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According to popular understandings, children grow from a state of dependence to eventually become independent adults. Interdependence helps to disrupt the in/dependence binary and is a useful concept for making sense of the experiences young people with variations in sex characteristics in relation to healthcare. This study used semi-structured interviews with 32 health professionals, 33 caregivers and 12 young people recruited in the UK and Sweden. The analysis is guided by the questions: (1) how do young people, carers and health professionals position themselves in the adult/young person relationship in the context of healthcare? (2) how is the (in/ter)dependence of young people imagined when young people, carers and health professionals talk about healthcare? Our analysis shows how carers and health professionals might support dominant understandings about young people growing towards independence while providing little opportunity for young people's agency and voice. Interviews with young people gave clear examples of their negotiating relational ways of being, seeking agency in the context of healthcare and not simply becoming independent of adults. This analysis also draws attention to the ways young people might be silenced within healthcare contexts. The present paper is based on secondary analysis of data from the SENS. It works with concepts of relationality and interdependence to draw out the possibilities of voice and agency for young people with variations in sex characteristics in healthcare contexts.

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Objective: To explore the relationship between international students' social support at intake and international student distress at end of treatment. Participants: Data was collected from participants (n = 40,085) from 90 United States universities using the Center for Collegiate Mental Health (CCMH) database. Methods: Participants completed measures of psychological distress and perceived social support. Using multilevel modeling, we predicted participants' distress at end of treatment by international student status, social support, race, and length of therapy. Results: We found that international students who reported lower social support at intake ended treatment with higher levels of psychological distress when distress at intake was controlled compared to United States peers. Conclusions: Understanding the significance of social support for international students can help to inform mental healthcare professionals' approach to psychotherapy.

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Anti-Black racism is often overlooked in predominantly White spaces such as psychotherapy. This pervasive disregard and dehumanization reflects the perpetuation of ongoing racial trauma that can influence the psychological health of Black people seeking psychotherapy. Therapists, therefore, ought to be equipped and comfortable to have conversations about anti-Blackness and anti-Black racism in sessions, though evidence suggests they are often uncomfortable discussing race and racism in practice. To understand therapists' comfort when clients discuss anti-Black racism, we used a multiple case study approach to interview five practicing clinicians (two White, two Black, one biracial Asian and White). Within-case analysis elicited a sense of participants' personal experiences of being comfortable, and at times less so, when clients discussed having endured anti-Black racism. Cross-case analysis led to the identification of four themes: (a) Beyond Acknowledgment, (b) Drawing Personal Awareness into the Moment, (c) Engaging with One's Own Emotional Responses, and (d) I Am versus I Should: Proactive and Reactive Comfort. These findings are discussed within the scope of multicultural competence, multicultural orientation, and the value of cultural comfort when clients' discuss anti-Black racism. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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We employed a convergent mixed methods design to examine therapist and counseling center effects on international student clients' (ISCs) counseling outcomes. Using the Center for Collegiate Mental Health (CCMH) data set (2015-2017), we conducted a three-level hierarchical linear model with clients (N = 85,110) nested in therapists (N = 1,267), and therapists nested in counseling centers (N = 111), with clients' international status predicting distress (DI) in their last sessions while controlling for initial DI. Compared to domestic students, the average last session DI was significantly higher among ISCs. Random effects were significant, suggesting that some therapists and centers were more effective in their work with ISCs than others. When the proportion of ISCs seen was accounted into the model, we found a cross-level interaction in which the last session DI differences between ISCs and domestic students were significant for centers seeing a small percentage of ISCs but not for centers with large percentages of ISCs in the caseload. Grounded theory analysis of qualitative data from 11 therapists with international backgrounds revealed therapist and center factors that converged with our quantitative findings. Participants reported adhering to general clinical frameworks when working with ISCs given the lack of training on international competence (which may help explain the effectiveness gap), but also noted nuanced culturally-informed components that likely contribute to more effectively working with ISCs. Findings around center effects were complemented by qualitative results emphasizing systemic representation and engagement with diversity, creative outreach efforts, and administrative/leadership support. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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Evidence-based practice necessitates the inclusion of client identity and contextual information when conceptualizing diagnosis. OBJECTIVE: To examine how therapists' perceptions of Generalized Anxiety Disorder is influenced by client environmental contextual and identity factors, like class and race. METHOD: Therapists (n = 138; 76% women; Mage = 38.3) were randomly assigned three of six client vignettes and asked to provide diagnostic recommendations, confidence in diagnosis, and perception of client's concerns. Vignettes differed in their description of client class, race, and contextual factors. A linear mixed-model was used to test confidence in diagnosis and generalized linear mixed-models were conducted to predict diagnosis and client concerns. RESULTS: Therapists altered diagnosis, confidence, and client concerns based on client contextual factors-but not identity factors. CONCLUSIONS: Therapists consider contextual factors in making clinical decisions, with overall tendency towards diagnosis regardless of if symptoms met the diagnostic criteria of being "excessive" given the environmental context.

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The extent to which therapists are comfortable discussing clients' cultural identities in psychotherapy has been considered a valuable component of how therapists integrate clients' cultures into treatment. Cultural comfort specifically reflects a therapist's way of being at ease, relaxed, and open when discussing clients' cultural identities in treatment. Some initial research has demonstrated the relationships between cultural comfort and clinical outcomes, yet this work has relied largely on cross-sectional designs. The purpose of this preliminary study was to use longitudinal psychotherapy data to explore the relationships between clients' perceptions of their therapists' cultural comfort and clients' distress over the course of psychotherapy. Data were collected from 48 clients who attended 476 sessions in a doctoral training clinic. Multilevel modeling was used to account for the nested nature of the data. Results showed that, when session number was held constant, within-client increases in their perceptions of their therapists' cultural comfort were predictive of decreases in psychological distress. We discuss these findings in light of the multicultural orientation literature and with respect to the implications for therapists striving to be comfortable with culture in sessions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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Hope is often identified as a central process in psychotherapy, with researchers supporting links between clients' hope, symptom distress, and process variables. However, this body of literature is yet to specifically ask what it means for psychotherapists to have hope for their clients. Our purpose, with this descriptive phenomenological study, was to understand the meaning of therapists' hope for their clients. This information has the potential to better inform how therapists think about their own hope for clients and the ways in which this is transmitted to clients who may enter therapy in a state of hopelessness. To accomplish this, we interviewed psychologists (N = 8) using a semistructured interview protocol. Interviews were transcribed then analyzed in accordance with descriptive phenomenology guidelines. Four themes were identified: (a) a sense of holding and possibility; (b) fundamental, dynamic, and reflective practice; (c) client influence (positive and negative) on hope; and (d) connection through hope. The findings are discussed in light of therapist effects in psychotherapy, the internal world of therapists, and training implications. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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