A Systematic Review of Cultural Competence Trainings for Mental Health Providers

Chu, W., Wippold, G., & Becker, K. D. (2022).

Professional psychology,

research and practice, 53(4), 362–371.

https://doi.org/10.1037/pro0000469

Abstract

We conducted a systematic review to characterize features and evaluate outcomes of cultural competence trainings delivered to mental health providers. We reviewed 37 training curricula described in 40 articles published between 1984–2019 and extracted information about curricular content (e.g., cultural identities), as well as training features (e.g., duration), methods (e.g., instructional strategies), and outcomes (i.e., attitudes, knowledge, skills). Training participants included graduate students and practicing professionals from a range of disciplines. Few studies (7.1%) employed a randomized-controlled trial design, instead favoring single-group (61.9%) or quasi-experimental (31.0%) designs. Many curricula focused on race/ethnicity (64.9%), followed by sexual orientation (45.9%) and general multicultural identity (43.2%). Few curricula included other cultural categorizations such as religion (16.2%), immigration status (13.5%), or socioeconomic status (13.5%). Most curricula included topics of sociocultural information (89.2%) and identity (78.4%), but fewer included topics such as discrimination and prejudice (54.1%). Lectures (89.2%) and discussions (86.5%) were common instructional strategies, whereas opportunities for application of material were less common (e.g., clinical experience: 16.2%; modeling: 13.5%). Cultural attitudes were the most frequently assessed training outcome (89.2%), followed by knowledge (81.1%) and skills (67.6%). To advance the science and practice of cultural competence trainings, we recommend that future studies include control groups, pre- and post-training assessment, and multiple methods for measuring multiple training outcomes. We also recommend consideration of cultural categories that are less frequently represented, how curricula might develop culturally competent providers beyond any single cultural category, and how best to leverage active learning strategies to maximize the impact of trainings.

Here are some thoughts:

This systematic review by Chu and colleagues provides a comprehensive examination of cultural competence trainings for mental health providers, synthesizing findings from 37 unique curricula published over a 35-year period. A key insight is the uneven distribution of focus across cultural identities: while race/ethnicity, sexual orientation, and general multiculturalism are frequently addressed, other critical identities—such as religion, immigration status, and socioeconomic status—are significantly underrepresented. This raises important ethical and practical concerns, as mental health providers may be inadequately prepared to serve clients from these less-represented backgrounds. Furthermore, the authors note that discrimination and prejudice are the least commonly covered topics, a troubling omission given the high prevalence of microaggressions in therapy and their negative impact on therapeutic alliance and client outcomes.

The review also highlights methodological and pedagogical patterns in training design. Most studies relied on single-group pre-post designs, with only a small fraction employing randomized controlled trials, limiting causal inferences. Didactic methods like lectures and discussions dominate, while active learning strategies—such as role-playing, modeling, and feedback—are underutilized, despite evidence supporting their effectiveness in skill acquisition and adult learning. Interestingly, while self-assessment was the primary outcome measure, its susceptibility to social desirability bias suggests a need for more objective or multi-informant evaluations, such as behavioral observations or client-reported measures. The authors also point out that most trainees were graduate students, underscoring the need for ongoing cultural competence training among practicing professionals to ensure lifelong development.

For psychologists, this review serves as both a validation and a call to action. It affirms that cultural competence trainings are generally effective in improving attitudes, knowledge, and skills, but it also identifies clear gaps in content, methodology, and evaluation. The authors propose several forward-looking recommendations, including the incorporation of active learning strategies, expansion of cultural identity coverage, integration of discrimination-related content, and use of more rigorous research designs. By addressing these areas, psychologists can enhance the relevance, impact, and sustainability of cultural competence trainings, ultimately improving mental health care for culturally underserved communities.

End-of-Life Decision Making in Multidisciplinary Teams: Ethical Challenges and Solutions–A Systematic Review

Mujayri, H. et al. (2024).

jicrcr.com.

https://doi.org/10.63278/jicrcr.vi.814

Abstract

Background: To provide high quality end of life (EOL) care, multidisciplinary teams (MDTs) need to be able to proficiently navigate the intricacies of ethical dilemmas faced by EOL care; to maintain an equilibrium between patient autonomy, family involvement and cultural competence. Yet, the lack of cohesive EOL decision making currently continues to occur because of communication barriers, role ambiguity and a lack of sufficient ethics training within MDTs. As a consequence, these issues demonstrate the necessity of having structured protocols to help MDTs make ethically sound decisions in the EOL care.

