Should Your Therapist Look Like You?

This post is part two of a series.

I posted here about the disadvantages of picking a therapist who looks like you. I noted the much more important issue of finding a therapist who is actually good at therapy, and then I explored some of the likely problems that arise when therapists are chosen for the way they look. These amount to misalliances, which I defined as “positive relationship[s] organized around something other than the work of therapy.” These include a mutual admiration society, a culture of pleasantry, a failure to explore the psychology of moments easily read as cultural, or an assumption that the therapist already knows the patient’s experience.

There’s recent empirical support for my hypothesis (Boswell et al., 2022). In an admittedly small sample of 218 patients, some were randomly allowed to pick their therapist per usual, and some were assigned to a group where a therapist was chosen for them. In the latter group, a therapist was chosen who had demonstrated success with treating the kind of life problem (for example, anxiety) that brought the person to therapy.

The results showed that expertise was more important for a successful therapy than letting the patient specify the characteristics of the therapist. The effect, as expected, was even more pronounced for patients with more complicated and severe life problems. The effect, perhaps not as expected, was also more pronounced for patients of different ethnic backgrounds.

Perhaps patients of different ethnic backgrounds are more likely to ask for a therapist of a particular race, and to weigh that specification over considerations of expertise. This is especially true in the current culture of therapy, which so often presents the therapist as someone who will validate, cheerlead, and support the patient rather than as someone who will collaborate with the patient to change the patient’s patterns of relating to others and to themselves. Someone who looks like you is more likely to be able to validate your point of view, but someone with expertise is more likely to question your point of view. The latter is more likely to lead to change as well as productive discomfort.

There are also older studies supporting the irrelevance of client-therapist match to treatment outcomes (for example, Gamst et al., 2004, studying children). Richard Dana, a co-author of that study, developed the concept of etiquette in providing services, suggesting that the therapist had to learn not to inadvertently put off a client from a different background. For example, I shook hands with everyone, until I learned not to try to shake hands with Orthodox Jewish women to make them feel like they belonged in my office.

The concept of etiquette is useful because the term communicates how crucial it is and how unimportant it is at the same time, much like table manners. No one is going to enjoy a meal served in a manner that offends them or makes them feel like they don’t belong at the table. On the other hand, it’s still really important to make a good meal. Even more important than good etiquette in therapy, of course, is the willingness of the therapist to take responsibility for and explore the emotional effects of missteps. I think that Orthodox Jewish woman, who taught me why my offer of a handshake put her off, did in the end feel welcome by my willingness to listen and adjust. I assured her that there would be no further physical contact in our work together.

One implication of misalliances that arise when clients choose therapists who look like them is that therapists would do well to employ the old wisdom around exploring the patient’s expectations of therapy. Too often, the patient thinks therapy is a place to avoid discomfort and to pursue soothing. This leads to choosing a therapist who looks like they will fit that bill. If the patient thinks therapy is a place to change patterns of relating, they are more likely to look for the most experienced person they can afford. A therapist who can explore and understand the patient’s idiosyncratic expectations of therapy is off to a good start in exploring and understanding the patient’s idiosyncratic expectations of other relationships.