ΔΗΜΟΣΙΕΥΣΗ ΕΡΕΥΝΑΣ στην Διεθνή Εφημερίδα Έρευνας και Επανεξέτασης ΤΗΣ ΨΥΧΟΛΟΓΟΥ ΨΥΧΟΘΕΡΑΠΕΥΤΡΙΑΣ ΕΛΕΝΗΣ ΣΚΟΛΗ ΑΠΟ ΤΗΝ ΑΛΜΩΠΙΑ

 

Τιμή για την Αλμωπία η δημοσίευση Επιστημονικής Έρευνας  της Ψυχολόγου Ψυχοθεραπεύτριας Ελένης Σκολή  στην  Διεθνή Εφημερίδα Έρευνας και Επανεξέτασης η οποία στοχεύει στην ταχεία δημοσίευση υψηλής ποιότητας ερευνητικών αποτελεσμάτων, διατηρώντας παράλληλα μια αυστηρή διαδικασία αξιολόγησης.

International Journal of Research and Review [Indexed, Peer-Reviewed Journal] Volume 12; Issue: 9; September 2025 Website: www.ijrrjournal.com Research Paper E-ISSN: 2349-9788; P-ISSN: 2454-2237 International Journal of Research and Review (ijrrjournal.com) 443 Volume 12; Issue: 9; September 2025 Trainee Integrative Therapists’ Experiences of the Role of Culture in Therapy: An Interpretative Phenomenological

Analysis Eleni Skoli1 , Sotiria Efthymiou2 , Triantafyllia Iliopoulou3 , Georgios Pilafas4 , Penelope Louka5 1Accredited Lecturer, University of Derby (UK) at Mediterranean College campus, Thessaloniki, Greece 2Senior Vulnerability Expert, European Union Agency for Asylum (EUAA), Brussels, Belgium 3Accredited Lecturer, University of Derby (UK) at Mediterranean College campus, Athens, Greece 4Programme Leader ‘MSc Applied Psychology’, University of Derby (UK) at Mediterranean College campus, Athens, Greece 5Associate Provost (Research), Mediterranean College, Greece Corresponding Author: Eleni Skoli DOI: https://doi.org/10.52403/ijrr.20250945 ABSTRACT By the rise of multiculturalism in contemporary societies, there is a growing body of research on issues of culture in therapy. In this context it has been acknowledged that the clients’ and therapists’ intersecting identities interact influencing the course of therapy. At the same time, there is strong criticism of traditional approaches and, consequently on the integrative movement, claiming their lack of cultural awareness and applicability on diverse clients. As the importance of training has been highlighted in assisting trainees’ awareness, knowledge and reflection, the current study acknowledging the importance of the integrative trainee therapists’ views and reflection on relevant issues aimed at investigating their experiences concerning the role of culture in psychotherapy, using Interpretative Phenomenological Analysis. Through the data analysis three Group Experiential Themes emerged. The first one concerned the experience of the therapists’ being in therapy that concerned their views on the need for exclusion of their culture, the parts of its intrusion and their emotional reactions to work with diverse to them clients. The second theme contained their views and experiences of their interaction with diverse to them clients and contained their views on the role of the clients’ cultu

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 444 Volume 12; Issue: 9; September 2025 perceptions and thoughts that emerge from their social group membership, thus, their cultural identity, and are taught to them by the institutions of their context. Consequently, cultural diversity occurs when different cultural groups or their members encounter each other in the same location (Wong et al., 2006). Considering a series of events that occurred in the last decades, contemporary societies are becoming increasingly multicultural and, consequently, there is a rise of interest in cultural issues in psychology and psychotherapy research and practice (Englar-Carlson and Smart, 2014). Specifically, as for psychotherapy, it is considered that the different overlapping identities that individuals bear can influence its course (Sue et al., 2019). Both therapists and clients bear their individual and cultural identities, who are mirrored in therapy, meet each other, conflict and interact (Mahalik et al., 2011; Thomas & Schwarzbaum, 2016). Moreover, the importance of researching culture draws upon the idea that therapists’ cultural identity and view of the clients’ culture can be highly influential on the quality of their services (Anderson et al., 2019; Harris et al., 2008), while their awareness, knowledge and skills on culture can be strongly related to the therapeutic outcomes (Owen et al., 2017; Zhang & Burkard, 2008). Lastly, being able to work effectively with cultural diversity is an issue of ethical practice. Thus, the BACP (2016) in its last update of the Ethical Framework included the necessity of the therapists’ commitment to being aware of their cultural identity and values, respectful of the client’s ones and offering services that are efficient and accessible to all clients. At the same time, however, it seems that traditional psychotherapeutic approaches fail to capture cultural diversity, leading to providing insufficient theory and tools to psychotherapists so that they can address cultural issues in therapy (Jones-Smith, 2018). Thus, according to Harris et al. (2019), as a synthesis of its components, the modern integrative movement in psychotherapy also fails to address culture and gender in an appropriate way. As a result, it seems necessary to construct a new framework that will draw from multicultural theories, to ensure the quality of services provided to socially oppressed clients (Harris et al., 2009), meaning those who have limited access to resources, status, and power because of their social position that derives from their social identity (Cudd, 2016). At the same time, it is necessary for traditional approaches and tools to be adapted and applicable in modern multicultural social contexts (Prochaska & Norcross, 2014). Acknowledging the importance of the therapists’ ability to work with diverse clients and be aware of cultural issues in therapy, many researchers turned their interest to multicultural awareness of the psychotherapy curricula. Relevant research indicates a lack of cultural awareness of the training programs (Ridley et al., 2011) even though training and supervision may strongly affect the trainees’ ability and skills to work in multicultural contexts (Lee & Khawaja, 2013). Additionally, trainee therapists seem to usually lack the skills to address and work therapeutically with culturally diverse clients (Day-Vines et al., 2007; Neville et al., 2006). Moreover, especially when working in multicultural environments usually they feel that they lack the necessary skills to work with such clients, as they have not been adequately trained in their basic studies, leading them to search for further training (Sue et al., 2019). Consequently, as proposed by Moleiro et al. (2017), cultural awareness of training programs and supervision is very important, especially in multicultural environments like Europe. Taking the above into consideration, namely the influence of culture in the therapeutic process, the lack of knowledge and skills among psychotherapists, the consequences this might have on therapy, the lack of cultural awareness among traditional approaches and in the integrative psychotherapeutic movement and the

 Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 445 Volume 12; Issue: 9; September 2025 importance of training, the current research aims to shed more light on issues of culture in therapy in a multicultural framework, as experienced by trainee integrative therapists, a field with limited body of research (Geerlings et al., 2017). The rationale of the present study draws upon the idea that it is important to acknowledge the views and experience of novice integrative psychotherapists of culture in therapy as it can result in useful data that will facilitate constructing a culturally sensitive integrative framework and offer them the support they need to work more effectively in multicultural environments (Paprocki, 2014). At the same time, it has been claimed that therapists’ exploring their experience and beliefs about culture contribute to the way they interact with their clients in therapy (Owen, 2013). More than that, this issue is considered very important to be studied in Greece, as it constitutes a multicultural environment in which there is a lack of relevant research. Consequently, the current study aims to investigate integrative trainee therapists’ experience of culture in therapy and the way it can influence the therapeutic process with adult clients, using qualitative methodology and, more specifically, Interpretative Phenomenological Analysis. Their experience is explored regarding the influence of their and their clients’ culture on the therapeutic process in terms of emotions, thoughts, challenges and limitations they might experience. IPA is the method of choice due to its usefulness in investigating unexplored topics that are highly experientially and emotionally laden (Larkin & Thompson, 2012), as the current one. LITERATURE REVIEW 1. Culture and cultural diversity in psychotherapy 1.1. Perspectives and models of integrating cultural diversity in therapy A series of recent events in the late 20th and the beginning 21st century resulted in the creation of growing multicultural societies and subsequently in the raising of a new movement concerning multicultural counseling and psychotherapy (Gallardo, 2012; Sengar, 2018). Similarly, it is claimed that traditional psychotherapy is reproducing the social power relations and, subsequently, is not inclusive or it is even oppressive towards socially excluded and culturally diverse clients. Subsequently, social justice and responsibility are considered an issue of concern for psychotherapy and mental health practitioners that are called to find ways to work ethically and effectively with diverse clients (Gorski & Goodman, 2015; Ratts et al., 2016). In this context, nine cultural factors that psychotherapists should consider in their practice were proposed, known by the acronym ADDRESSING, namely age, disability, religion and spirituality, ethnicity and race, sexual orientation, socio-economic factors, indigenous heritage, national identity and client’s gender (Hays, 2012). As a result, two broad perspectives of working with diversity in psychotherapy arise, namely cultural relativism and cultural universality. On the one hand, from a cultural relativist perspective, every culture has an undeniable value and must be respected for its contribution to the global culture. Thus, behaviors and mental health issues should be judged by different standards across cultures and, consequently, they should be assessed in the way they manifest within each culture, while therapy and treatment of disorders should take into consideration the cultural differences that might be present (Sue et al., 2019). On the other hand, cultural universality proposes that there is a universal reality and truth and that cultural identities do not make a difference in its experience. Consequently, in mental health, it is supported that the existence of mental phenomena that are global, manifest in the same way across cultures and thus, treatment does not consider culture as a factor of influence

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 446 Volume 12; Issue: 9; September 2025 However, according to the relevant research, despite the possible validity of both perspectives and the co-occurrence of global and distinct characteristics of mental phenomena, culturally sensitive therapeutic interventions are considered more appropriate and effective when working with diverse clients (Hall et al., 2016; Smith & Trimble, 2016). As cultural relativism gained recognition and empirical support, a new perspective, that of multiculturalism, arose based on this epistemology. The multicultural perspective in psychotherapy suggests that it is, not only necessary but overall, an ethical obligation of psychotherapists to be able to work with diverse clients with respect to their cultural backgrounds and values and to be aware of how this diversity might influence the process (Anderson and Middleton, 2018; Arthur, 2019). In psychotherapy, multiculturalism refers to the inclusion and integration of the cultural factors that intervene with the therapeutic process and extend beyond race/ethnicity, to other factors such as worldviews, values, gender identity, sexual identity, religion. More specifically, the multicultural movement expects professionals to be aware of the differences between them and their clients in terms of cultural influences, of the way their own culture influences their views and of the way they work with diverse clients (Ratts & Pedersen, 2015). This shift to addressing multiculturality in psychotherapy draws upon the idea that clients’ and therapists’ culture intrude into the psychotherapeutic process and relationship. As found in different studies in variable populations, culture can influence the clients’ values and beliefs and, consequently, the way they perceive and give meaning to their symptoms, their idea of what constitutes an issue, the attributions they make as well as the possible solutions. In other words, culture intrudes in therapy since its initial step, that of the client’s request (Applewhite et al., 2009; Huang & Zane, 2016; Weatherhead & Daiches, 2010). To address such issues, different theories and models for working with diverse clients were suggested. Theories and frameworks on working with diversity. One of the first theories that aimed to shape a multicultural framework for psychotherapy is that of multicultural competence. According to this theory, proposed by Pederson and Lefley (1986), there is a variety of therapeutic skills and characteristics that are related to better therapeutic outcomes and can be cultivated and remain stable across different clients. Generally, the definitions proposed through the years can be categorized according to the emphasis they impose to different variables, namely the therapist, their skills and interventions, or the psychotherapeutic processes (Sue et al., 2009). Drawing from this perspective Sue (2001) proposed the multidimensional model of cultural competence, according to which, competence consists of three variables, namely awareness, knowledge and skills. More specifically, cultural awareness is someone’s awareness of their own and their clients’ cultural identity, with the assumptions, norms, stereotypes, biases, beliefs and representations they bare, and which can intrude on the therapeutic process (Chu et al., 2016; Sue & Torino, 2005). Cultural knowledge constitutes the therapist’s knowledge and available accurate information concerning diverse cultures (Sue & Torino, 2005). Moreover, it refers to the therapist’s knowledge of the oppression that each culture and client have been subjected to and the way this culture has been conceptualized by Western psychotherapeutic approaches (Tseng & Streltzer, 2008). Lastly, it refers to the understanding of the client’s personal culture, the way that it may influence their request and expectations, the way they relate and the process itself (Sue & Torino, 2005). The third variable, that of cultural skills refers to the therapists’ skills and available tools that enable them to work with culturally diverse clients. Overall, skills are related to the practice itself and constitute the ability to apply a culturally

