A Systematic Review of Cultural Competence Trainings for Mental Health Providers

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.

Cultural competence is a core value of professional psychology that is represented in the practice guidelines and mandates of its governing organizations. The American Psychological Association (APA) published the Multicultural Guidelines (APA, 2017a) to provide psychologists with a framework to aid in the provision of multiculturally competent practice. This document outlines 10 guidelines to taking a strengths-based approach when working with underserved communities (Clauss-Ehlers et al., 2019). The APA further demonstrated its commitment to cultural competence such that the organization went beyond these recommendations to develop enforceable standards in their Ethical Principles of Psychologists and Code of Conduct (APA, 2017b). Of particular importance to delivering multiculturally competent services are Ethical Standards 2.01a and 2.01b – Boundaries of Competence, which indicates that psychologists must only provide services with populations and in areas within the boundaries of their competence based on their education and training and must establish an understanding of cultural factors to implement effective services.

Equipping the mental health workforce with cultural competence involves training professionals to engage in the lifelong, developmental commitment to and practice of providing culturally sensitive care. Such training could borrow from and build on the APA Multicultural Guidelines, beginning with understanding oneself as a multicultural being as a precursor to engaging in culturally sensitive care and implementing culturally adapted treatments. Training providers to develop cultural competence is not at odds with efforts to train providers in culturally adapted treatments or to initiate systems-level changes to meet the needs of culturally diverse groups. Rather, training providers is and should be among one of many strategies to effectively serve culturally underserved groups and address mental health disparities.

To that end, cultural competence in mental health services can be understood as the provision of appropriate and effective services that are sensitive or congruent to the cultural identities of the client (Sue et al., 1998; Whaley & Davis, 2007). In its broadest definition, an identity is one’s subjective sense of self. A cultural identity refers to one’s sense of affiliation and belongingness with a sociocultural group. These groups have their own defining set of values, behaviors, and beliefs embedded within dynamic, intergenerational, social, historical, and political factors (Whaley & Davis, 2007). For example, cultural identities may be grouped by race (e.g., American Indians), religion (e.g., Muslims), ability status (e.g., people with disabilities), or immigration status (e.g., refugee, temporary worker). Inherently, all individuals have cultural identities and intersecting identities that create unique experiences.

While there has been ambiguity regarding the precise definition of cultural competence (e.g., Whaley, 2008), there is general agreement that cultural competence is multidimensional. One of the most widely used frameworks of provider-level cultural competence was proposed by Sue and colleagues (1982; 1992). Their tripartite model includes (a) cultural attitudes (e.g., sensitivity to one’s own values and biases, and its impacts on one’s perceptions of the client, presenting problems, and therapeutic relationship); (b) cultural knowledge (e.g., knowledge about one’s own cultural background, the client’s cultural background, and how systems operate on those identities and treatment); and (c) cultural skills (e.g., ability to use therapeutic strategies that are culturally appropriate and sensitive). Sue and colleagues’ conceptualization of cultural competence is accepted in the field to encapsulate an other-orientated stance (e.g., cultural humility) and concrete professional skills to enhance an individual’s work with others. Importantly, cultural competence is fluid, meaning that there is no point at which a provider’s competence is fully “attained” and does not require further development. Rather, a provider’s cultural competence can develop or degrade over time, depending on their skills to meet the everchanging needs of clients and our diversifying society. Therefore, it is of paramount importance to understand how to effectively and efficiently promote provider cultural competence.

Due to its strong conceptualization and practical utility, the tripartite model is routinely applied to inform the assessment of student and practitioner cultural competence across diverse professions, including psychologists (e.g., Johnson & Federman, 2014), school teachers (e.g., Vincent & Torres 2015), public administrators (e.g., Rice, 2007), and physician assistants (e.g., Domenech Rodríguez et al., 2019). Across fields, the literature is growing at a rate that facilitates systematic reviews regarding cultural competence trainings (e.g., Beach et al., 2005; Benuto et al., 2018; Chipps et al., 2008; Clifford et al., 2015; Lie et al., 2011; Price et al., 2005; Truong et al., 2014). These trainings have shown positive outcomes. For example, Beach and colleagues (2005) found strong evidence that cultural competence trainings improve health care providers’ knowledge, attitudes, and skills. Findings from studies involving psychologists tend to converge with those involving other health professionals. For example, a review by Benuto and colleagues (2018) found trainings to be effective in increasing psychologists’ knowledge in topics such as racism and discrimination. There has also been some evidence on the effects of cultural competence trainings on patient outcomes in healthcare, though there is a lack of a high-quality research to further examine this relationship (Lie et al., 2011).

