Difference, identity and power in psychological therapy

: therapist and service user perspectives

Abstract

Section A
Growing cultural diversity across Westernised nations increases the need for culturally responsive psychological therapy. This qualitative systematic review used thematic synthesis to explore Mental Health Workers’ (MHWs) experiences of working with differences in cross-cultural therapy. Eleven qualitative and mixed-methods studies from the UK, the USA, Canada, Germany, South Africa and Northern Ireland were included.
Two analytical themes were developed: ‘Power, Politics and Silence’, and ‘Adaptation under Uncertainty’. The review found that what felt professionally safe to name about culture and identity was shaped by sociopolitical context and institutional constraints, including reliance on Eurocentric models and inconsistent training and supervision. In response, MHWs described relational calibration, including pacing, selective therapist self-disclosure, and self-directed learning, to protect the therapeutic relationship and support shared meaning-making. Participant accounts also suggested that cultural and emotional labour was unevenly distributed, with the global majority MHWs often positioned as cultural informants and white MHWs describing hypervigilance about causing offence.
Recommendations include integrating culture, identity, and power across training curricula, providing culturally responsive supervision and reflective spaces, and developing policies that support cultural humility, repair, and equitable distribution of cultural labour.

Section B
Background: UK psychological therapy for ‘psychosis’ is delivered within medicalised systems criticised for diagnostic bias and limited cultural responsiveness for marginalised groups. This study explored whether and how intersecting identity markers were attended to in therapy for ‘psychosis’, and what might improve care. Method: Ten participants from marginalised backgrounds who had received NHS therapy for ‘psychosis’ in England completed semi-structured interviews. Data were analysed using reflexive thematic analysis within a critical realist stance, informed by the Power Threat Meaning Framework (PTMF; Johnstone & Boyle, 2018), intersectionality theory (Crenshaw, 1989, 1990), and minority stress theory (Meyer, 2003). Results: Two themes were generated. Theme 1, What Could Be Voiced (and What Couldn’t), described a hierarchy of “sayable” identities. Therapist self-disclosure could open space for identity talk, but race and gender were easier to discuss than spirituality or religion, class, and disability; gender also shaped comfort when relating across difference. Theme 2, When Therapy Works, captured how therapy became helpful when relational safety enabled collaborative meaning-making and narrative repair, linking unusual experiences to adversity, identity-based stressors, and wider systems. Conclusions: Identity work in ‘psychosis’ therapy is shaped by relational safety and wider service contexts that influence what feels safe to disclose. Implications include explicit invitations to discuss identity, careful use of therapist self-disclosure, and improved confidence in working with spirituality and religion without default pathologisation.

Date of Award	2026
Original language	English
Awarding Institution	Canterbury Christ Church University