Date of Award

2023

Document Type

Dissertation

Degree Name

Doctor of Philosophy in Clinical Psychology

Department

Psychology

First Advisor

Benjamin Saunders

Committee Chair and Members

Benjamin Saunders, Chair

Kevin Meehan

Marie Brown

Keywords

Clinical processes, Cultural mistrust, Multicultural psychology, System consciousness, System justification, Treatment disparities

Abstract

Despite advances in mitigating explicit biases, research finds that therapists’ implicit bias has not significantly decreased in magnitude or impact on their clinical work over the past several decades. This bias propels, among other harms, misdiagnosis and overdiagnosis, weaker therapeutic alliances, poorer quality of care, and re-activation of racialized trauma among patients of color. Because of these disparities, many individuals develop experience-based cultural mistrust toward the healthcare system, which clinicians often misinterpret as psychopathology, perpetuating the mistreatment-to-mistrust cycle. This dissertation was the first to apply system justification theory to clinical process research, investigating whether and how therapists’ justification of the mental healthcare system impacts their patients’ cultural healthcare mistrust within the alliance. To this end, participants reported on their racialized stress, cultural mistrust, and healthcare system distrust, then were exposed to an experimentally manipulated vignette “therapist” at one of three levels of system justification (low, high, non-responding), and described their working alliances with their assigned therapist. The negative effect of racialized stress on working alliance was found to be partly mediated by healthcare system distrust, though not by cultural mistrust. Low therapist system justification emerged as significantly beneficial to working alliances, particularly for participants with more racialized stress and healthcare system distrust. Non-responsiveness to patients’ mistrust had the most significant negative effects across all analyses. These results speak to the importance of therapists’ capacity to openly address minoritized patients’ mistrust and to manage their own instinct to justify the systems within which they operate. Exploratory results, clinical implications, and future directions for research are discussed.

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