Consequences of cultural humility

Introduction

The cultural humility of counsellors significantly improves their working alliance with clients, explaining about 60% of the variance, as Zhu, Luke, et al. (2025) revealed. Specifically, in this study, the researchers utilised Amazon Mechanical Turk to recruit adults who were receiving counselling or psychotherapy.  Over 600 participants completed the survey.  The survey included

• the cultural humility and enactment scale (Zhu et al., 2022), such as “My counsellor is open to changing their views on cultural issues”,
• a short variant of the working alliance inventory, such as “What I am doing in therapy gives me new ways of looking at my problem” (Hatcher & Gillaspy, 2006),
• the real relationship inventory (Kelley et al., 2010) to gauge the quality and sincerity of the relationship between the client and therapist, such as “I was open and honest with my therapist”, and
• the Barrett–Lennard relational inventory to measure whether the client perceived the therapist as empathic, such as “My counsellor usually senses or realizes what I am feeling.”

As hypothesised, cultural humility was positively and strongly associated with both the working alliance and the quality or sincerity of the relationship between the client and therapist.  When counsellors and clients have developed a strong working alliance, in which they agree on therapeutic goals and tasks as well as establish an emotional bond, clients are more likely to benefit significantly from the sessions (for a meta-analysis, see Flückiger et al., 2018).  The degree to which the therapist was perceived as empathic partly mediated these relationships.

Several accounts could explain why cultural humility enhances the perceived empathy of therapists.  For example

• when therapists demonstrate cultural humility, they are more likely to be curious and interested in the client—and this curiosity or interest might foster understanding and empathy,
• when therapists demonstrate cultural humility, they are not as likely to reach premature, and thus misguided, conclusions about clients, again fostering understanding and empathy.

A systematic review

Since the 2010s, many other studies have also explored the associations between cultural humility, therapeutic alliance, and psychotherapy outcomes.  Accordingly, Orlowski et al. (2025) conducted a systematic review and meta-analysis to characterise these relationships more definitively. To distil the relevant literature, the researchers first entered keywords that revolve around cultural humility, working or therapeutic alliance, and treatment, clinical, or therapy outcomes into three databases: PsychINFO, Medline and ProQuest Dissertations and Theses.  The researchers used Chat GPT to optimise the search string.  This procedure uncovered 13 cross-sectional studies that fulfill the selection criteria, all of which were conducted in the US between 2013 and 2023.

Before conducting the meta-analysis, Orlowski et al. (2025) applied the Joanna Briggs Institute or JBI Checklist to evaluate the quality of these cross-sectional studies.  Although all the studies utilised valid measures and statistical techniques, six of these studies did not control other variables appropriately. The meta-analysis then revealed that

• cultural humility was positively and highly associated with measures of therapeutic alliance, r = .66,
• cultural humility was positively and moderately associated with measures of therapeutic outcome, r = .39,
• the funnel plot and Egger’s test, conducted using the robumeta package in R (Fisher & Tipton, 2015) did not unearth evidence of publication bias—such as the tendency to exclude non-significant relationships,
• although the effect sizes were heterogenous, no significant moderators were uncovered. 

The benefits of cultural opportunities and cultural comfort

Cultural opportunities

According to the seminal framework of multicultural counselling orientation (Davis et al., 2018), or MCO, cultural humility—in which practitioners adopt a mindset in which they want to learn from their clients and appreciate their experiences—manifest in two behaviours, at least within counselling settings.  These two behaviours are called cultural opportunities and cultural comfort (Davis et al., 2018).  Specifically

• cultural opportunities are moments, during therapy, in which clients share cultural beliefs, values, or experiences and the practitioner, seamlessly and authentically, integrates these perspectives into the therapeutic experience,
• cultural comfort is the capacity of practitioners to discuss cultural matters with ease and openness, devoid of defensive reactions.

Research has verified the benefits of these cultural opportunities. In one informative study, Owens et al. (2016) administered an online survey to 247 clients of 50 therapists who operated at a university counselling centre.  The survey included

• the Cultural Humility Scale to measure cultural humility,
• a measure that uncovers cultural missed opportunities, comprising questions like “I wish my therapist would have encouraged me to discuss my cultural background more” or “My therapist avoided topics related to my cultural background”,
• the Patient’s Estimate of Improvement (Hatcher & Barends, 1996) to assess the degree to which clients felt that psychotherapy had improved various facets of their life, such as relationships, work, productivity, and so forth, comprising questions like “To what extent have your intimate relationships improved or gotten worse over the course of therapy?”,
• the Schwartz Outcome Scale-10 (Blais et al., 1999)—a control variable to measure wellbeing, epitomised by items like “I am generally satisfied with my psychological health”.

As hypothesised, cultural humility was inversely related to cultural missed opportunities.  And these cultural missed opportunities were negatively associated with the degree to which patients felt the psychotherapy had improved their life—especially if the cultural humility of therapists was limited.  Accordingly, if practitioners embrace cultural humility, they are not as likely to overlook helpful opportunities to integrate cultural perspectives into therapy. Consequently, their clients are more likely to feel the therapy has been successful.  Future research is warranted to explore whether these benefits of cultural opportunities extend to other settings.   

Cultural comfort

The cultural comfort of practitioners can also benefit clients, such as decrease their distress (Bartholomew et al., 2021) or diminish the likelihood these individuals will discontinue therapy prematurely (e.g., Owen et al., 2017).  Bartholomew et al. (2021), for example, conducted a longitudinal study to explore whether the cultural comfort of therapists diminishes the distress of clients.  In this study, 48 clients of a doctoral training clinic, completed an online questionnaire before and after each session they attended.  In particular

• before each session, to measure symptoms of distress, these participants completed the Counseling Center Assessment of Psychological Symptoms–34 (Locke et al., 2012), comprising items like “I feel worthless” or “I drink more than I should”,
• after each session, to measure the degree to which participants felt the clinician demonstrated cultural comfort, these individuals completed the Therapist Cultural Comfort Scale (Pérez-Rojas, Bartholomew, et al., 2019)—in which participants, in response to the stem “When important parts of my culture come up or are discussed, my therapist”, indicated the degree to which the practitioner demonstrated various behaviours or mannerisms such as “seems comfortable in our interaction” or “stumbles with words” [reverse-scored].

Across 476 sessions, the data revealed that, when the cultural comfort of therapists increased, the level of distress that clients experienced subsequently decreased (Bartholomew et al., 2021).  This study, therefore, compellingly reveals that cultural comfort may improve therapeutic outcomes.  Presumably, when therapists demonstrate they feel comfortable when discussing cultural matters—sometimes manifesting as cultural references (Gundel et al., 2020) or cultural language (Pérez-Rojas, Brown, et al., 2019)—clients do not feel the need to suppress their identity, values, or beliefs.  Clients can thus disclose more information about themselves, facilitating the therapeutic alliance.