking biases or stereotypes they may possess
toward certain identities. This also provides the opportunity to conceptualize how the cli-
ents’ identities may be interacting with the presenting problem, and how intersectionality
between clients and therapist may influence treatment. Some therapists may prefer to
avoid structured, written assessments of personal information (especially with clients
from marginalized groups who feel unsafe disclosing certain aspects of their identity), and
instead choose to collect demographic information in face-to-face tailored ways in session.
However client information is gathered, it is crucial to think about intersectionality by
conceptualizing people’s social locations (and resulting power and oppression dynamics)
beyond a simple analysis of demographic data (Torres, Mata-Greve, Bird, & Herrera Her-
nandez, 2018).

Self-Assessment Questions
Because it is impossible for even the most well-informed and well-intended therapist to
feel confident working with every possible combination of clients’ intersecting identities, it
is crucial to pause and do a self-assessment early in treatment when starting a new case.

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Within the reality of clinical practice, it is unlikely that this process of assessment and
self-reflection for every new client would be sustainable. We see this process as a useful
training tool for beginning therapists, or therapists who may be new to intersectionality or
social justice concepts. In Table 1, we have listed suggested self-assessment questions
which aim to challenge therapists to go beyond surface-level categorizations of client iden-
tities. The meaning and relevance of many of the self-assessment questions are self-ex-
planatory or have already been discussed. However, we will expand on the intention
behind some of the more nuanced questions in the following section.
While therapists are assessing the intersection of their identity with each member in
the client system, they should be conceptualizing the intersection of client identities to one
another as well. Power dynamics within couple and family systems are crucial to consider
when joining and establishing the direction of treatment. Without intentionally thinking
about these dynamics from the outset of treatment, therapists run the risk of interacting
with the system in an isomorphic way which perpetuates rather than challenges existing
power structures.
Assessing how much understanding or experience the therapist has with certain client
identities is important because it has the potential to impact the conceptualization of
treatment. This does not imply that therapists without previous knowledge or experience
cannot effectively treat clients with unfamiliar or different identities. However, as with
any presenting problem or client, therapists who are not competent to treat certain issues
should be willing to educate themselves further, or be aware of local resources to where
the client could be referred.
Which path the therapist decides to take hinges largely on the next question about how
comfortable or uncomfortable they feel in addressing aspects of the clients’ identities. A
therapist who feels comfortable, curious, and open to expanding their worldview is an
ideal candidate for having these conversations. However, therapists should be honest with
themselves about their levels of discomfort with certain issues. While we are not suggest-
ing a legitimized way for therapists to discriminate against certain clients, our aim is to
optimize the care received by each client based on their identity. If a therapist does not feel
able or willing to challenge themselves to grow in such a way, perhaps the client would
benefit most from a warm hand off to a more appropriate resource.

TABLE 1
Self-Assessment Questions for Therapists

Self-assessment questions

On what dimensions of identity do I differ from the client(s) as indicated by the demographics collected?
How might I unintentionally oppress the client(s) if I’m not careful?a
What aspects of intersectionality exist within the family/couple system I am treating? How might I
unintentionally reinforce problematic power dynamics within the system if I’m not careful?
How will differences in mine and the client’s identity potentially impact the bond, goals, and tasks of
treatment?
How much knowledge/experience do I have with each aspect of the client’s identity which differs from my
own? What common stereotypes exist about the client’s identity which could unconsciously influence my
work with them?a
How comfortable/uncomfortable am I with addressing these aspects of intersectionality I have identified?
What aspects of oppression are involved in the conceptualization of the presenting problem?a
What contextual factors going on in society at large need to be addressed based on mine and the client’s
intersectionality?
Based on my clinical judgment and interactions with the client(s), how do I believe they will respond to
having a conversation about intersectionality?
a
Questions adapted from Salmon (2017).