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 447 Volume 12; Issue: 9; September 2025 sensitive approach and the relevant tools (Sue et al., 2009; Sue & Torino, 2005). However, there is concern about whether those characteristics are indeed stable as research has failed to support this claim of multicultural competence theory (Owen et al., 2011). As a result, Owen (2013) proposed an alternative, the multicultural orientation framework, to examine the dynamic nature of culture in therapy. This framework, which consists of cultural humility, cultural comfort and cultural opportunities, focuses on how clients’ and therapists’ cultural values and worldviews interact and influence the relational experience of the therapeutic process. Consequently, the framework offers a process- oriented approach which takes into consideration the way that therapeutic alliance is formed, influenced by culture, and the specific traits and characteristics that are related to better therapeutic outcomes (Davis et al., 2018). In this context, cultural humility has been proposed as competitive to cultural competence. The concept of cultural humility aims to conceptualize the culturally competent and efficient therapist as one who engages in continuous self-reflection and critique, aiming to work better with diverse clients (Sue et al., 2019) and is built around two main axes. The first axe is that of selfreflection and the therapist’s commitment to lifelong learning. This means that they should be aware of their own values, as shaped by their own cultural background, to be able to put them aside to better understand their clients’ values and realities and to be open to learning from them. This is considered a never-ending process based on the idea that culture itself is everchanging, and thus that mastery cannot be attained. The second axe is that of the focus on the client, meaning the adoption of a respectful stance for the client’s phenomenology and needs and the rejection of the therapist’s role as that of the authority (Bramesfeld et al., 2019). Despite to what is implied by cultural competence models, here the mastery of the therapist is rejected as a means of reproducing the power imbalances of the broader social context (Fisher-Borne et al., 2015). Cultural humility rejects both the authority of the therapist and cultural blindness, meaning the neutrality of the approach of culture (Bramesfeld et al., 2019; Fisher-Borne et al., 2015). A recent addition to the model of cultural humility is that of the intersectionality as suggested by Bramesfeld et al. (2019) who updated the recommendations for practitioners. More specifically, it is suggested that practitioners should be prepared to work with diverse clients as modern societies become increasingly diverse and this should be done by considering their and the clients’ multiple identities and the way they interfere and interact with each other shaping their experiences. In parallel, practitioners should acknowledge that all clients bear intersecting identities that place them in different positions under the oppressionprivilege spectrum. From an intersectional perspective, every therapeutic encounter constitutes a multicultural experience in which the therapist has to pursue the understanding of the clients’ worldview and subjective experience and to be aware of the way these identities might be related to mental health (Dhamoon, 2011). At the same time, it is quite important for them to continuously self-reflect and to acknowledge their own social position, the oppression or privileges that may come along with their intersecting identities and the fact that the therapeutic relationship is by itself a sociocultural context that is influenced by these identities (Bostwick et al., 2014; Dadlani et al., 2012; Sue et al., 2019). Therefore, the above perspectives have provided new models and methods of working with culturally diverse clients in psychotherapy. With the rise of concern for effective practice in multicultural contexts, different methods have been formed for psychotherapy with socially oppressed clients (Wendt, Gone & Nagata, 2015).

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 448 Volume 12; Issue: 9; September 2025 Adapting a social psychology perspective based on theories such as social comparison and stereotyping (Cabral & Smith, 2011) and matching cultural characteristics of therapists and clients, a new method emerges that can increase the positive outcomes of therapy and facilitate therapeutic alliance (Harrison, 1975). However, relevant research fails to support the hypothesis that matching can be beneficial for all oppressed clients, with one of the classic studies leading to contradictory results in different ethnic groups (Sue et al., 1991). A more recent meta-analysis conducted by Cabral and Smith (2011), shows that matching was more relevant to clients’ preferences and perceptions, as clients show a tendency to prefer a therapist of their own race. However, matching did not seem to influence clients’ perceptions and evaluation of their therapists and on the therapeutic outcome. As Cabral and Smith (2011) claimed, therapist’s competence seems to be more of a determinant of a positive outcome than matching as this does not necessarily impose greater similarity between client and therapist given the variability of intra-racial differences. Moreover, another approach proposes cultural adaptation of therapeutic approaches and interventions as the solution to meeting diverse clients’ needs (Bernal & Domenech Rodriguez, 2012). According to the meta-analysis conducted by Rathod et al. (2018), cultural adaptation is mostly applied in terms of language, family and social relationships, cultural norms and ethics, tools and methods, therapeutic alliance and goal. However, they claim that relevant research uses diverse criteria for assessing what constitutes “cultural adaptation” and thus, it is difficult to assess its utility and effectiveness for diverse clients. At the same time, the meta- analysis of Soto et al. (2018) shows an overall high efficacy of cultural adaptation, however, high inconsistency of the results is detected among different studies, guiding to the conclusion that there is need for future research on the specific adaptations that can be useful, under which circumstances and for which specific population. Another discourse on improving practice for diverse clients argues the importance of standards of cultural competence, aiming to propose specific characteristics of the therapists that will facilitate effective treatment (Sue et al., 2009). Standards of cultural competence refer to those skills and abilities of the therapist to adapt and work with clients that are different from them and especially when they are members of socially oppressed groups (Bernal & Domenech Rodríguez, 2012). In this context, and according to the multicultural competence model, awareness of own beliefs, awareness of clients’ culture, the therapist’s skills and available culturally competent tools, as well as their continuous learning regarding relevant issues and methods, are considered very important for ensuring quality and appropriateness of therapy (Boroughs et al., 2015; Sue et al., 2009). Soto et al. (2018) conducted a metaanalysis in which it is found that the results of its efficacy on clients’ participation and outcomes varied across studies. According to the researchers, this variability might be explained by the differences between clients’ perceptions and therapists’ selfperceived cultural competency, as better therapeutic outcomes were explained by clients’ and not therapists’ perceptions. Aiming to give an answer to the above insufficiencies, the multicultural orientation framework offers new methods and approaches in the field. More specifically, the component of cultural humility proposes the therapist’s respect, openness and kind curiosity about the clients’ phenomenology and the avoidance of making assumptions on their issues (Foronda et al., 2016). According to the second component, that of cultural comfort, the therapist must be aware of those feelings that may emerge at any point when having culturally relevant conversations and to be able to manifest calmness and non-defensiveness when it comes to cultural issues (Hook et al., 2017)

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 449 Volume 12; Issue: 9; September 2025 Lastly, the component of cultural opportunities is significant when clients make statements or bring up issues related to culture that are seen as an opportunity for the exploration of the client’s cultural values and beliefs and thus, for a better understanding of their experience (Owen, 2013). The multicultural orientation framework, indeed, seems to propose new methods that can be beneficial when working with diverse or socially oppressed clients, in terms of clients’ satisfaction and therapeutic outcomes (Anders et al., 2021). Moreover, research shows the utility of those methods in supervision (Watkins et al., 2019) and professional training (Abbott et al., 2019). In any case, the abovementioned models and methods aim to offer new tools and frameworks to therapists so that they can overcome the challenges and obstacles and to be able to provide effective services to their clients. 1.2. Challenges and harmful practices in working with diverse clients For many decades now, the multicultural counseling and psychotherapy movement, has been concerned with possibly harmful treatment, while its original claim is that traditional psychotherapeutic practice was inadequate or even harmful to clients from socially oppressed groups (APA, 2003; Wendt et al., 2015). Thus, relevant literature and research turn towards detecting challenges and possibly harmful practices. One of the main criticisms in traditional practice supports that available approaches and tools are Eurocentric and designed for white clients. This is visible from the very beginning of a therapeutic process, namely the evaluation and diagnosis, with Sue and Sue (2008) claiming that most of the standards that determine what is “normal” or “deviant” are based on Caucasian cultures, leading to an overdiagnosis of diverse populations, and, consequently, to enduring their stigmatization (Wendt et al., 2015). At the same time, a relevant barrier that undermines the effort for equal and effective services, is that of monocultural therapeutic orientation, meaning the application of the therapist’s cultural values to all clients which limits the therapist’s effectiveness in terms of assessment, case formulation and, subsequently of intervention (Gallardo et al., 2012). Apart from the assessment, frequent issues that are presented in therapeutic services to diverse clients are the high drop-out rates, poorer outcomes and client satisfaction. More specifically, higher drop-out rates are attributed to factors such as inadequate services or the therapist’s cultural incompetence which have been observed by clients that belong to ethnic minorities (Ault-Brutus, 2012). At the same time, many researchers have found that diverse clients demonstrate lower levels of satisfaction, and higher levels of mistrust to therapists (Berke, Maples-Keller & Richards, 2014; Chang & Berk, 2009). Moreover, clients’ satisfaction with their therapist’s cultural competence seems to be more related to the therapeutic outcomes than the self-rate of the therapists’, indicating the importance of client’s perceptions (Soto et al., 2018). In the same context, the research conducted by Moleiro et al. (2018), who assessed the competence of psychotherapists in terms of their cultural awareness, knowledge and skills, found that most of the participants were placed at the level of culture blindness or precompetence. In addition, because of the lack of knowledge and tools that derives from the Eurocentric and heteronormative nature of traditional psychotherapeutic services, clients that belong to socially diverse groups very often report harmful practices that they have been subjected to (Jones-Smith, 2018; Morris et al., 2020). As found in the research of Morris et al. (2020) about the experiences of gender non-conforming clients, almost all participants experienced different forms of harmful treatment. More specifically, they mentioned the lack of respect for their identity in the form of microaggressions and misgendering and lack of competence on gender issues. Also,

 Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 450 Volume 12; Issue: 9; September 2025 they mentioned as very harmful the focus of the therapists on their gender identity with many of them either overrating or underrating its relation to the clients’ presenting issues. Similar harmful practices have been detected also in other studies on LGBTQIA+ clients, such as pathologizing gender or sexuality non-conforming identities, ignoring the client’s sexual identity or reproducing heteronormativity by assuming the client’s conforming identity (Fell, Mattiske & Riggs, 2008; Semp & Read, 2015). As mentioned above, an important sidestep frequently observed in psychotherapy with diverse clients is microaggressions. Microaggressions constitute an indirect, seemingly unharmful way of communicating discrimination and prejudice that implies negative or even hostile attitudes toward a person or an entire group (Sue et al., 2007). Microaggressions might have the form of non-verbal communication clues (Schultz, 2017; Sue et al., 2007) or verbal expressions (Gomez, 2021; Sue et al., 2007). Thus, an expression, like asking a person of an ethnic minority “Where are they really from” (Gomez, 2021, p. 375) or a stance, like color or gender blindness (Hunte, 2016) constitute microaggressions that reproduce social oppression (Gomez, 2021; Sue et al., 2007). Moreover, microaggressions seem to be very frequent with Hook et al. (2016) finding that 53% to 81% of racial or ethnic minority clients reported having experienced it at least once during psychotherapy. In any case, relevant research shows that practitioners that are not specifically trained to work with diverse clients usually lack the necessary knowledge and skills to do so. In any case, as claimed by Martin (2017), working with diverse clients can cause uncertainty to the therapist as unfamiliar and unknown issues and cultural perspectives might emerge in the therapeutic process. Thus, as proposed by Martin (2017) therapists should make use of their personal therapy and supervision to work with diversity and tolerate the uncertainty imposed by it. At the same time, to avoid insufficient or harmful practices, therapists must be aware of their own values, discriminating attitudes and prejudice and educate themselves on issues related to cultural diversity (Jones-Smith, 2018; Sue et al., 2019). 1.3. Culture in psychotherapeutic training Many scholars have highlighted the importance of training in ensuring therapist competence in working with diverse clients claiming that cultural competence can work in favor of the quality of their services to all clients, even non-socially oppressed ones (Schouler-Ocak et al., 2015). According to Fund and Lo (2016) regardless of their overall training and experience, psychotherapists should have relevant training, either in the context of their main or with complementary training, to work with diverse clients. Despite its importance, there seems to be a lack of appropriate training in issues of multiculturality in psychotherapy. More specifically, researchers generally detect a low level of trainees’ satisfaction with the adequacy of their training to assist them in working with diverse clients. It has been found that trainees do not have access to training related to LGBTQIA issues or, if they do, they are not satisfied with its quality and content (Lyons et al., 2010; Price et al., 2005). At the same time, it has been claimed that multicultural training curricula mostly focus on race/ethnicity, and, to a lesser extent, on sexuality, religion and immigration, neglecting other areas (Chu et al., 2022), indicating a lack of inclusivity. Another important note on multicultural psychotherapy training is that it is mostly client-targeted and neglects the therapist’s identity who can either be a member of an oppressed social group themselves (Brown, 2009) or a member of a privileged group and thus feel threatened by the raising interest on diversity due to their own negative attitudes (Sue et al., 2009). As for

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 451 Volume 12; Issue: 9; September 2025 the latter, it has been claimed that gaining awareness of one’s prejudiced attitudes, stereotypes and cultivating acceptance must be the central pillar of culturally competent training, along with cultivating multicultural skills, knowledge and awareness (Boroughs et al., 2015; Kirmayer, 2013). As the interest in more culturally competent training of psychotherapists and mental health practitioners is rising, there is a growing body of publications on relevant guidelines. More specifically, SchoulerOcak et al. (2015) suggest that culturally competent training should be a mandatory part of all therapist’s training while they should be accessible to all social groups, in terms of accessibility for disabled students, language and fees, while supervision of trainees has to be culturally sensitive and competent as well (Benute et al., 2019; Moleiro et al., 2017). Moreover, there is a suggestion for more practical knowledge and enhancement of teaching with experiential techniques such as role plays, case studies, observations, as well as reflective clinical practice (Owiti et al., 2014). According to Boroughs et al. (2015), psychotherapy training curricula should introduce trainees to social issues and to the societal context of different groups, inclusive language use and appropriate assessment methods. Despite the growing interest in the field of training, though, there is much criticism on the main axe of psychotherapeutic training, namely the psychotherapeutic approaches themselves. 1.4. Culture across psychotherapeutic approaches According to Jones-Smith (2018) the traditional psychotherapeutic approaches are mostly Eurocentric, reflecting the theorist’s cultural values and influences, who are usually white males. This creates approaches that generally fail to capture global phenomena while proposing processes that cannot be generalized in different cultures. The current analysis focuses on the most popular approaches, namely Psychoanalysis, Cognitive Behavioral Therapy, and Person-Centered approach. Psychoanalysis is one of the most influential approaches in psychotherapy, while, at the same time, at least in its original form, was considered as addressed only to privileged people. Psychoanalysis has been criticized for being Eurocentric, normative, sexist, colonialist, conservative and reductionist (Frosh, 2018; Prochaska & Norcross, 2014). More specifically, according to Prochaska and Norcross (2014), psychoanalysis ignores the social context in which the individual issues are presented but rather adopts an exclusive focus on the individual’s intrapsychic dynamics and processes, adopting a Eurocentric and patriarchal view towards conceptualizing symptoms, disorders and processes of change. However, despite this being the case for the grassroots of psychoanalysis, contemporary theorists and practitioners are gradually adopting a more culturally sensitive approach, aiming to integrate psychoanalysis, culture and society (Frosh, 2018; Henderson, 2012). One of the most widespread approaches whose popularity is continuously rising is that of Cognitive Behavioral Therapy (CBT), which, however, has been widely criticized for being highly Eurocentric and for ignoring the cultural differences of the clients. At the same time, despite being considered an evidence-based approach, there are concerns that the supporting evidence is drawn from studies on nondiverse populations (Hays, 2014). Thus, it has been claimed that the concepts and processes of change in CBT are themselves non-applicable to culturally diverse clients. For example, the concept of change and the individual’s responsibility for their change usually proposed assumes that each person does or should value individuality over community, something that, according to Jones-Smith (2018) might be perceived as irrelevant, absurd or even offensive by some culturally diverse clients. Also, other CBT tools, such as cognitive restructuring by challenging someone’s thoughts and beliefs

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 452 Volume 12; Issue: 9; September 2025 or the focus on the here and now contribute to ignoring the client’s cultural background, influences, values and beliefs. However, according to Hays (2014) the above are not limitations but rather constitute a chance for further consideration on the future development of the approach. Thus, new tactics have been proposed in the context of CBT to overcome those limitations such as a stronger investment in the therapeutic relationship, culturally adapted CBT, or culturally sensitive CBT (Beck, 2016; Hays, 2014). Lastly, Person-Centered Approach (PCA) is, by its turn, considered highly individualistic and deterministic, failing to capture and integrate different cultural views and experiences (Laungani, 1999). More specifically, the importance of the “self” and self-actualization appears to be a Western, individualistic approach to the human experience, as other cultures might not place importance on the “self”, while, at the same time seems to ignore the restricting reality of many diverse clients (Kirmayer, 2007; Prochaska and Norcross, 2014). At the same time, concepts such as that of locus of evaluation or autonomy might seem irrelevant to other cultures where individuals can function well with an external locus of evaluation, less autonomy and more connectedness (Bohart, 2013; Prochaska & Norcross, 2014). Moreover, it has been claimed that altering selfperception constitutes another culturally specific process that draws upon privileged worldviews as, for many people from oppressed groups, altering their selfperception would be insufficient and somehow impossible as the cultural, social and institutional oppressions that prevent them from self-actualization would remain (Lerman, 1992). As traditional approaches seem to bear the values, beliefs and processes of their theorists that are mostly white upper-class males, the integrative movement, synthesizing those elements, seems, by its turn to have failed to capture cultural differences. Thus, it has been criticized as not being culturally and gender-sensitive enough to provide the theory and tools which would ensure that psychotherapeutic practice can be beneficial and harmless for diverse clients (Harris et al., 2019). However, acknowledging this need and the experienced inadequacy of many contemporary psychotherapists, new approaches, such as that of multicultural orientation or feminist therapy have been developed aiming to the reforming of traditional psychotherapeutic practice (Prochaska & Norcross, 2014). 2. Relevant research- Psychotherapist’s experience of culture in therapy There is a growing body of research on psychotherapists’ cultural competence, humility, skills and culturally sensitive interventions that they may implement. However, the aim of the current analysis is to draw attention to their views and experience of culture in the therapeutic process, especially when working with diverse clients, a field that is not yet broadly and in-depth analyzed. A study conducted by Atkins et al. (2017), using grounded theory with the participation of white professionals identified the way they perceive and define the process of multicultural awareness development. In this process, the participants identified causal influences, namely their professional and personal experience as well as their training. More specifically, their personal experience consists of their experience of being diverse in terms of any of their intersectional identities and family influence. In terms of professional experience, they mentioned the influence of working with clients on their multicultural awareness development, namely the way they address fear, acknowledge their skills and weaknesses, and confront their negative or biased assumptions. At the same time, they acknowledge the utility of peer support in terms of sharing experiences and working in environments that encourage reflection. Finally, participants acknowledge the importance of training and supervision,

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 453 Volume 12; Issue: 9; September 2025 however, most of them undermine the importance of academic knowledge as, for most of them it was inconclusive and scattered. Another research concerning the role of culture in therapy is that of Barreto (2013) with the participation of 8 immigrant therapists in the USA. The participants witnessed a traumatic culture shock by having to adapt their life and practice to new cultural norms and a loss of identity as immigration resulted in a serious loss of their professional status, privileges, respect and support they had when they worked in their homeland. Moreover, the need to regain their professional status and respect made them use different adaptive strategies such as trying not to draw attention to their work, aiming to fit in with the host country’s professional standards, doing further studies and certifications or claiming recognition of their certifications and experience. Another important process they mention is that of developing a new professional identity, a process that is influenced by interaction with clients and colleagues. In this context, they mentioned experiences of being cut down to their identity as an immigrant and aiming to form a new integrative identity that could fit both their home and their host culture. Expanding the results of this study becomes evident how culture and cultural identity can influence both therapists and their clients. Another research on culture in therapy was conducted by Owen-Pugh and Baines (2013) with the participation of novice professionals who were called to discuss their clinical experience with LGBTQIA+. The themes that emerged were that of engaging with learning, with participants witnessing that they draw from past personal or professional experience or learned from the clients themselves to effectively work with those clients. At the same time, most of them mentioned that they feel challenged, with inadequate training and skills. Another issue is finding efficient strategies, with participants mentioning their lack of available appropriate strategies as a big obstacle in their effort to support their clients. However, all of them mention that they make use of their supervision with half of them finding valuable support, while others hesitate to bring issues related to gender and sexuality as they didn’t know their supervisors’ attitude and competence to work with those issues. Moreover, participants engage in self-reflection to put flawed assumptions aside while LGBTQIA+ professionals also find it difficult to work with their internalized homophobia. Finally, almost all participants express concerns about the focus that should have been made on sexuality and witness being hesitant or having ambivalent ideas about whether it is an issue that should have been brought up. The third issue that emerged is that of the challenge faced in entering the clients’ world with participants witnessing difficulties and awkwardness in facing the oppression experienced by their clients in contrast to their privilege, while LGBTQIA+ professionals mentioned that they feel pressure to perform better or that they are ambivalent on issues of selfdisclosure. The researchers, acknowledging that the above issues are related to internalized heteronormative ideas and to the lack of relevant training, identify the core category of “Confronting homophobia and heterosexism”, indicating how unprepared novice counselors may feel when working with diverse clients without the available knowledge and tools for multicultural practice. Despite the very limited relevant evidence on psychotherapists’ experience of culture in therapy, many scholars have argued the importance of self-awareness and reflection on this topic. Thus, it has been stated that therapists should reflect on their attitudes, ideas and beliefs about marginalized social groups and, at the same time, observe and reflect on their own experiences, fears, challenges, self-efficacy and skills (Bramesfeld et al., 2019; Daniel et al.,

