Discrimination and the Development of Working Alliance in College Counseling Clients – A Pilot Study at a Single College Counseling Center

Many college counseling center clients who experience identity-based discrimination have more severe psychological symptoms and experience disparities in treatment outcomes compared to those without discrimination (Center for Collegiate Mental Health [CCMH], 2023; Paradies et al., 2015; Tan et al., 2025). This is unsurprising, as discrimination can impose significant emotional, social, and cognitive burdens on individuals (Hatzenbuehler, 2009; Major & O’Brien, 2005; Pachankis, 2008). This may be especially true for individuals who have intersectional marginal identities, as they tend to experience greater psychological and physical distress compared to individuals who have discrimination against a singular part of their identity (e.g., Center for Collegiate Mental Health [CCMH], 2023 Denise, 2014; Tan et al., 2025; Vargas et al., 2020).

Those who experience discrimination may also have difficulty forming a strong working alliance in therapy. The working alliance is the collaborative relationship between a therapist and client, characterized by agreement on therapeutic goals, consensus on the tasks needed to achieve them, and the development of a trusting emotional bond (Bordin, 1979). As one of the most researched constructs in psychotherapy, a strong working alliance has consistently been shown to be a positive predictor of treatment outcome (Horvath et al., 2011). However, individuals with certain combinations of marginalized identities are more likely to experience challenges forming alliances with their therapist, which might be an adaptive response to past discriminatory experiences (Hatzenbuehler, 2009; Major & O’Brien, 2005; Pachankis, 2008; Trusty et al., 2024).

Due to the interpersonal nature of many discriminatory experiences, individuals who have been targeted by discrimination may understandably demonstrate more struggles forming a working alliance in therapy. Because of the integral role of a close and trusting therapeutic relationship between therapist and client, barriers to building this relationship could inhibit treatment process and outcome. Thus, better understanding the relationship between discrimination and the working alliance among college counseling center clients with recent experiences of discrimination could help improve treatment outcomes for these students. Prior research has revealed that students with recent experiences of discrimination demonstrate equivalent improvement in symptoms of distress, social isolation, and suicidal ideation during counseling services compared to students without discrimination (CCMH, 2023).  In this blog, we expanded this investigation to explore if counseling center clients with recent histories of discrimination show comparable increases in working alliance during the course of treatment at counseling centers.  Specifically, the following questions were answered pertaining to the role of discrimination in the development of the working alliance during counseling services:

• Do clients who report no discrimination, discrimination based on a singular part of their identity, and discrimination related to multiple intersectional identities differ in their working alliance at the beginning of counseling services? 

• Do clients who report no discrimination, discrimination based on a singular part of their identity, and discrimination related to multiple intersectional identities differ in their development of a working alliance across short-term counseling?

To answer these questions, we utilized deidentified data collected from 994 clients who attended five individual therapy sessions at a single large counseling center during the 2021-2024 academic years.  Our analysis focused on the first five sessions, as there was a significant decline in sample size beyond the fifth session.  Self-reported experiences of identity-based discrimination over the past six months were collected using the Standardized Data Set (SDS), which was administered at the beginning of the first session. Students were asked, “In the past 6 months, have you experienced discrimination or unfair treatment due to any of the following parts of your identity?”  Students responded yes or no for each of the following six identities: Disability, Gender, Nationality/Country of Origin, Race/Ethnicity/Culture, Religion, and Sexual Orientation.  Overall, 12.9% of clients reported experiencing discrimination in one or more areas of their identity.  All groups of students disclosed some level of identity-based discrimination, although it was more likely to be indicated by students with marginalized identities.

The working alliance was assessed using the Session Alliance Inventory (SAI; Falkenström et al., 2015). The SAI is a six-item client survey with item responses ranging from 0 to 5, where higher scores reflect a more positive rating of the alliance.  Of note, there tends to be a ceiling effect with the SAI and other related instruments, where a significant proportion of the scores are concentrated at the higher end of the scale.  When there are ceiling effects present, small differences or changes in scores can sometimes reflect outsized effects. 

Do clients who report no discrimination, discrimination based on a singular part of their identity, and discrimination related to multiple intersectional identities differ in their working alliance at the beginning of counseling services? 

The figure below displays the average working alliance scores after the first session of counseling for students who reported no discrimination, discrimination related to a single identity, and discrimination based on multiple intersectional identities.  The results revealed minimal or negligible differences between the three groups.  Thus, clients who reported any recent discrimination (one or multiple areas) indicated similar levels of alliance after the first session as clients who did not experience discrimination.    

Do clients who report no discrimination, discrimination based on a singular part of their identity, and discrimination related to multiple intersectional identities differ in their development of a working alliance across short-term counseling?

The following figure shows the average working alliance scores from Session 1 to Session 5 for clients who reported 1) no discrimination, 2) discrimination based on one aspect of their identity, and 3) discrimination based on multiple facets of their identity. The working alliance for all groups slightly increased across the course of treatment.  

The alliance improvements experienced by all three groups were equivalent, highlighting that students with recent histories of discrimination, compared to those with no discrimination, displayed a comparable improvement in alliance across the course of counseling services. 