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PETTYJOHN, TSENG, & BLOW / 321
It is also important for therapists to ask themselves what aspects of the client’s inter-
sectionality (and related dynamics of social oppression) are involved in the conceptualiza-
tion of the presenting problem. While every aspect of a person’s identity is an important
part of who they are and how they experience the world, every part may not be relevant to
therapeutic treatment depending on the presenting problem, and therefore may not need
to be explicitly addressed. For example, if a woman who uses a wheelchair initiated ser-
vices with an able-bodied therapist to address her grief over the recent loss of her hus-
band, it could feel disrespectful and off-topic for a therapist to spend time trying to initiate
a conversation about these ability differences. However, if this therapist/client intersec-
tion occurred with the woman presenting for general symptoms of anxiety and depression,
it could be useful for the therapist to prompt a conversation about her physical limitations
and how they may be impacting her ability to engage with others or navigate life in a
world that is not handicap-friendly.
Consideration of contextual factors going on outside the therapy room is important
when having this conversation as well. As mentioned previously, we argue that legal sta-
tus, religious views, and gender identity are contentious points of power and oppression in
the United States. While a therapist might not have found it necessary to inquire about
clients’ legal status 5 years ago, in the current context it could have a drastic impact on
their overall well-being, family functioning, and challenges contributing to their present-
ing problem. Additionally, due to the rise in hate crimes against Muslims and transgender
individuals in the past year (Human Rights Campaign, 2018; Kishi, 2017), clients who
belong to these groups may now have increased anxiety working with a non-Muslim, or
cisgender therapist compared to several years ago. Failing to recognize social issues occur-
ring on a macro-level which impact clients is another example of allowing invisible lines of
power and oppression to infiltrate the therapy room.

How to Structure Conversations about Intersectionality

Conversations about intersectionality between therapist and clients may become rele-
vant at any point throughout treatment. For some clients, this conversation needs to hap-
pen up front during the “joining” process to explicitly address differences in perspective
and power in the room before diving deeply into treatment. The need for this may be indi-
cated by clients appearing resistant/quiet in sessions or seeming anxious while discussing
certain aspects of their identity (e.g., experiences with racial discrimination or their
romantic relationship with a same sex partner). Other clients may open the door later in
treatment when revisiting past experiences, or when external events occur and weigh on
them emotionally. For example, author (M.P.) has engaged in conversations about inter-
sectionality with clients several months into therapy while discussing their experiences
with childhood trauma, poverty, and identity as a racial minority. This author has also
found these conversations to be helpful when they intersect with relevant sociopolitical
events which negatively impact clients with marginalized identities (e.g., addressing
rhetoric about “illegal immigration” and “building the wall” with Hispanic clients). For
other clients, this conversation may not naturally come up. We encourage therapists to
think critically about whether the client does not wish to discuss identity issues, or if they
simply feel uncomfortable initiating the conversation themselves. We do not propose that
these conversations are helpful or necessary for all therapist/client relationships; however,
therapists’ ignorance of these issues or anxiety about broaching intersectionality in treat-
ment should not be the driving reasons why this does not come up.
When therapists encounter situations in which a conversation about intersectionality is
clinically relevant, they should open a dialogue by first positioning themselves through
statements such as “From my experience as a white, American woman raised in the