Aim: The purpose of this paper is to identify and review major ethical factors that affect ethical decision-making in EOL MDTs, and explore the themes of patient autonomy, communication, cultural sensitivity, ethics training, and institutional barriers.

Method: Ten studies were reviewed systematically according to PRISMA criteria using data sources including PubMed, Scopus, Web of Science, and CINAHL databases. The analysis included studies published between the years 2020 and 2024 and the ethical decision–making challenges and solutions that MDTs face in EOL care contributing to those decisions.

Results: Four key themes were identified: Issues concerning balancing patient autonomy with family input, communication challenges in MDTs, cultural sensitivity in EOL care and the necessity of ethics training. Results indicate that MDTs are often faced with ethical dilemmas when patient’s wishes diverge from those of their family and experience communication difficulties that resulted in degradation of care quality. Simulation is an entertaining and effective way to develop cultural awareness and ethics training in EOL care practice.

Conclusion: Ethical challenges in EOL decision making must be addressed with an intervention encompassing improved ethics training, MDT role clarity, culturally aware practice, and institutional support. These strategies, if implemented will support MDTs in providing patient centered and ethically sound EOL care. Further study of ethics training, communication frameworks and cultural competence on EOL decision-making in MDTs is warranted for future research.

Here are some thoughts:

This article is critically important for practicing psychologists because it directly addresses the core ethical, communicative, and interpersonal challenges they face as integral members of multidisciplinary teams (MDTs) in end-of-life (EOL) care. The systematic review identifies key themes—such as balancing patient autonomy with family input, navigating communication breakdowns within teams, and addressing cultural and religious sensitivities—that are central to a psychologist’s role. Psychologists are often the clinicians best equipped to facilitate difficult family meetings, mediate conflicts between patient wishes and family or team concerns, and ensure that care is culturally competent and patient-centered. The article underscores a significant gap in ethics training and recommends simulation-based learning, urging psychologists to seek or advocate for such training to better handle complex moral dilemmas. Furthermore, by highlighting institutional barriers and role ambiguity, it empowers psychologists to push for clearer team protocols and systemic support, ultimately enabling them to contribute more effectively to ethically sound, compassionate, and collaborative EOL decision-making.

Facing death differently: revolutionising our approach to death and grief

Selman, L. (2024). 

BMJ, q2815.

https://doi.org/10.1136/bmj.q2815

Here is an excerpt:

End-of-life care hasn’t just been medicalised, it has been deprioritised. Healthcare systems and education focus on cures and life extension, sometimes at the expense of quality of life and compassionate care for dying people.

In the UK, about 90% of dying people would benefit from palliative care, but 25% don’t get it. Demand is set to rise 25% over the next 25 years as lifespans increase and health conditions grow more complex, yet the sector is already critically underfunded and overstretched. Just a third of UK hospice funding comes from the state, with the remaining £1bn raised annually through charity shops, fundraising events, and donations. This funding gap sends a clear message: care for dying people is less valued than aggressive treatments and high-tech medical advances. (It’s surely no coincidence that 9 in 10 of the clinical and care workforce in UK hospices are women, reflecting a long history of “women’s work” being undervalued.)

This patchwork funding model leaves rural and other underserved communities with glaring gaps in care, particularly for children. As demand for palliative care rises, the case for proper government funding for end-of-life care provision in care homes and the community, including hospices, grows ever more urgent.

In the meantime, stark inequities exist in access to hospice, palliative, and bereavement services. Marginalised communities face the greatest number of hurdles in accessing support at a time when compassion is most needed. Ethnic minority groups, in particular, encounter language barriers, inadequate outreach, and a shortage of culturally competent providers. Thirty per cent of people from ethnic minority groups but just 17% of white people say they don’t trust healthcare professionals to provide high-quality end-of-life care.

The article is here.

Here are some thoughts:

Selman highlights the significant challenges and ethical concerns surrounding end-of-life care in the UK. Despite 90% of dying people benefiting from palliative care, 25% do not receive it, and demand is expected to rise by 25% over the next 25 years due to increasing lifespans and complex health conditions. However, the sector remains critically underfunded, with only a third of hospice funding coming from the government and the rest relying on charitable efforts. This funding gap reflects a societal undervaluation of end-of-life care compared to high-tech medical interventions, raising ethical questions about priorities and the equitable distribution of resources.