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 454 Volume 12; Issue: 9; September 2025 Hence, the aim of the study is to fill the gaps as derived from literature review. Also, taking into consideration the lack of relevant research on the experiences of trainee psychotherapists regarding the role of culture in therapy in Greece, this study may constitute the basis for further research. Therefore, the aim of the study is to explore the therapists’ experience of culture and its influence on them as well as their clients’ responsiveness. MATERIALS & METHODS Study Design The current analysis adopts a qualitative research design since it is the most suitable method to investigate in-depth the experience of the participants. The data were collected using semi-structured interviews, as the aim was to elicit detailed and rich information about the participants’ experience (Smith & Osborn 2008). This data collection method was chosen as it allowed a real-time dialogue with the participants, leading to richer data, while leaving space for their free expression and for unexpected issues and ideas to elaborate (Bernard & Ryan, 2010; Willig, 2013). For the purpose of the research, a semistructured interview protocol was constructed for meaningful questions to be created beforehand and to facilitate the discussion (Pawar, 2004). The interview protocol contained 10 open-ended questions divided into four axes, namely definitions of culture and diversity, the role of the clients’ culture and the role of the therapist’s culture based on their experience. Analytic Approach Given the study's aim, Interpretative Phenomenological Analysis (IPA) was employed due to its appropriateness in terms of ontological assumptions and epistemology. This method of analysis was chosen as it could allow the in-depth exploration of a complex issue as the participants’ perceptions, meanings and emotions (Shaw, 2011; Smith et al., 2022) and the way these factors and processes are related to the participants’ cultural background and identity. IPA draws upon critical realism and hermeneutics philosophy, based upon interpretative phenomenology, while it is also influenced by symbolic interactionism. More specifically, adopting a phenomenological approach, it aims to make sense of the subjects’ everyday lived experiences by exploring the way they talk about them (Neubauer et al., 2019; Smith et al., 2022). In the present study, drawing from interpretative phenomenology, the aim was to understand the topic as lived and presented by the participants with a specific focus on the way they discuss it, meaning that the aim was not to answer if and how culture influences therapy, but its role as perceived and interpreted by the participants. Moreover, IPA draws upon hermeneutic philosophy, operating within a double hermeneutic (Smith et al.., 2022). Thus, importance was attributed to the way subjects used language as a means of expressing their inner world as deriving from hermeneutics philosophy (Freeman, 2008). At the same time, researchers aimed to interpret the participants’ meaning making of their experience, trying to be aware and reflect on their preunderstandings and own experience while drawing meaning from how participants talked about their inner world and experience of culture in psychotherapy. Lastly, symbolic interactionism in IPA is manifested as a focus and interest in how participants construct the meaning of their experiences (Shinebourne, 2011; Smith et al., 2022). In the current study, within the context of symbolic interactionism, an ideographic approach was adopted to investigate the experience and meaning attributed to the role of culture by each participant in a small group, in-depth and extensively, within the given context aiming to give voice to each participant’s unique experiences. Analysis was conducted following the guidelines and suggestions of Smith,

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 455 Volume 12; Issue: 9; September 2025 Flowers and Larkin (2022). Audio-recorded interviews were transcribed verbatim and anonymised. Analysis commenced with repeated readings of each transcript to achieve familiarity with the data. Initial exploratory notes were made in the margins, attending to descriptive, linguistic, and conceptual aspects of participants’ accounts and consisted of the foundation for the extraction of experiential statements. These statements were then used to generate Personal Experiential Themes (PETs) within each case, which were then clustered to identify connections and overarching patterns for each participant. Consistent with IPA’s idiographic commitment, each case was analysed individually before moving to the next. Once all cases were analysed, patterns across cases were examined to develop superordinate, Group Experiential themes (GETs) that captured shared and divergent aspects of participants’ experiences. All analytic process was conducted without the use of any software, To enhance reflexivity and rigour, the lead researcher maintained a reflexive journal throughout the research process, documenting personal responses and analytic decisions and sharing it with the research team. Additionally, regular peer discussions with members of the research team were conducted to review emergent themes and ensure analytic transparency. An audit trail of decisions made during analysis was maintained to support the credibility and dependability of the findings. Given the lead researcher’s interest and relevant experience in cultural issues, reflexivity constituted an essential part of the research to ensure its quality. Thus, there was an effort to detect her pre-understandings that could intrude into the process and her cultural and ideological values that might influence it (Finlay, 2008). The researcher was constantly involved in reflection in collaboration with the research team, before, during and after each step (Anderson, 2020). Participants The participants were recruited using purposive sampling by implementing the snow-ball method, as the aim was to detect participants that would meet specific inclusion criteria, thus a concrete sample (Langdridge, 2007). The inclusion criteria were Greek cis-gender and heterosexual males and females and trainees in Integrative Psychotherapy Programs with 1- 5 years of clinical experience with culturally diverse to them adult clients, in terms of sex, gender, sexuality, religion, cultural, ethnic or social background. The exclusion criteria included participants being members of socially oppressed cultural groups and having completed studies in interculturality. The sample was 7 people, including the pilot interview, as this sample size ensured the in-depth exploration of the data, which is a mandatory condition for implementing IPA (Pietkiewicz & Smith, 2012; Levitt, 2015). The sample consisted of 1 male and 6 females, ages 25 to 48, with 1-5 years of experience in integrative psychotherapy after being trained in the specific approach. PROCEDURE For the recruitment of the participants an announcement was sent to forums and groups of Integrative Psychotherapy on social media. Once participants were found, the researcher contacted them sharing the information sheet and giving clarifications if needed. After the sample collection, the interview date and time were determined. The interviews were conducted online as this method would allow the recruitment of participants from different areas of the country and based on evidence that support online research as a reliable method (Salmons, 2012). To ensure the quality of the collection process the participants were asked to connect from a private place, free from stimuli that might distract them (Gillham, 2001). The demographics, information and consent form were first sent and signed and then the interviews were conducted. The interviews were conducted online in Greek, the participants’ mother

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 456 Volume 12; Issue: 9; September 2025 tongue. The choice of language was made acknowledging the importance of verbal expression in the context of IPA studies. Thus, it was considered that Greek would facilitate participants’ expression, while another language and difficulty in expression would constitute a serious limitation of the research quality (Pietkiewicz & Smith, 2014). At the first stage of the data collection process a pilot interview was conducted aiming to ensure the usefulness and appropriateness of the interview protocol and make any improvements if needed in case where difficulty in comprehension, repetitiveness or deficits was noticed (Creswell, 2007). As no issues arose during the pilot interview, the protocol remained the same for all participants, while also being flexible during the process. The interviews lasted between 45 and 60 minutes, were audio-recorded and a debriefing form was sent to participants after the interview. Research ethics The research was conducted only upon the approval of the Research Ethics Committee of the University of Derby. The Ethical Guidelines for Research in the Counselling Professions of the British Association for Counselling and Psychotherapy (BACP, 2019) and the Code of Ethics of the British Psychological Society (2009) were followed throughout the research procedure. Moreover, all material related to the study were managed and stored following the guidelines of the Data Protection Act 2018 (Legislation.gov.uk., 2018) and, also, their management complied to Data Protection Law Enforcement Directive (GDPR, 2018) as obligatory given the fact that the research was conducted in Greece which is a member of the European Union. Information and consent form were provided to and signed by the participants prior to their interviews. Participants were clearly informed that their participation was voluntary, as well as for the research aims, process, possible risks and ethics. In the same context they were reassured of the confidentiality and anonymity of the research. At the end of the interviews, participants also signed the debrief form through which they were informed about their right to withdraw at any time, up to two weeks after the conduction of their interview by communicating with the researcher and with no obligation to state the reason and consequences. ANALYSIS Data analysis resulted in three Group Experiential Themes, namely the therapist’s being in therapy, views and experience of the interaction with diverse clients and managing diversity. The themes and subthemes that constitute them are analytically presented below with the support of relevant extracts. 1. The therapist’s being in therapy: to be, not to be, how to be This theme highlights the participants’ need to exclude their personal and cultural parts and identities from the therapeutic process, while also detecting ways in which they intrude into therapy. Moreover, this theme contains the emotional experience of dealing with cultural diversity in therapy as an integral part of the participants’ experience of themselves in this context. 1.1. Excluding own identity as a necessity for ethical practice Most participants suggest that therapists should not share the views and opinions that derive from their own cultural or individual identities thus coordinating their practice to ethical standards. “It made me angry. About how much harm you can do to someone without knowing it. […] And I was angry because I think that as a therapist you have to be neutral in these delicate matters. I'm a Christian too and my grandfather was a priest, and I grew up in the church but oh no you don't do that” (Barbara, 123-131) Barbara used her personal experience as a client to support that therapists must not let

 Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 457 Volume 12; Issue: 9; September 2025 their opinions intrude therapy and form judgments towards clients, describing an incident where her therapist shared her religious beliefs to judge a professional choice of hers causing her anger. Despite not being hurt, she expressed her concern about how harmful this can be to clients. This realization and the consequent anger made her stricter on this opinion for herself and others, shaping a rule that “you don’t do that”, meaning sharing your personal beliefs. This rule appeared to be an integral part of Olivia’s practice, too, who, while being an integrative therapy trainee, implements Lacanian psychoanalysis. “And I think that every therapist should be fully aware in their therapy of uh…how their subjectivity is involved in the therapy. In psychoanalysis we do not work with our subjectivity, it is completely the opposite direction. Our subjectivity is excluded. When it is present and accidentally involved, we immediately take it to therapy and supervision. For example, it has happened to me that I got stressed about an incident and I shouldn't be stressed because the subject is stressed!” (Olivia, 266-273) In most of her interview, Olivia noted the importance of the therapist not coming as a subject into therapy. Thus, for her, there is no space for the therapist’s subjectivity, putting this principle in the center of her practice and totally identifying with the principles of her approach. In fact, she was surprised and shaken by the fact that she experienced emotional reactions during therapy as this indicated that some of her parts were present, something unacceptable to her. For this reason, Olivia used and pointed out the importance of personal therapy and supervision so that therapists may entirely exclude themselves from the process. “Also, I don't say anything about religion, so they don't know what I believe. And I try not to let it affect others. I have this in mind for a while. Because okay, I'm an Orthodox Christian, and I believe, I can often be influenced by this. And something that the other person tells me, I might think about it from a moral point of view, but I hold back, because now I know it, I hold back, I work it inside me and I hold back and say “no look at it in terms of what will be helpful for your client and not what you think” (Chloe, 325- 331) In a more moderate manner, concerning her religious beliefs, Chloe, acknowledging the importance of excluding her cultural identity, described a continuous selfreflective process towards this aim. Chloe, being religious herself, expressed an inner battle between her belief in the supportive power of religion and her religious morals, and her professional role and a constant effort to “hold back”. To deal with this, she has found a rule according to which she puts the client’s benefit first and puts aside her personal beliefs that derive from her cultural identity. 1.2. The Inescapable Presence of Therapist Identity in the Therapeutic Space Despite most participants’ acknowledgment of the importance of excluding their personal beliefs and cultural identities, all participants detected ways in which their identities intrude therapy. “(during the interview) I realized things about me too. It was like a mini-supervision because I thought about things about myself and how I am as a therapist, and I think it's a very important thing to explore because we might say that therapists are neutral or objective; objectivity does not exist for me. There is only subjectivity or intersubjectivity or whatever exists in the interaction of 2-3 or more people. And there is no way we are not affected by our personal issues. It's utopic” (Chloe, 527-532) In this extract Chloe challenges the beforementioned idea of the total exclusion of the therapist’s identities. Thus, she acknowledges that therapists come to the therapeutic process with their own preconceptions, identities and even prejudices. She strongly supports that it is not realistic to expect therapists not to enter