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Christian faith, I may not always understand your experiences as a Pakistani woman who
practices Islam. I invite you to correct me when I get things wrong.” During this process,
therapists can share what they are comfortable with about their own identity first (the
topic of therapist self-disclosure will be addressed under the potential challenges section)
in an effort to not put clients “on the spot.” Using clinical judgment by gauging the client’s
reactions to this disclosure, therapists should follow up with questions that would help
them conceptualize how the client’s intersectionality may influence the presenting prob-
lem, and what the client views as valuable tasks and goals to pursue in therapy. An exam-
ple question could be “You mentioned to me at the beginning of therapy that you have
struggled with anxiety, and now we are having this conversation regarding your stress
and frustration being a Muslim in the U.S. This might be a bold assumption, but I am curi-
ous, maybe part of the anxiety you experience is related to your identity as a Muslim
woman in the U.S.? I might be completely wrong, but if you feel my assumption might
make sense, can you help me understand that?” Reflections or questions about client iden-
tity should always end with eliciting client’s feedback through questions such as “Did
what I say/ask fit for you? Please correct me if I am wrong because I want therapy to be
helpful for you, and you are the expert of your experiences.” This opens a door for clients
to safely express their comments and share if the conversation around intersectionality is
or is not relevant to their presenting problems. It also gives space for correction if thera-
pists are unintentionally operating from a stereotype or generalization which does not fit
their experience.
As clients share what they view as defining pieces of their own identity and experience,
therapists should maintain a stance of curiosity and cultural humility, acknowledging
that “we can never truly know another person, their experiences, lives, and legacies,
unless we are open to acknowledging what we do not know” (Mock, 2008, p. 432). Thera-
pists should allow clients to guide the conversation as much as they would like and ask
about what they do not know as clients unfold their experiences. These conversations
demonstrate humility, transparency, and the willingness to be corrected; they also decon-
struct the hierarchy between therapists and clients and invite clients to choose whether
they want to delve further into the conversation around intersectionality.
Throughout the process, it is crucial that therapists continually check in with their own
internal reactions. As stated previously, engaging in conversations about intersectionality
can be anxiety provoking, especially when it involves people with differing identities and
differing levels of privilege and oppression. Preparing for the conversation ahead of time
by answering the self-assessment questions and going in with an understanding of poten-
tial challenges may help the therapist feel better equipped to manage their internal state
in the moment.

Training and Supervision

We argue that the way knowledge and skills relating to diversity are currently taught
is often too cognition-oriented. Though it seems logical to learn about every dimension of
intersectionality, such as understanding the characteristics of every cultural group or reli-
gion, it is impossible to grasp all the details and nuances of every intersection. While well-
intentioned, this runs the risk of simplifying and overgeneralizing each culture. After
gaining an “understanding” of the specific cultural characteristics of different groups, stu-
dents are often left with the idea that they need to follow “cultural prescriptions” for treat-
ing clients from this group in blanket terms (Hardy, 2016). Instead of attempting to
convey textbook knowledge on various aspects of diversity or specific dimensions of inter-
sectionality, we encourage training programs to adopt an approach that trains students in
the presented model: to remain curious, take a stance of cultural humility, and explore

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how their own intersectionality influences that of their clients. In other words, we encour-
age a process-oriented rather than content-driven approach to educating students on
issues of diversity in therapy.
Integrate the concept of intersectionality throughout the curriculum
We suggest that graduate-level training programs introduce the concept of intersection-
ality at the outset of clinical training. Faculty members should prompt students to think
about their own identities by introducing the intersectionality wheel (Figure 1). Allowing
students to be aware of and honest about their own positioning on the various axes of the
grid, and to develop a deeper and more complex understanding of themselves, can pave
the way to understand their clients similarly. Engaging in ongoing self-reflection through-
out the training process is necessary to develop sensitivity and competency on issues of
intersectionality. We also want to note that Figure 1 is complex, and such a figure can
never be complete. Figure 1 should be used as a useful training tool for student therapists
as a touchstone that can be reviewed, updated, and refined over the course of a therapist’s
lifetime, rather than a chart to memorize and follow in a very structured manner.
We also encourage acknowledging the isomorphism of this process in student/faculty
and supervisee/supervisor identities. When faculty or supervisors identify the influence of
intersectionality in their relationships with students or supervisees, they demonstrate
transparency and the importance of integrating the concept of intersectionality into clini-
cal practice, as students and trainees can understand its impact through experiencing this
process. Supervisors who ignore the differences of intersecting identities risk ruptures in
supervisor–supervisee relationships and miss a valuable opportunity to model how to have
these conversations in an effective way. Supervisors should integrate conversations on
intersectionality during case consults by being culturally sensitive, modeling cultural
humility, and educating themselves on issues of diversity in therapy. Supervisors should
be intentional about having ongoing conversations with their students, as supervision pro-
vides an opportunity for trainees to practice engaging in these vulnerable, and often
intimidating, conversations in a safe space.