These reviews have significantly advanced our understanding of cultural competence trainings; however, there remain opportunities to build on their contributions and expand the impact of the literature. First, the scope of trainings in previous reviews has been limited to a single cultural identity, specifically race/ethnicity (e.g., Beach et al., 2005; Price et al., 2005). A systematic review that broadens the conceptualization of cultural diversity would offer benefits to the field by extending our understanding of the utility of cultural competence trainings for a range of cultural identities, which include those based on race/ethnicity, gender, sexual orientation, religion, socioeconomic class, ability status, immigration status, among others. Second, there has been no published review that examines cultural competence trainings in mental health providers broadly, as the only review focused exclusively on clinical and counseling psychologists (i.e., Benuto et al., 2018). A review that expands the scope of mental health providers is of interest to psychologists because psychologists are leaders in developing, implementing, and assessing evidence-based cultural competency trainings for mental health providers. Psychologists can continue to be on the forefront by understanding, and then adapting, strategies developed and implemented by other fields that train mental health providers.

To this end, the first aim of this systematic review was to address these gaps by reviewing published studies of cultural competence trainings that had been delivered to mental health providers broadly (e.g., professional discipline, training level) and for a range of cultural identities in terms of their features (e.g., training length), content (e.g., cultures covered), methods (e.g., instructional strategies used), and outcome measurement (e.g., method and domain). The second aim was to identify curricula content and methods that were common in trainings that showed positive outcomes in each outcome domain (i.e., attitudes, knowledge, skills). By providing a synthesis of curricula, it is possible to then identify strengths and opportunities with regard to what has already been and what could be developed and tested. Additionally, aggregating findings across studies could reveal patterns about training features associated with positive growth in cultural competence.

Method

Inclusion and Exclusion Criteria

Studies had to meet several criteria established a priori to be included in this review. Inclusion and exclusion criteria are described in Table 1 and followed a PICOTS (Population, Intervention, Comparison, Outcomes, Timing, Setting) framework (Samson & Schoelles, 2012).

Table 1.

Inclusion and Exclusion Criteria.

Parameter	Inclusion Criteria	Exclusion Criteria
Publication	Studies published in English in peer-reviewed journals	Grey literature (e.g., dissertations, theses, book chapters)
Population	At least 50% of training sample consist of individuals who are receiving graduate training to or are currently providing mental health therapy services	At least 50% of training sample consist of: Healthcare professionals (e.g., physicians, psychiatry residents, nurses) Non-providers (e.g., administrators) Indirect providers (e.g., supervisors) Undergraduate students
Intervention	Any training in standard course or workshop format	Study abroad programs Service-learning courses
Comparison	Any comparative or control group if not single-group design	None
Outcomes	At least one cultural competence training outcome measured for training participant	Satisfaction outcomes only Non-cultural competence related outcomes Non-participant outcomes
Timing	Any training duration Publication date after 1/1/1980	Published before 1/1/1980
Study Design	Single group pre-post test Single group post-test only Quasi-experimental Randomized controlled trial	Case study Theoretical study
Setting	Any setting	None

Search Strategy

The review was conducted following the PRISMA guidelines. Five databases (i.e., PsycINFO [EBSCO], PubMed-MEDLINE [Ovid], Web of Science [Clarivate], ERIC [EBSCO], Google Scholar) were searched using an a priori-defined search string: (cultur* OR multicultur* OR transcultur* OR cross-cultur* OR diversity) AND (competenc* OR sensitivity OR awareness OR knowledge) AND (training* OR curriculum* OR teach* OR intervention* OR workshop* OR course* OR development) AND (“mental health”). Previous reviews and meta-analyses (Anderson et al., 2003; Beach et al., 2005; Benuto et al., 2018; Bezrukova et al., 2012; Brock et al., 2019; Chae et al., 2020; Chipps et al., 2008; Clifford et al., 2015; Govere & Govere, 2016; Lie et al., 2011; Malott, 2010; Price et al., 2005; Smith et al., 2006; Truong et al., 2014), reference lists, and additional searches were also utilized to identify potential articles.

Selection Process

The search strategy produced 5,479 articles. After duplicates were removed using Mendeley, a reference management program, there were 3,948 remaining articles to be screened using the article title and abstract. Of the articles screened, 237 were identified as potentially relevant. Then, the full-text article was retrieved to determine whether all inclusion criteria were met, removing an additional 197 articles. The final sample consisted of 40 articles (Figure 1). A full list of articles included in this review is provided in the Supplemental Materials.

Figure 1.

PRISMA Flow Diagram.