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 458 Volume 12; Issue: 9; September 2025 as subjects, despite the idea of an “objective therapist” which can only be considered as “utopic”. “This is an interesting question. I had never thought about it to be honest because we consider our cultural values as given and self-evident...ok I think that...the fact that ok we are not the most progressive country in the world, but more progressive than eastern countries, Third World countries…Which helps somehow…to be a little more open-minded and approach things scientifically” (Steven, 161-165) In the case of Steven, there was a lack of reflection on his identity throughout his interview while in the above extract, he admitted that the ways in which his cultural identities intrude therapy is something that has not concerned him up until now. During the interview, though, his reflection resulted in realizing that his national identity has a positive effect on therapy, especially in contrast to less progressive, according to him, nations, as it leads him to have a more scientific approach to therapy. “In those cases where I feel that these people need acceptance and I, as Paula, am more aware of- some issues that I, as Paula and a woman, have some views on, in terms of feminism, I would perhaps be more aware if I saw a woman who possibly is in an abusive relationship. Maybe I would be a little bit more like (laughs) I would want her to intervene, so to speak. Should I have been more motivated perhaps?” (Paula, 168-173) Paula admits that her gender identity is important to her work and describes how this might intrude therapy. Bearing ideas and beliefs that are related to her identity and her experience as a woman she claims that, in cases of gender violence, this would shape her expectations for the therapeutic outcome. Paula experiences the matching of her gender identity to that of the client as creating a motivational dynamic that would lead her to undertake an active role in the process, something that is presented as acceptable and even a booster of her work. 1.3. Emerging emotions: from fear to motivation Apart from expressing their experiences of their identities in therapy, the participants also shared their experience working with diverse to them clients regarding their emotional reactions and their sense of cultural competence. Most participants underline their initial fear, insecurity and even self-doubt when they first worked with diverse to them clients. “Because I really had a fear of the unknown but I am also a person who believes that at the core there is good, I am personcentered. Eh, I didn't get into it (fear), however, I was quite preconceived, scared, aloof. Until I started to learn, to learn their language, that is, I did a lot, I approached a lot. I may had been scared but I didn't show it” (Barbara, 23-26) Barbara uses emotional language to describe her first experience with nationally and religiously diverse to her clients stating that she was quite “preconceived, scared, aloof” indicating the great insecurity that surrounded the experience of working with the “unknown”, meaning people with cultural identities that she was not familiar with. At the same time, she claims that she made a great effort to not let her fear show and to learn more about their culture, indicating that her initial fear and insecurity derived from a sense of lack of knowledge and incompetence. “uh the first thing I would feel, I would say…hmmm…An alert that “oh now she tells me something serious (laughs) since she trusted me I have to respond to that trust” (Steven, 147-149) Steven, when facing confessions of sexual trauma by women, something which he is not familiar with, expressed a strong activation to look worthy of their trust. While also laughing when confessing this, Steven, directly and indirectly, expressed his awkwardness and his need to look competent towards such sharing. “But I was thinking if someone comes to the office who is a Muslim. And he has a completely different mindset from me, that I

 Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 459 Volume 12; Issue: 9; September 2025 morally disagree with. What am I doing there? How will I handle it? I think I would find it soooo hard” (Chloe, 175-175) Despite having worked with people with different religions than hers, Chloe expresses her worry and insecurity about how to deal with issues that derive from client’s culture and from her personal morals which are opposed to the client’s culture. In fact, using direct questions Chloe vividly expresses this intense worry of not knowing how to handle such situations. “And in fact, this was told by a client that has been going on for 3 years now. And it was this year that he told me that “at some point I thought of going to talk to a priest, like a type of confession and get relief”. So, there I wondered. How (going to a priest) can be liberating, comforting, and what we do together (in therapy) is not?” (Eve, 201- 205) In this extract, Eve referred to a present client of hers that told her that he would visit an orthodox priest to ask for spiritual guidance to be relieved. Eve, being baptized but not identifying as a religious person, felt threatened by her client’s intention. Thus, posing a question using direct speech, and making a direct opposition of therapy versus religion, she indicated that the client’s searching for relief elsewhere left her uncomfortable and insecure, wondering about the effectiveness of the therapy, in contrast to religion, as not being able to offer him the relief he was searching for after 3 years. 2. The experience of interactional dynamics: how are you in therapy, how are we in therapy In accordance with sharing their views and experiences of their own identity and self as being in therapy, participants talk about their experience of interacting with diverse to them clients. In this context, they mention the ways in which they believe that the client’s cultural identity affects therapy, while they talk about the role of diversity in contrast with cultural similarity in it. Moreover, they underline the importance as well as the obstacles in shaping a therapeutic relationship with culturally diverse clients. 2.1.Holding the Cultural Other: Therapists’ Lived Experiences of Navigating Clients’ Cultural Identities This sub theme focuses on the participants’ views upon the way in which clients’ culture affects therapy, from the very beginning. A commonplace between participants is the idea that individual factors, interacting with cultural ones, play a significant role in the therapeutic process. “You know it's what we were saying before that I can't block my own prejudices. I think that this person also has his suitcase, he has inside some things that he has experienced, he is what he is. How to leave out what he has when he comes to the office” (Eve, 475- 479) Throughout her interview, Eve uses the metaphor of the “suitcase” to describe the total of a person’s individual and cultural characteristics that form their unique identity. As if in a “suitcase”, both the therapist and the client bear their identities, preconceptions, views, beliefs, even prejudices, which interact and influence the therapeutic process. According to her, she, as well as any client, bears preconceptions about other’s affiliation groups which shape the way they come to therapy. “If we take for example what we said before…that I had a trans person…for me…it was just that maybe I didn't know some other parts according to the norm. I mean, if I didn't get into it, if I just went ahead and said OK. Trans. Err…Like me…so is this (person)-she. So, I would have behaviors…and…I think something traumatic might come out of it all” (Barbara, 67-71) Barbara brings up an important experience to her, which is the first time she worked with a trans woman. Making use of this experience, she realizes and embraces the idea that it is crucial to have knowledge of the client’s identities, including their cultural ones, and not to approach them

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 460 Volume 12; Issue: 9; September 2025 under a fake vein of similarity. To her, ignoring the client’s culture might lead a therapist to inappropriate, even traumatic behaviors and choices. “I think it would be quite difficult for me to work with people from Muslim countries I would say. This would be quite difficult for me because I find it very...at least that's how I see it. Way behind the sun to put it simply. Because I think that in our times...how can I say it? It's like they're still living in the Middle Ages” (Steven, 100-102) Steven bases his difficulty in working with Muslim clients on the idea that they are less civilized than him and consequently diminishing his affiliation groups. Characteristically, despite looking hesitant as to how to express this idea, he uses strong negative metaphors like “way behind the sun” and “Middle Ages” to emphasize the difference between his and their cultures, indicating his feeling of belonging in a superordinate culture. Evidently Steve’s own culture and personal values may interrupt the therapeutic process since the client is considered as non-equal. “Sometimes it (religion) can also play the role I said before. To create dysfunctional views, dysfunctional attitudes, dysfunctional life attitudes that make life difficult for them…it can also be the opposite because I mentioned faith…it can create a hope and optimism for them and be liberating” (Paula, 112-115) Paula expresses her idea of how clients’ religious culture can negatively influence the client and be an integral aspect of their issues. By repeating the word “dysfunctional” she emphasizes how religious beliefs can restrict clients and be related to beliefs that may undermine the therapeutic process or even be the cause of the clients’ problems. In this extract, she tries to moderate this idea, by adding that religion can also have a positive effect, cultivating hope that some therapists may focus on both sides of one cultural aspect. 2.2. Walking the Line Between Familiar and Foreign: Navigating cultural Similarities and Differences All participants acknowledge therapy as a dynamic process in which cultural similarity or differentiation between the therapist and the client influences the process. “Not necessarily beneficial. It is simply the most CONVENIENT to have a therapist whom you feel very close to you in terms of characteristics and background. Beneficial…I don't know if it would help. In the long run, maybe it would be more beneficial to go to someone who wouldn't fit this profile, because it would trigger things that you haven't worked on and maybe you're trying to avoid” (Steven, 300-306) Steven claims that similarity might be convenient, however, he believes that this convenience might work against an in-depth therapeutic process. He gives weight to the long-term consequences of this dynamic, claiming that difference might not accelerate the therapeutic process, but through the dynamics created between different identities, the client might face triggers stemming from the therapist’s characteristics that may contribute to a deeper therapeutic process, despite being more difficult. Thus, between convenience and a deeper and meaningful process, Steven seems to suggest the latter. “For example, I have a patient at my age, with similar studies and uhhhh…the recommendation of the supervisor which was that because there is this similarity between us, similar age, studies, etc., similar goals in her life, this was the complaint which brought “when I will achieve this, that” in relation to studies. (I had) To take care not to enter into an imaginary axis of confrontation, rivalry, just because we were of a similar age” (Olivia, 198-203) In this case, Olivia talked about working with a client with very similar characteristics and background. According to her, and to her supervisor, this may create a problematic dynamic where the client projects her deficits and complaints from