POTENTIAL CHALLENGES
Conversations around therapist and client intersectionality can improve the therapeu-
tic alliance and, as a result, potentially improve therapeutic outcomes. However, Bergin
and Garfield (1994) identified the use of self-disclosure in therapeutic relationships as one
of the most complicated relationship variables, and for this reason, therapists should enter
these conversations with caution and careful planning. While there are benefits associated
with the process of self-disclosure (as discussed throughout this paper in the context of
addressing intersectionality), there are also risks. Therapists should be careful to ensure
that all elements of self-disclosure are clinically relevant to the given context. Therapists
who share more than necessary may make the client uncomfortable, or end up turning the
focus of the session onto themselves rather than the client. Self-disclosure should be
viewed as an intervention to be used strategically by therapists, and not as a way to
ease the therapist’s own anxieties.
The process of discussing intersectionality in family or couple cases is more complicated
than in individual cases, given that more people in therapy create many more intersec-
tions, and multiple alliances must be tended to (Pinsof, 1994). Within a couple or family,
when one person experiences the process of discussion of intersectionality as helpful but
another does not, alliances could become split as different clients respond in different
ways. It is feasible that individuals may use their positionality as points of leverage in
their intimate relationships to gain power, and discussions of intersectionality issues

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could play into these relational dynamics in complex ways. For example, a male client in a
heterosexual couple may be reluctant to acknowledge his position of privilege and how this
may be contributing to relational conflict. This means that when discussing intersectional-
ity in couple or family cases, alliances and existing relationship issues should be consid-
ered at the system level within couple/family alliances overall, as well as each individual’s
alliance with the therapist (Friedlander, Escudero, Heatherington, & Diamond, 2011).

CLINICAL CASE EXAMPLE

Positionality of Author
My (C.T.) positionality is a female, Taiwanese international student living in the United
States. I identify my privileged positions as being in a heterosexual marriage, being
young, having no disabilities, being well-educated, and being at an SES level where I do
not have to worry about basic survival. In the United States, my marginalized positions
are identified as being a non-white, non-European, and non-U.S. citizen, having English
as my second language, and being a female.

Case Description
The Schmid family is composed of father (Simon), 41 years old; mother (Linda),
38 years old; and Lucas, 8 years old (pseudonyms were used to protect client identity).
This is an interracial adopted family: Lucas is Latinx, adopted at birth by Simon (born in
South Africa) and Linda (born in the United States), both of whom are white. The identi-
fied patient of the family is Lucas—the parents reported that he was unable to focus on
tasks and homework, and were concerned about his hyperactivity. During the first three
sessions, I worked with the parents to gather information regarding their concerns about
Lucas.
During one session, I was curious about Simon and Linda’s parenting styles and won-
dered how coming from different cultures affected their parenting approaches. I asked, “I
have noticed differences in parenting styles between U.S. and Taiwanese culture, and I
wonder if you have had similar experiences with each of your cultural upbringings?” My
self-disclosure led to Simon and Linda sharing their family origin stories and discussing
how they navigated the differences between their two cultures when it came to parenting.
During my work with them, I noticed that Linda was often overwhelmed by anxiety,
mostly due to Lucas not being able to behave. During one session, Linda came in frus-
trated, sharing that she was upset about Lucas’s poor school performance. Both Linda and
Simon are highly educated, so I originally hypothesized that they might have unreason-
ably high expectations for Lucas, but when we explored their expectations, they fell into
the normal range—all they wanted was to have Lucas pass in school. I validated her frus-
tration and started to hypothesize that her feelings might have an underlying meaning. I
told her “Linda, I know you’re frustrated. Can I ask you a bold question? If you feel like I
don’t make sense, feel free to correct me. For me, being an Asian woman in the U.S., I
sometimes feel like I have to work harder to get people to acknowledge that I’m competent
and good enough. I wonder, given the history of racism in this country, do you sometimes
worry that Lucas might be discriminated against because of his skin color, especially when
your family lives in an area with a majority white population? And might that be why
you’ve tried so many different things in hopes of seeing an improvement in his behaviors?
To ensure he succeeds and avoids becoming a ‘minority fail’ statistic?”
Her anger softened, and I saw tears gather in her eyes. She told me that all her col-
leagues are white, and some of them make racist remarks. Anxiety strikes her every time
she takes Lucas to work with her because whenever he misbehaves, she worries about her