Summary, Implications, and Future Directions

In this blog, we explored the relationship between the experience of discrimination and working alliance across the course of short-term treatment at a single large college counseling center. We discovered the following:

Overall, 12.9% of clients reported experiencing discrimination in one or more areas of their identity.  All groups of students disclosed some level of identity-based discrimination, however it was more likely to be indicated by students with marginalized identities.

• The findings revealed minimal or negligible differences between students who reported no discrimination, discrimination based on a singular part of their identity, and discrimination related to multiple intersectional identities.  Thus, clients who reported one or multiple areas of discrimination indicated similar levels of alliance after the first session of services as clients without discrimination. 

• The working alliance for students who reported no discrimination, one area of discrimination, and discrimination based on multiple intersectional facets of their identity slightly improved across the course of treatment.  The alliance increases for all three groups were equivalent.

These preliminary findings from this pilot study suggest that students who enter treatment with recent histories of discrimination experience equivalent improvement in their working alliance during counseling services as students who report no discrimination.  These results complement the results from the 2023 CCMH Annual Report, which discovered that clients with recent experiences of discrimination experienced comparable improvement in symptoms as students without discrimination.  Of note regarding the current pilot study, the improvements in alliance displayed by all groups of clients were small, however any notable change could have a meaningful outcome due to the aforementioned ceiling effects of the SAI instrument. While the current findings further highlight the benefit of college counseling centers services, where students with and without histories of recent discrimination experience equivalent alliance increases across the course of treatment, further national data is needed to determine if these results generalize to the broader college counseling center community.

The following suggestions are provided for clinicians when working with a client who reports experiencing discrimination:

• Attend to a client’s responses on their SDS and other paperwork at the beginning of services.  If they indicate experiences of discrimination, this is an important area to explore during services. 

• Engage the client in direct and open conversations to assess their lived experiences of discrimination and validate their reactions and responses. 

• Explore the role of intersectional identities in clients’ unique lived experiences.

• Closely collaborate with clients on the goals and tasks of treatment, including exploration of the extent to which managing/healing from discrimination may be a focus of therapy.

• Explore the interpersonal impacts of discrimination on clients and discuss how these past experiences could influence the immediate dynamic between the therapist and the client.

• Provide psychoeducation about working alliance and its importance in psychotherapy, and invite the client to collaboratively identify barriers towards building a robust and trusting working alliance.

• Identify actionable steps to advocate for clients who experience discrimination (e.g., institutional support of identity-based services on campus, supporting students in reporting bias incidents, etc.).

• Although discrimination is not a mental health diagnosis, it provides vital environmental and contextual information that is associated with more severe mental health symptoms. While college counseling centers can effectively support students with experiences of discrimination, addressing the working alliance and psychological symptoms are only a small piece of the solution. Systemically, culturally informed support services (e.g., cultural centers, identity-based programs) are vital to buffer the impact of discrimination experiences, provide education/professional development to the campus community, and initiate advocacy to remedy societal sources of discrimination. 

 --

References

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16, 252–260. https://doi.org/10.1037/h0085885

Center for Collegiate Mental Health. (2023). Annual Report. https://ccmh.psu.edu/assets/docs/2023_Annual%20Report.pdf

Falkenström, F., Hatcher, R. L., Skjulsvik, T., Larsson, M. H., & Holmqvist, R. (2015). Development and validation of a 6-item working alliance questionnaire for repeated administrations during psychotherapy. Psychological Assessment, 27(1), 169–183. https://doi.org/10.1037/pas0000038

Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–730. https://doi.org/10.1037/a0016441

Horvath, A. O., Del Re, A., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. http://dx.doi.org/10.1037/a0022186

Lee, R. T., Perez, A. D., Boykin, C. M., & Mendoza-Denton, R. (2019). On the prevalence of racial discrimination in the United States. PloS one, 14(1), e0210698.

Major, B., & O’Brien, L. T. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393-421. https://doi.org/10.1146/annurev.psych.56.091103.070137

Pachankis, J. E. (2008). The psychological implications of concealing a stigma: A cognitive-affective-behavioral model. Psychological Bulletin, 133, 328–345. https://doi.org/10.1037/0033-2909.133.2.328

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-analysis. PLOS ONE, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

Tan, H., Matsick, J. L., Castonguay, L. G., Janis, R. A., White, T. D., Magruder, S. A. N., Chun-Kennedy, C. L., & Scofield, B. E. (2025). Previous Experiences of Discrimination Impact College Students’ Mental Health and Treatment Outcomes at University Counseling Centers. [Manuscript in preparation]. Department of Psychology, The Pennsylvania State University.

Trusty, W. T., Castonguay, L. G., Chun-Kennedy, C. L., Magruder, S. A. N., Janis, R. A., Davis, K. A., Augustin, D. C., & Scofield, B. E. (2024). Client characteristics and early working alliance development: A person-centered research approach. Psychotherapy Research. Advance online publication. https://doi.org/10.1080/10503307.2024.2418868

Appendix

Published 9/15/2025