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 461 Volume 12; Issue: 9; September 2025 her life to the therapist. Here, Olivia also detects the danger of herself entering a process of indirect confrontation with her client that would lead to negative consequences and, of course, would put the entire process at stake. “That is, even if all these elements are the same as mine, I will still have to adapt, I will have something different in front of me, I will not have myself anyway. So, it made me realize that it's part of the uh reality of therapy anyway. And now I might not…not be sooo…uh not make it such a big deal in my head” (Chloe, 205-209) Chloe, after her journey of trying to deal with diverse clients, concludes that cultural differentiation is “the reality of therapy”. In this way, she indicates that there might be some salient similar cultural characteristics, but there are so many contributing factors to a client and their issues that similarity is probably fictitious, while differentiation is the rule. This also helps her debunk the issue of working with different to her clients and be more confident with that. “Your characteristics, are also connected with uh…experiences that one has…Uh…and if this person comes to me…I'm in the majority I think...uh yeah it would be interesting to see how much trust they can show in this relationship in this work” (Eve, 468-473) Concerning cultural differentiation, Eve raises the concern that it can cause mistrust as the therapist might represent privileged identities. Thus, client’s traumatic experiences of oppression might be projected to the therapist that, in her case, is a member of privileged social groups in her social context, and lead to hesitance. 2.3. Walking a Fine Line: Building Authentic Relationships Across Cultural Difference Referring to the interaction of different people in therapy, participants highlighted the importance of the therapeutic relationship and the appropriate conditions to work with diverse to them clients, while they also talk about issues of power imbalance between them. In this context, most of the participants express their belief that unconditional acceptance constitutes the necessary condition for therapy with diverse clients. “I repeat it is very important for me to be fair right? And to eeee…to the best of my abilities to work with someone...eh and to…and finally any prejudices from any of my identities have been filtered. It would be very disappointing for me not to achieve this or not to have achieved this” (Eve, 404- 408) Eve shares her intense effort to put aside any prejudice she might have that works against unconditional acceptance. It seems that it is the very core of her work, and she confesses that any deviation would cause her great “disappointment”, indicating that this is a necessary condition for her therapeutic work. Though it is not easy to filter her own prejudices, at least following this tendency would narrow down the cultural gap between clients and therapists. “The fact that I would ask about a subject, investigate it, want to learn more, also made the clients feel more accepted and that I agree and go along with them. In matters that may make them different, I am with them” (Alice, 381-384) In this extract, Alice highlights the importance of being authentic and accepting her limitations and lack of knowledge. She shares a strong willingness to learn through her own study but also by directly asking her clients. This openness about possible unawareness does not put the relationship at stake, rather it indicates the therapist’s will to enter the client’s world and thus empowers the relationship by creating an alliance where the therapist might learn from her client and manifests her acceptance and authenticity. “And we enter (in the position of power) willingly or not, trying to save someone. To help. Because they put us in this position and we-me personally, not to speak in general, I can say that I sometimes fall into the trap of the helper, not the helper simply, the savior? The one who will know better, Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 462 Volume 12; Issue: 9; September 2025 not to act like a know-it-all, but who will have something more to say because I feel they are asking for it” (Chloe, 458-463) For Chloe this process creates great discomfort as it activates an instinct “to save” someone, to fulfill their expectations. As seen in the extract Chloe started talking using the third person up to the point where she felt the need to express her personal experience, switching to first singular (“me personally”). This indicates the intensity of this experience and her need to share this discomfort, characterizing it as a “trap” that she “falls into”, metaphorically expressing how she experiences this internal need to save as an important misstep that she must avoid. 3. Navigating through cultural diversity: entering a “different world” The last theme that emerged consists of participants’ experiences of managing and dealing with diversity in therapy. More specifically, all participants described the challenges and difficulties they faced during their work, the resources they have used and their limitations and suggestions for managing challenges. 3.1. Navigating the Unknown: Cultural and Personal Challenges in Therapeutic Encounters In the context of the challenges, they face when working with diverse to them clients, most of the participants detected specific groups they have difficulties working with. “I don't know if it has to do with the culture as much as theeee…the nature of addiction, which is that they keep being manipulative, making excuses, lying...and that delays the process, it holds it steady for too long or you feel like you are expecting that there is progress that is false. There is much stronger back and forth I believe which would tire me” (Paula, 89-94) Paula manifests a strong discomfort when thinking of the work with drug users as she attributes characteristics to them that would undermine and delay the therapeutic process. Paula seems to like a structure and specific timeframe in her work, and these characteristics of drug users are difficult for her to keep up with, as they disturb the structure that she is used to and may lead to her tiredness. “Outside therapy… (someone’s going to church every Sunday) gives me some information and I make some assumptions about what they might…about their openness or something huh? Inside the ee…I co-exist, ok? I don't exclude them(smiles)…ehh…but usually…Usually, the experience I have in life[…]my experience my-my experiences show that they also have a-it is connected with conservatism in things…so when I hear that…there I put a question mark” (Eve, 182-190) Eve expresses her difficulty in working with people who are religious Christians. In this extract, with long pauses and corrections, she manifests her hesitation in sharing something that might look stereotypical and thus tries to moderate it by making a distinction between her private life and therapy. Thus, indirectly implies that in private life she might take a distance from religious people, something that she does not in therapy, but does not totally erase her suspicions, and thus “puts a question mark”, probably meaning that she is more aware to detect points of conservatism. “The part where I was completely (laughs) inexperienced, with a trans…person...which ok, I knew what it means, but along the way it was strongly created that ok what is come out what is one, the other…I didn't show it in therapy. But directly I started reading, I found supervisor EXCLUSIVELY in this topic. I might have done every, after every session I did supervision. I was working on it, I was devoted to the client” (Barbara, 47- 51) As being inexperienced with gender nonconforming clients, Barbara describes the great effort she did to work ethically and competently with a trans client. She uses all available resources and gets into intensive supervision to cover possible ignorance on related issues, despite having already a Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 463 Volume 12; Issue: 9; September 2025 general knowledge. For her, it seems very important to go beyond superficial knowledge and to ensure ethical practice. “I started thinking that ok, let's say therapy goes well and she (a refugee Muslim woman) gets to the point of doing what she wants, ending her marriage. This could mean she would die!” (Alice, 133-135) Alice shares her experience of working with a refugee Muslim woman who wanted to break up with her husband. Alice shapes the idea that a successful therapy would result in the client’s empowerment to leave her marriage. However, she worries because what would sound like a positive change according to traditional therapy, would pose great danger for the life of the client for reasons of honor in Eastern cultures, indicating in a powerful way the challenges faced when applying Western approaches in non-Western cultures. 3.2. Bridging Cultures: Approaches and Resource Use To manage diversity and deal with the above-mentioned challenges, participants refer to how they approach multicultural therapy, the resources they use as well as the limitations of the available resources. In this context, a commonplace amongst most of the participants is that working with diverse to them clients is an opportunity for learning. “I think it's very important eeee to-toto…understand this to enter their world to understand the other's world, right?” (Eve, 50-52) Eve mentions “the client’s world” indicating the great differences between her and some culturally diverse clients. She sees the therapist as an explorer of a different world, indicating that she approaches her clients with curiosity, interest and openness and able to show understanding in whatever emerges during the therapeutic process which is “very important” to her. “So, if I have understood some things about women in therapy, it might help me to…To handle some situations better in my interpersonal relationships as well” (Steven, 88-90) Steven experiences such work as an interesting challenge that can be helpful for his life outside therapy, too. Specifically, the regular contact and deep understanding required in therapy have offered him useful insights about women, something that may contribute to relating better to them in personal life, too, indicating that professional and personal life are mutually supported and associated. “(in traditional modalities) the therapist is a key tool of therapy. But not free from his subjectivity, those cultural things he carries, his identity…and therefore if…Eh, if at a declaration level, one approach says that I, for example, Person Centered Approach (PCA), you accept unconditionally and so on, I think that to the extent that someone enters as a subject, there may be obstacles” (Olivia, 259-262) For Olivia, the active involvement of the therapist is perceived as a disadvantage, since it leaves space for the therapist’s preconceptions and cultural beliefs to intrude and undermine the true unconditional acceptance of the client. Also, despite PCA supporting the importance of acceptance, Olivia claims that this stays at a “declaration level” as this cannot be safely and totally achieved as long as the therapist enters therapy as a subject. “And attachment theory […] since we're talking about diversity...Not all people are related in the same way…In every culture with each other, I mean. They don't develop relationships in the same way. Some things that are ok for the Western world are not for the East” (Alice, 249-252) Talking about the limitations of different modalities, Alice detects the inapplicability of attachment theory to non-Western cultures. Specifically, modalities that form theories about relationships seem limited and unable to meet the variability of relationship formation and function across cultures. Once again Alice highlights the limitations of theories and approaches and

 Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 464 Volume 12; Issue: 9; September 2025 the obvious difficulties when applying Western theories to non-Western cultures. DISCUSSION The analysis of the data shed light on important aspects of the trainee therapists’ experience related to cultural issues in therapy, which come as a culmination of part of previous research while challenging other related claims. Thus, in the narratives that formed the three emergent themes, there are parts that can contribute to existing literature. In the first theme, that of experiencing themselves in therapy, participants highlight the importance of excluding views and judgments that derive from their cultural identity, noted parts where it is inevitable and accepted for their culture to intrude, while they also express their negative or positive reactions while working with diverse to them clients. In the same context, some participants reflect on their preconceptions and the role of their culture in therapy and their difficulties with unconditional acceptance, manifesting cultural awareness (Chu et al., 2016), something that is expected by all therapists in multicultural movement (Ratts & Pedersen, 2015). Moreover, only a few participants point out the importance of acknowledging also the privileges that derive from their culture, as proposed by Bostwick et al. (2014). Lastly, as also found in previous research (Martin, 2017), working with diversity causes uncertainty to most participants due to their lack of familiarity with specific groups, indicating the importance of familiarization and relevant experience and training. In the second theme, participants share their experience of interacting with diverse clients, expressing their views on the influence of their culture, the different implications of cultural similarity or diversity between them, and the importance and obstacles of therapeutic relationships. Participants detect what has been supported by previous research, namely the pervasive influence of the clients’ identities, from their initial request to issues of openness, trust and relationship formation with diverse therapists (Huang & Zane, 2016; Weather head & Daiches, 2010). Moreover, some of them highlight the importance of seeing clients as a whole, acknowledging the experiences that might be related to the social positions that derive from their cultural identities, manifesting a level of cultural knowledge (Sue & Torino, 2005) and rejecting cultural blindness, that is in line with the idea of cultural humility (Bramesfeld et al., 2019). At the same time, most participants seem to be concerned about balancing the importance they attribute to the client’s culture for their presenting issues, as also found in the research of Owen-Pugh and Baines (2013), a concern that can work against adopting harmful practices such as blindness or pathologizing (Semp & Read, 2015). Lastly, they acknowledge the existence of different identities that interact and contribute to the formation of each person’s unique identity, something that constitutes psychotherapy as a multicultural environment by nature, where two different people, bearing their identities interact with each other, an idea also proposed by Dhamoon (2011) in the context of embodying intersectionality in the model of cultural humility. On the same grounds, they challenge the idea of similarity as fictitious, indirectly rejecting the method of matching characteristics as a way of working with diversity in therapy (see Harrison, 1975). On the contrary, some of the participants seem to work eclectically, adapting to the client’s needs, manifesting a spontaneous tendency to implement the efficient method of cultural adaptation (Soto et al., 2018). In terms of the therapeutic relationship participants’ discomfort with the position of power attributed to them by clients and their aim for a more egalitarian relationship with clients seem connected with relevant criticism of traditional psychotherapy for reproducing societal power imbalances (e.g. Gorski & Goodman, 2015; Ratts et al., 2016). However, while most of them seem

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 465 Volume 12; Issue: 9; September 2025 in line with this criticism, others normalized imbalance thinking of it as a necessary condition for therapy, or of the legitimization of social imbalances themselves. In the last theme, managing diversity, participants share their experiences regarding the challenges they face, the way they approach diversity in therapy, the resources they use, and their limitations. Some of the participants highlight their need for familiarization with different cultural identities and with their norms, with previous research showing that familiarization, gaining knowledge from direct experience and the reflection upon it indeed constitutes an integral part of therapists’ cultivation of awareness development (Atkins et al., 2017; OwenPugh & Baines, 2013). This knowledge could also be helpful in adapting their assessment and working methods to the needs and norms of different cultures and avoiding the monocultural therapeutic orientation (Gallardo et al., 2012). Moreover, most participants seem to approach multicultural therapy with kind curiosity, as an opportunity for learning, an overall stance that is very close to the concept of cultural humility, one of the most recent developments in multicultural therapy (Sue et al., 2019). Most participants also valued the need for authenticity in terms of acknowledging the limitations of their knowledge and involvement in continuous learning through studying or directly discussing with their clients, another important component of humility (Foronda et al., 2016). As for their training and approaches, all participants detected a lack of sufficient training to work with cultural diversity, a finding that seems to be repeated in relevant studies (e.g. Lyons et al., 2010; Moleiro et al., 2017; Owen-Pugh & Baines, 2013). Thus, they highlight the need for culturally informed knowledge in the context of their basic psychotherapy training, a suggestion also made by Schouler-Ocak et al. (2015). They also express their need for experiential and applicable training as also proposed in the guidelines of Owiti et al. (2014). At the same time, they attribute great importance to supervision, although dangers of nonculturally competent supervision are always at stake, agreeing with the suggestion of Benute et al. (2019) which also emphasizes the need for culturally sensitive supervision. The same concern is also detected in the study of Owen-Pugh and Baines (2013) which points out that a non-culturally competent supervision may cause trainees hesitation for sharing issues related to gender and sexuality in supervision. Concerning traditional psychotherapeutic approaches, most participants recognize a level of inapplicability as pointed out in relevant literature (Jones-Smith, 2018). Thus, one participant criticized attachment theory as non-applicable in other cultures due to the diversity in relationship forming, an idea detected in relevant literature that challenges the universality of theory (Keller, 2018). Participants also seem not to prefer CBT when working with diverse clients, with one exception, expressing concern about respecting cultural boundaries when applying methods such as challenging dysfunctional thoughts that might derive from their cultural background, a part that has been strongly criticized as culturally insensitive in the context of this approach (Jones-Smith, 2018). Some of the participants, though, seem to prefer PCA when working with diverse to them clients, focusing on the necessary conditions of change as proposed by Rogers (1957). Thus, they did not address other basic concepts that have been criticized as Eurocentric (Bohart, 2013; Kirmayer, 2007), indicating that their preference might refer mostly to the therapeutic relationship forming and not to the general applicability of PCA. Thus, their tendency to work eclectically with diversity seems to reflect the need for adapting the integrative movement in a new multicultural reality in therapy and modern societies in general (Harris et al., 2019). In conclusion, the current research, through the lived experience of the participants,

 Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 466 Volume 12; Issue: 9; September 2025 highlights the phenomenon of multicultural awareness in psychotherapy training and practice. At the same time, the importance of familiarization with other cultures, overcoming prejudices and unconditionally accepting clients is strongly supported, while emphasizing the crucial role of the therapeutic relationship in overcoming social gaps, challenging social power relations and creating a therapeutic context that promotes social justice and inclusion. Implications & Future directions The research findings open a new field of study in the Greek context, namely the culture in psychotherapy with some important implications. The participants’ experiences highlight important aspects and limitations of multicultural psychotherapy, such as insufficiency in training given that psychotherapy is characterized by diversity in terms of different intersectional identities, indicating the importance of experiential, inclusive and competent training and supervision in all programs, even if they do not focus on cultural issues. Moreover, participants stand critically towards traditional approaches highlighting their lack of inclusivity and limited application, especially in Eastern cultures. In addition, they mention the difficulty in adapting the concept of “positive change” in different requests influenced by the clients’ backgrounds, indicating the restrictive nature of “change” in Western psychotherapy. As this experience reflects the overall criticism of relevant literature and with the rise of the integrative movement, the need for updating traditional approaches and tools becomes evident. Lastly, some of the participants show lack of reflection or familiarization with specific cultural groups which indicates the need for raising awareness of trainee psychotherapists in different social groups and reflecting on their preconceptions in a meaningful way. Regarding recommendations for future studies, the current study highlights the importance of investigating cultural issues in mental health services with the aim of addressing its limitations in a multicultural context. Also, as implied by the findings, there is a differentiation in the experiences of participants according to their gender identity, religion and age. Thus, future research could focus on specific identities to investigate their experiences in-depth. At last, but not least, since participants highlight the importance of supervision, future research could address the issue of culturally competent supervision in Greece to investigate its competence, limitations, and the experiences of the supervisors themselves. Declaration by Authors Ethical Approval: The research project received ethical approval from the Ethics Committee of the University of Derby at Mediterranean College in Thessaloniki, Greece. The Committee adheres to the research ethics guidelines of the British Psychological Society (BPS) and the British Association for Counselling and Psychotherapy (BACP). All participant names used in this study are pseudonyms to ensure confidentiality and anonymity. Acknowledgement: The authors acknowledge the leadership role of Ms. Eleni Skoli in the conception, coordination, and execution of this research project. Source of Funding: None Conflict of Interest: The authors declare no conflict of interest. REFERENCES 1. Abbott, D. M., Pelc, N. and Mercier, C. (2019) “Cultural humility and the teaching of psychology”, Scholarship of Teaching and Learning in Psychology, 5(2), pp. 169– 181. https://doi.org/10.1037/stl0000144 2. American Psychological Association (2003) “Guidelines on multicultural education, training, research, practice, and organizational change for psychologists”, The American Psychologist, 58(5), pp. 377- 402. DOI: 10.1037/0003-066x.58.5.377 3. American Psychological Association (2018) “APA adopts new multicultural guidelines”, American Psychological Association, 49(1),

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 467 Volume 12; Issue: 9; September 2025 pp. 47. Available at: https://www.apa.org/monitor/2018/01/multi cultural-guidelines 4. Anders, C., Kivlighan, D. M. III, Porter, E., Lee, D. and Owen, J. (2021) “Attending to the intersectionality and saliency of clients’ identities: A further investigation of therapists’ multicultural orientation”, Journal of Counseling Psychology, 68(2), pp. 139–148. do:10.1037/cou0000447 5. Anderson, J. (2020) “Reflection”, ELT Journal, 74(4), pp. 480-483. 6. Anderson, K. N., Bautista, C. L. and Hope, D. A. (2019) “Therapeutic alliance, cultural competence and minority status in premature termination of psychotherapy”, American Journal of Orthopsychiatry, 89(1), pp. 104-114. Doi: 10.1037/ort0000342 7. Anderson, S. K., and Middleton, V. A. (2018) Explorations in diversity: Examining the complexities of privilege, discrimination, and oppression. New York, NY: Oxford University Press. 8. Applewhite, S. R., Biggs, M. J. G. and Herrera, A. P. (2009) “Health and mental health perspectives on elderly Latinos in the United States”, In F. A. Villarruel, G. Carlo, J. M. Grau, M. Azmitia, N. J. Cabrera and T. J. Chahin (Eds.), Handbook of U.S. Latino psychology: Developmental and community-based perspectives (pp. 235– 249). Sage Publications, Inc. 9. Arthur, N. (2019) Counselling in cultural contexts: Identities and social justice. Springer. 10. Atkins, S. L., Fitzpatrick, M. R., Poolokasingham, G., Lebeau, M., and Spanierman, L. B. (2017) “Make it personal: A qualitative investigation of White counselors’ multicultural awareness development”, The Counseling Psychologist, 45(5), pp. 669-696. 11. Ault-Brutus A. A. (2012) “Changes in racial-ethnic disparities in use and adequacy of mental health care in the United States, 1990-2003”, Psychiatric Services, 63, 531- 540. 12. BACP (2018) “Ethical Framework for the Counselling Professions”, BACP. Available at: www.bacp.co.uk/events-andresources/ethics-andstandards/ethicalframework-for-thecounselling-professions (accessed 30 October 202) 13. Barreto, Y. K. (2013) “The experience of becoming a therapist in a foreign culture”, Journal of Humanistic Psychology, 53(3), pp. 336-361. Doi: 10.1177/0022167812471076 14. Beck, A (2016) Transcultural Cognitive Behavioural Therapy for Anxiety and Depression: A Practical Guide. London, UK: Routledge 15. Benute, L. T., Singer, J., Newlands, R. T. and Casas, J. B. (2019) “Training culturally competent psychologists: Where are we and where do we need to go?”, Training and Education in Professional Psychology, 13(1), pp. 56-63. 16. Berke, D. S., Maples-Keller, J. L. and Richards, P. (2016) “LGBTQ perceptions of psychotherapy: A consensual qualitative analysis”, Professional Psychology: Research and Practice, 47(6), pp. 373–382. doi:10.1037/pro0000099 17. Bernard, H. R. and Ryan G. W. (2010) Analysing qualitative data. Systematic approaches. London: SAGE. 18. Bernal G. and Domenech Rodríguez M. M. (2012) Cultural adaptations: Tools for evidence-based practice with diverse populations. Washington, DC: American Psychological Association. 19. Bohart, A. C. (2013) “The actualizing person”, The handbook of person-centred psychotherapy and counselling, 2, pp. 84- 101. 20. Boroughs, M. S., Bedoya, C. A., O’Cleirigh, C. and Safren, S. A. (2015) “Toward Defining, Measuring, and Evaluating LGBT Cultural Competence for Psychologists”, Clinical Psychology: Science and Practice, 22(2), pp. 151–171. doi:10.1111/cpsp.12098 21. Bostwick, W. B., Boyd, C. J., Hughes, T. L., West, B. T. and McCabe, S. E. (2014) “Discrimination and mental health among lesbian, gay, and bisexual adults in the United States”, American Journal of Orthopsychiatry, 84(1), pp. 35-45. 22. Bramesfeld, K. D., Platt, L. F., and Bal, J. K. (2019) “Mental Health, Multicultural Competence, and Cultural Humility from an Intersectionality Framework”, In Zangeneh, M. and Al-Krenawi, A. (Eds.) Culture, Diversity and Mental Health-Enhancing Clinical Practice (pp. 3-20), Springer Nature. 23. Brown, L. S. (2009) “Cultural competence: A new way of thinking about integration inEleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 468 Volume 12; Issue: 9; September 2025 therapy”, Journal of Psychotherapy Integration, 19(4), pp. 340–353. doi:10.1037/a0017967 24. Cabral, R. R. and Smith, T. B. (2011) “Racial/ethnic matching of clients and therapists in mental health services: A metaanalytic review of preferences, perceptions, and outcomes”, Journal of Counseling Psychology, 58(4), pp. 537–554. doi:10.1037/a0025266 25. Chang, D. F., and Berk, A. (2009) “Making cross-racial therapy work: A phenomenological study of clients’ experiences of cross-racial therapy”, Journal of counseling psychology, 56(4), pp. 521- 536. Doi:10.1037/a0016905 26. Chu, J., Leino, A., Pflum, S. and Sue, S. (2016) “A model for the theoretical basis of cultural competency to guide psychotherapy”, Professional Psychology: Research and Practice, 47(1), pp. 18-29. Available at: https://psycnet.apa.org/buy/2016-05588-002 27. Chu, W., Wippold, G. and Becker, K. D. (2022) “A systematic review of cultural competence trainings for mental health providers”, Professional Psychology: Research and Practice, 53(4), pp. 362–371. Doi:10.1037/pro0000469 28. Cudd, A. E. (2006) Analyzing oppression. Oxford University Press. 29. Dadlani, M. B., Overtree, C. and PerryJenkins, M. (2012) “Culture at the center: A reformulation of diagnostic assessment”, Professional Psychology: Research and Practice, 43, pp. 175–182. doi.org/10.1037/a0028152 30. Daniel, J. H., Roysircar, G., Abeles, N., and Boyd, C. (2004) “Individual and culturaldiversity competency: Focus on the therapist”, Journal of Clinical Psychology, 60(7), pp. 755–770. doi:10.1002/jclp.20014 31. Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., ... and Placeres, V. (2018) “The multicultural orientation framework: A narrative review”, Psychotherapy, 55(1), pp. 89-100. 32. Day-Vines, N. L., Wood, S., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K. and Douglass, M. (2007) “Broaching the subjects of race, ethnicity, and culture during the counseling process”, Journal of Counseling and Development, 85, pp. 401– 409. Doi: 10.1002/j.1556- 6678.2007.tb00608.x 33. Dhamoon, R. K. (2011) “Considerations on mainstreaming intersectionality”, Political Research Quarterly, 64(1), pp. 230-243. Doi: 10.1177/1065912910379227 34. Englar-Carlson, M. and Smart, R. (2014) “Positive psychology and gender”, in Teramoto Pedrotti J. and Edwards L. (Eds.), Perspectives on the intersection of multiculturalism and positive psychology (pp. 125-141). Springer, Dordrecht. 35. Fell, G. R., Mattiske, J. K., and Riggs, D. W. (2008) “Challenging heteronormativity in psychological practice with lesbian, gay and bisexual clients”, Gay & Lesbian Issues and Psychology Review, 4(2). Available at: https://core.ac.uk/download/pdf/14937632.p df 36. Finlay, L. (2008) “A dance between the reduction and reflexivity: Explicating the “phenomenological psychological attitude””, Journal of Phenomenological Psychology, 39, pp. 1-32. Available at https://brill.com/view/journals/jpp/39/1/artic le-p1_1.xml 37. Fisher-Borne, M., Cain, J. M. and Martin, S. L. (2015) “From mastery to accountability: Cultural humility as an alternative to cultural competence”, Social Work Education, 34(2), pp. 165-181. Doi: 10.1080/02615479.2014.977244 38. Foronda, C., Baptiste, D. L., Reinholdt, M. M. and Ousman, K. (2016) “Cultural humility: A concept analysis”, Journal of Transcultural Nursing, 27(3), pp. 210-217. 39. Freeman, M. (2008) “Hermeneutics”, In L. M. Given (Ed.), The Sage encyclopedia of qualitative research methods (pp. 385-388). London: Sage 40. Gallardo, M. E. (2012) “Therapists as cultural architects and systemic advocates: Latina/o skills identification stage model”, In M. E. Gallardo, C. J. Yeh, J. E. Trimble, and T. A. Parham (Eds.), Culturally adaptive counseling skills: Demonstrations of evidence-based practices (pp. 77–112). Thousand Oaks, CA: Sage. 41. Gallardo, M. E., Yeh, C. J., Trimble, J. E., and Parham, T. (2012) Culturally adaptive counseling skills: Demonstrations of evidence-based practices. Sage 42. GDPR (2018). Guide to the General Data Protection Regulation. Available at: https://gdpr.eu/tag/gdpr/ 43. Geerlings, L. R. C., Thompson, C. L., Bouma, R. and Hawkins, R. (2017)