The article also sheds light on stark inequities in access to palliative and bereavement services, particularly for marginalized communities. Ethnic minority groups face additional barriers, such as language difficulties, inadequate outreach, and a lack of culturally competent care providers. Trust in healthcare professionals for end-of-life care is significantly lower among ethnic minority groups (30%) compared to white individuals (17%), highlighting systemic failures in addressing the needs of diverse populations. These disparities underscore the ethical imperative to ensure equitable access to compassionate, culturally sensitive care for all.

Ultimately, the piece calls for a reevaluation of societal and healthcare priorities, emphasizing the need to balance life extension with quality of life and dignity in dying. It advocates for increased government funding, culturally competent care, and a shift in values to prioritize compassion and equity in end-of-life care. These issues are not only practical but deeply ethical, reflecting broader questions about how societies value and care for their most vulnerable members.

Toward a Social Bioethics Through Interpretivism: A Framework for Healthcare Ethics.

Dougherty, R., & Fins, J. (2023).

Cambridge Quarterly of Healthcare Ethics, 1-11.

doi:10.1017/S0963180123000452

Abstract

Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term “social bioethics.” Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As an exemplar, the authors use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare.

My summary: 

The authors argue that traditional bioethical frameworks, which focus on individual rights and responsibilities, are not sufficient to address the complex ethical issues that arise in healthcare. They argue that social bioethics can help us to better understand how social structures, such as race, class, gender, and sexual orientation, shape the experiences of patients and healthcare providers, and how these experiences can influence ethical decision-making.

The authors use the example of psychiatric services to illustrate how social bioethics can be used to reframe common ethical issues. They argue that the way we think about mental illness is shaped by social and cultural factors, such as our understanding of what it means to be "normal" and "healthy." These factors can influence how we diagnose, treat, and care for people with mental illness.

The authors also argue that social bioethics can help us to understand the role of healthcare ethics consultants in shaping broader social, political, and economic systems. They argue that these consultants participate in a process of "social discourse," in which they help to define the terms of the debate about ethical issues in healthcare. This discourse can then have a cyclical effect on the design and delivery of healthcare.

Here are some of the key concepts of social bioethics:

• Social structures: The systems of power and inequality that shape our society.
• Social discourse: The process of communication and negotiation through which we define and understand social issues.
• Healthcare ethics consultants: Professionals who help to resolve ethical dilemmas in healthcare.
• Social justice: The fair and equitable distribution of resources and opportunities.

Culture: The Grand Web of Meaning

Chao, Melody Manchi and Kesebir, Pelin,
Found in The Experience of Meaning in Life: Perspective from the Psychological Sciences
(September 16, 2011).  J. Hicks, C. Routledge, eds., Springer Press, 2011.

Abstract:    

Meaning and culture mutually constitute each other. Culture rests on meaning, whereas meaning exists and is propagated in culture. The uniquely human quest for meaning transpires against the background of culture and is simultaneously recreating culture. The current chapter aims to explore different aspects of this dynamic relationship between meaning and culture. We begin by defining meaning and culture, and elaborating the nature of their intricate relationship. Then, we analyze the universal and relative aspects of meaning systems across cultures. Finally, we examine meaning in the backdrop of multiculturalism to illuminate how individuals navigate through different cultural webs of meaning and its implications to cultural competence.

The book chapter is here.

Are research ethics guidelines culturally competent?

Ben Gray, Jo Hilder, Lindsay Macdonald, Rachel Tester, Anthony Dowell, & Maria Stubbe
Research Ethics May 20, 2016

Abstract

Research ethics guidelines grew out of several infamous episodes where research subjects were exploited. There is significant international synchronization of guidelines. However, indigenous groups in New Zealand, Canada and Australia have criticized these guidelines as being inadequate for research involving indigenous people and have developed guidelines from their own cultural perspectives. Whilst traditional research ethics guidelines place a lot of emphasis on informed consent, these indigenous guidelines put much greater emphasis on interdependence and trust. This article argues that traditional guidelines are premised on relationships of equal power, and that often the researcher has more power that is not fully equalized by providing information. Where there is a relationship of unequal power, then focusing on interdependence and trust is more likely to achieve ethical safety. We illustrate this thesis by describing the detail of a research project looking at the use of interpreters, where we video-recorded live consultations and then interviewed the patient, interpreter and doctor. We conclude by suggesting that mainstream research ethics guidelines should pay more attention to the development of a trustworthy relationship between subject and researcher, and that, following the lead from clinical medicine, we should develop a culturally competent ethical framework for research on human subjects.

The article is here.