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PETTYJOHN, TSENG, & BLOW / 325
colleagues’ reactions. She also mentioned that she knows Lucas looks cute right now, but
she often tells Lucas that once he is able to drive, the police will not perceive him as cute
anymore. Because of all the stereotypes and discrimination in the United States, Linda
and Simon feel like they cannot just raise a good kid, they must raise Lucas to be better
than other kids. By sharing my own experience as a minority in the United States, I was
able to connect with Linda on a deeper level and help her conceptualize her anxiety in a
systemic framework.
Discussing systemic racism and identity issues resulting from being the white parents
of a Latinx child has become a main topic of discussion in recent therapy sessions. Simon
and Linda have told me how they have tried to find a Latinx church to attend to provide
Latinx role models for Lucas. They have also been paying extra attention to monitoring
the racial composition of each activity Lucas participates in. They did not want Lucas to
be the only racial minority child in any given activity. Both parents became very forthcom-
ing about the impact of race and social justice issues on their reactions to Lucas’s behav-
iors.
Instead of just trying to change Lucas, the parents first started to shift their parenting
approach by acknowledging and validating that Lucas is in a more vulnerable position as
a child of color in a predominantly white world, and second, the parents started to sepa-
rate their reactions and anxiety from his behaviors and learn how to provide support for
him without imposing their own fears. Sharing my own experience as a minority in the
United States provided legitimacy to the clients’ experiences and allowed for a systemic
perspective of the problem. By making the unspeakable explicit, it also facilitated the
development of a better therapeutic bond between myself and my clients as we connected
on a deeper level. I was then able to help Linda and Simon recognize, and productively
address, the anxieties and fears underlying their responses to Lucas, and thereby assist
them in improving their family dynamics.

CONCLUSION AND FUTURE DIRECTIONS

Clients’ intersectional identities affect how they view their presenting problems, as well
as their perceptions and experiences of therapy. Identities (such as race or gender) are
social constructs which place people in a hierarchical relationship to each other and the
therapist. By initiating conversations about intersectionality, therapists demonstrate
respect for each client’s unique positionality and explicitly challenge dynamics of power
and oppression by recognizing the effects of these systemic issues on people’s lives. We
assert that clinically relevant conversations about intersectionality regarding client and
therapist identities can strengthen the therapeutic alliance through improving the bonds,
tasks, and goals of treatment. Self-reflection and taking a proactive stance in learning
how to initiate conversations around intersectionality are imperative, as certain identities
can be the proverbial elephant in the room. Therapists should learn how to utilize conver-
sations about identities in a way that develops an authentic connection with clients. Ther-
apist training and supervision should provide explicit guidance for facilitating and
navigating conversations on intersectionality at a process rather than content level.
Future research should utilize existing measurement techniques to gather more formal-
ized feedback on how conversations about intersectionality impact the therapeutic alli-
ance. Alliance measurements, such as the Session Rating Scale (Duncan et al., 2003) or
the System for Observing Family Therapy Alliances (Friedlander et al., 2006), could be
useful tools for incorporating feedback from conversations about intersectionality into
therapy. Feedback from more clients from diverse backgrounds can help us develop a
clearer understanding of how the alliance evolves through these conversations.

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In addition, we hope more researchers will explore intersections of client and therapist
identities, specifically how therapists with marginalized identities address intersectional-
ity with clients who are in relatively privileged positions. This should expand on Watts-
Jones’ (2010) work, which found that most cross-racial therapeutic scenarios discussed in
the literature are comprised of white therapists and clients of color; discussions of interac-
tions between therapists of color and white clients have not been fully fleshed out in the
literature. People of color, both clients and therapists, often find it difficult to initiate dis-
cussions around racial differences with white people, given the history and current state
of racism and oppression in the United States. Other identities such as age, gender, sexual
orientation, and immigration status can also be challenging to navigate in the therapy
room, particularly for people with multiple oppressed identities. When therapists occupy
marginalized social positions, it may be more difficult for them to share their subjugated
social locations with clients who are privileged in those identities, which is why acknowl-
edging the difficulty of conversations about intersectionality and conducting more
research on the dynamics of these conversations are so imperative.

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