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 469 Volume 12; Issue: 9; September 2025 “Cultural Competence in Clinical Psychology Training: A Qualitative Investigation of Student and Academic Experiences”, Australian Psychologist, 53(2), pp. 161–170. doi:10.1111/ap.12291 44. Gillham, B. (2001) Research interview. Bloomsbury Publishing. 45. Gomez, J. P. (2021) “Verbal microaggressions as hyper-implicatures”, Journal of Political Philosophy, 29(3), pp. 375-403. Doi: 10.1111/jopp.12243 46. Gorski, P. C. and Goodman, R. D. (2015) “Introduction: toward a decolonized multicultural counseling and psychology”, In R. D. Goodman and P. C. Gorski (Eds.), Decolonizing “multicultural” counseling through social justice, (pp. 1–10). New York, NY: Springer. 47. Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N. and Stice, E. (2016) “A meta‐analysis of cultural adaptations of psychological interventions”, Behavior Therapy, 47(6), pp. 993–1014. 48. Harris, J. E., Shukla, N. and Ivey, A. E. Ivey, A. E., (2019) “Integrative psychotherapy with culturally diverse clients”, In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (3rd ed.). New York: Oxford University Press 49. Harris, T., Moret, L. B., Gale, J. and Kampmeyer, K. L. (2008) “Therapists' gender assumptions and how these assumptions influence therapy”, Journal of Feminist Family Therapy, 12(2-3), pp. 33- 59. Doi: 10.1300/J086v12n02_02 50. Harrison, D. K. (1975) “Race as a counselor-client variable in counseling and psychotherapy: A review of the research”, The Counseling Psychologist, 5(1), pp. 124- 133. Doi: 10.1177/001100007500500130 51. Hayes, J. A., Owen, J., and Bieschke, K. J. (2015) “Therapist differences in symptom change with racial/ethnic minority clients”, Psychotherapy, 52, pp. 308–314. http://dx.doi.org/10.1037/a0037957 52. Hays, P. A. (2012) Connecting across cultures: The helper’s toolkit, Thousand Oaks, CA: Sage 53. Hays, P. (2014) “An International Perspective on the Adaptation of CBT Across Cultures”, Australian Psychologist, 49(1), pp. 17–18. doi:10.1111/ap.12027 54. Henderson, D. (2012) Psychoanalysis, culture and society, Cambridge Scholars Publishing. 55. Hook, J. N., Davis, D., Owen, J. and DeBlaere, C. (2017) “Cultural humility: Engaging diverse identities in therapy”, American Psychological Association. 56. Hook, J. N., Farrell, J. E., Davis, D. E., DeBlaere, C., Van Tongeren, D. R., and Utsey, S. O. (2016) “Cultural humility and racial microaggressions in counseling”, Journal of Counseling Psychology, 63, pp. 269–277. Doi:10.1037/cou0000114 57. Huang, C. Y. and Zane, N. (2016) “Cultural influences in mental health treatment”, Current Opinion in Psychology, 8, pp. 131- 136. Doi: 10.1016/j.copsyc.2015.10.009 58. Hunte, R. (2016) “Black Women and Race and Gender Tensions in the Trades”, Peace Review, 28(4), pp. 436–443. doi:10.1080/10402659.2016.1237087 59. Husserl, E. (2012) Ideas: General introduction to pure phenomenology. Routledge. 60. Jones-Smith, E. (2018) Culturally diverse counseling: Theory and practice. Sage Publications. 61. Keller, H. (2018) “Universality claim of attachment theory: Children’s socioemotional development across cultures”, Proceedings of the National Academy of Sciences, 115(45), 11414- 11419. Doi: 10.1073/pnas.1720325115 62. Kirmayer, L. J. (2007) “Psychotherapy and the cultural concept of the person”, Transcultural psychiatry, 44(2), pp. 232- 257. 63. Kirmayer, L. J. (2013) “Embracing uncertainty as a path to competence: Cultural safety, empathy, and alterity in clinical training”, Culture, Medicine, and Psychiatry, 37, pp. 365-372. Doi: 10.1007/s11013-013-9314-2 64. Langdridge, D. (2007). Phenomenological psychology: Theory, research and method. Pearson education. 65. Laungani, P. (1999) “Client centred or culture centred counselling”, In S. Palmer and P. Laungani (Eds.), Counselling in a multicultural society (pp. 133-152). SAGE 66. Legislation.gov.uk. (2018) Data Protection Act 2018. Available at: http://www.legislation.gov.uk/ukpga/1998/2

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 471 Volume 12; Issue: 9; September 2025 85. Price, E. G., Beach, M. C., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., ... and Cooper, L. A. (2005) “A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals”, Academic medicine, 80(6), pp. 578-586. 86. Rathod, S., Gega, L., Degnan, A., Pikard, J., Khan, T., Husain, N., ... and Naeem, F. (2018). “The current status of culturally adapted mental health interventions: a practice-focused review of meta-analyses” Neuropsychiatric disease and treatment, pp. 165-178. Doi: 10.2147/NDT.S138430 87. Ratts, M. J. and Pedersen, P. B. (2015) Counseling for multiculturalism and social justice, Alexandria, VA: American Counseling Association. 88. Ratts, M. J., Singh, A. A., Nassar-Mcmillan, S., Butler, S. K. and McCullough, J. R. (2016) “Multicultural and social justice counseling competencies: guidelines for the counseling profession”, Journal of Multicultural Counseling and Development, 44(1), pp. 28–48. Doi: 10.1002/jmcd.12035 89. Reid, K., Flowers, P. and Larkin, M. (2005) “Exploring lived experience”, The psychologist, 18(1), pp. 20-23. 90. Ridley, C. R., Kelly, S. M. and Mollen, D. (2011) “Microskills training: Evolution, reexamination, and call for reform”, The Counseling Psychologist, 39, pp. 800–824. doi:10.1177/0011000010378438 91. Rogers, C. R. (1957) “The necessary and sufficient conditions of therapeutic personality change”, Journal of consulting psychology, 21(2), pp. 95-103. Doi: 10.1037/h0045357 92. Prochaska, J. O. and Norcross, J. C. (2014) Systems of Psychotherapy: A Transtheoretical Analysis. Boston: Cengage Learning (Cengage). 93. Rasmussen, H. N. and Lavish, L. (2014) “Broad definitions of culture in the field of multicultural psychology”, In Teramoto Pedrotti J. and Edwards L. (Eds.), Perspectives on the intersection of multiculturalism and positive psychology (pp. 17-30). Springer, Dordrecht. 94. Salmons, J. (2012) “Designing and conducting research with online interviews”, Caseslyons in online interview research, 1-30. Doi: 10.4135/9781506335155.n1 95. Schouler-Ocak, M., Graef-Calliess, I. T., Tarricone, I., Qureshi, A., Kastrup, M. C. and Bhugra, D. (2015) “EPA guidance on cultural competence training”, European Psychiatry, 30(3), pp. 431–440. doi: 10.1016/j.eurpsy.2015.01.012 96. Schultz, R. A. (2018) “Embodied nonverbal microaggressions from the perspective of dance/movement therapists: Interpretative phenomenological analysis”, American Journal of Dance Therapy, 40(2), pp. 224- 239. 97. Semp, D., and Read, J. (2015) “Queer conversations: Improving access to, and quality of, mental health services for samesex-attracted clients”, Psychology & Sexuality, 6(3), pp. 217-228. 98. Sengar, K. S. (2018) “Psychotherapy and Counselling in a Diverse World”, Indian Journal of Clinical Psychology, 45(2), pp. 1- 3. Available at: https://ijcp.co.in/wpcontent/uploads/2022/01/2018fb.pdf#page= 8 99. Shaw, R. L. (2001) “Why use interpretative phenomenological analysis in health psychology?”, Health Psychology Update, 10(4), pp. 48–52. 100. Shinebourne, P. (2011) “The Theoretical Underpinnings of Interpretative Phenomenological Analysis (IPA)”, Existential Analysis: Journal of the Society for Existential Analysis, 22(1), pp. 16-31. 101. Smith J.A. and Osborn M. (2008) “Interpretative phenomenological analysis”, in J. A. Smith (Ed.), Qualitative Psychology: A Practical Guide to Methods (2nd ed.). London: Sage. 102. Smith, T. B. and Trimble, J. E. (2016) Foundations of multicultural psychology: Research to inform effective practice, Washington, DC: American Psychological Association. 103. Soto, A., Smith, T. B., Griner, D., Domenech Rodríguez, M., and Bernal, G. (2018) “Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews”, Journal of clinical psychology, 74(11), pp. 1907-1923. https://doi.org/10.1002/jclp.22679 104. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A., Nadal, K. L. and Esquilin, M. (2007) “Racial microaggressions in everyday life: implications for clinical practice”, American psychologist, 62(4), pp. 271-281.

Eleni Skoli et.al. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis International Journal of Research and Review (ijrrjournal.com) 472 Volume 12; Issue: 9; September 2025 105. Sue, D. W., Sue, D., Neville, H. A., and Smith, L. (2019) Counselling the culturally diverse. Theory and Practice (8th ed.), John Wiley and Sons, Inc. 106. Sue, D. W. and Torino, G. C. (2005) “Racial-cultural competence: Awareness, knowledge, and skills”, in R. T. Carter (Ed.), Handbook of racial-cultural psychology and counseling, Vol 1: Theory and research (pp. 3-18). John Wiley & Sons, Inc. 107. Sue, S., Fujino, D. C., Hu, L., Takeuchi, D. T., and Zane, N. W. S. (1991) “Community mental health services for ethnic minority groups: A test of the cultural responsiveness hypothesis”, Journal of Consulting and Clinical Psychology, 59(4), pp. 533–540. doi:10.1037/0022- 006x.59.4.533 108. Sue, S., Zane, N., Nagayama Hall, G. C. and Berger, L. K. (2009) “The case for cultural competency in psychotherapeutic interventions”, Annual Review of Psychology, 60, pp. 525–548. doi: 10.1146/annurev.psych.60.110707.163651 109. Thomas, A. J. and Schwarzbaum, S. E. (2016) Culture and identity: Life stories for counselors and therapists. Sage Publications. 110. Tseng, W. S. and Streltzer, J. M. (2008) “Cultural Competence in Health Care”, New York, NY: Springer 111. Tylor, E. B. (1871(1958)) Primitive culture. New York, NY: Harper. 112. Watkins Jr, C. E., Hook, J. N., Owen, J., DeBlaere, C., Davis, D. E. and Van Tongeren, D. R. (2019) “Multicultural orientation in psychotherapy supervision: Cultural humility, cultural comfort, and cultural opportunities”, American journal of psychotherapy, 72(2), pp. 38-46. 113. Weatherhead, S. and Daiches, A. (2010) “Muslim views on mental health and psychotherapy”, Psychology and Psychotherapy: Theory, Research and Practice, 83(1), pp. 75-89. Doi: 10.1348/147608309X467807 114. Wendt, D. C., Gone, J. P. and Nagata, D. K. (2015) “Potentially harmful therapy and multicultural counseling: Bridging two disciplinary discourses”, The Counseling Psychologist, 43(3), pp. 334-358. 115. Willig, C. (2013) Introducing qualitative research in psychology (3rd ed.). Open University press 116. Wong, P. T. P., Wong, L. C. J. and Scott, C. (2006) “The positive psychology of transformation: Beyond stress and coping”, in P. T. P. Wong & L. C. J. Wong (Eds.), Handbook of multicultural perspectives on stress and coping. New York: Springer 117. Zhang, N. and Burkard, A. W. (2008) “Client and counselor discussions of racial and ethnic differences in counseling: An exploratory investigation”, Journal of Multicultural Counseling and Development, 36(2), pp. 77-87. Doi: 10.1002/j.2161-1912. 2008.tb00072.x How to cite this article: Eleni Skoli, Sotiria Efthymiou, Triantafyllia Iliopoulou, Georgios Pilafas, Penelope Louka. Trainee integrative therapists’ experiences of the role of culture in therapy: an interpretative phenomenological analysis. International Journal of Research and Review. 2025; 12(9): 443-472. DOI: https://doi.org/10.52403/ijrr.20250945