Data Extraction and Coding Process

To develop a codebook, we referenced previous reviews (Beach et al., 2005; Benuto et al., 2018; Price et al., 2005) and literature on cultural competence (Smith et al., 2006; Sue, 2001; Sue et al., 1982; 1992), mental health training (Beidas & Kendall, 2010; Bennett-Levy et al., 2009; Lyon et al., 2011; Meyers et al., 1998), and learning strategies (Hattie et al., 1966). The final codebook structure consisted of four categories (i.e., features, content, method, outcome measurement). Each category included two subcategories that were further broken into individual codes. The features category included the training subcategory, which included codes regarding the study design and training structure (e.g., training duration), and the participants subcategory, which included codes about the training sample (e.g., genders represented). The content category included the cultures subcategory, which included codes of the cultural identities discussed in the curriculum (e.g., religious identity), and the topics subcategory, which included codes of specific topics within each cultural identity (e.g., stereotypes). The method category included the format subcategory, which captured how the training was conducted (e.g., live, expert-led), and the strategies subcategory, which included codes of the instructional methods used (e.g., discussions). The outcome measurement category included the measures subcategory, which included codes for how outcomes were measured (e.g., self-assessment), and the domain subcategory, which included codes on the three domains of cultural competence (i.e., attitudes, knowledge, skills). Outcomes that were measured quantitatively were also coded whether they reached statistical significance or p < 0.05.

Each article was coded by the first author. For articles that included multiple studies, each study was coded independently. The second author coded a random sample (10%) of the articles to ensure accuracy. Any discrepancies were resolved by the first author. Data were entered and stored in a Microsoft Access database. Coding reliability was assessed using Cohen’s kappa, a commonly used measure of inter-rater reliability (McHugh, 2012). Reliability between the two raters ranged from moderate to almost perfect (κ = .67-.98) agreement (Landis & Koch, 1977).

Transparency and Openness

This study’s planned methods and analyses were not shared in a public registry (i.e., pre-registered) prior to conducting the study (APA, 2021). Data may be requested by emailing the corresponding author.

Results

The final sample included 40 articles published between 1984 and 2019, with many published after 2010 (n = 17, 40.5%). These 40 articles represent 42 trainings and 61 study groups, of which 17 (27.9%) were control groups and 44 (72.1%) were experimental groups whose participants received a cultural competence training. A total of 37 unique curricula were tested in this sample of studies.

Study Characteristics

Study characteristics (n = 42) are presented in Table 2. The majority of studies were conducted in the United States (78.6%). Many studies used single group, pre-post test designs (35.7%) and quantitative methods (45.2%) to assess outcomes. Across all studies, samples included at least one participant who was a master’s student (69.0%), doctoral student (47.6%), and mental health professional (31.0%). Across 38 studies (90.5%) that reported the discipline or professional fields of participants, study samples included at least one participant who represented counseling psychology (60.5%), clinical psychology (34.2%), social work (34.2%), marriage and family therapy (10.5%), psychiatry (10.5%), or other fields such as nursing (15.8%). Studies included mixed-discipline (26.3%) and single discipline samples (73.7%).

Table 2.

Study Characteristics.

	n	%
Design
Single-group pre-post test	15	35.7%
Quasi-experimental	13	31.0%
Single-group post-only test	11	26.2%
Randomized controlled trial	3	7.1%
Methodology
Quantitative	19	45.2%
Mixed	15	35.7%
Qualitative	8	19.0%
Year
>2010	17	40.5%
2000–2009	12	35.7%
1990–1999	8	19.0%
1980–1989	2	4.8%
Countries
United States	33	78.6%
Canada	4	9.5%
United Kingdom	3	7.1%
Israel	1	2.4%
Australia	1	2.4%

The total sample size of trained participants included 1,340 individuals, with sample sizes ranging from 4 to 169 (M = 32.7, SD = 34.4). Of the 25 (59.5%) studies that reported participant age, the average age was 34.3 years (SD = 6.5). Across 33 (78.6%) studies that reported gender, all included at least one female participant and 24 (72.7%) included at least one male participant. Across 35 studies (83.3%) that reported participants’ race/ethnicity, study samples included at least one participant who self-identified as non-Hispanic White (88.6%), Asian/Asian American (51.4%), Black/African American (48.6%), Hispanic/Latinx (37.1%), Multiracial (22.9%), American Indian/Alaskan Native (17.1%), Middle Eastern and North African (2.9%), and Native Hawaiian/Pacific Islander (2.9%).

Training Characteristics

The first aim of this review was to characterize cultural competence trainings in terms of their features, content, methods, and outcome measurement. We did this by examining patterns across the entire sample of 37 curricula.

Features.

When reported, the average length of a distinct training session was 4.0 hours (SD = 2.1) and the total training duration ranged from a single day to 36 weeks. Few curricula (n = 5; 13.5%) included a follow-up or booster component.

Content and Methods.

Curricula content and methods are summarized in Table 3. Among the 37 curricula, the most commonly covered cultural identities were of race/ethnicity (64.9%), followed by sexual orientation (45.9%) and general multicultural identity (43.2%). All other identities, such as those related to gender, religion, ability status, and socioeconomic status were discussed in less than one-quarter of curricula. Common topics included sociocultural/historical information (e.g., legal protections, 89.2%), identity issues (e.g., identity development, 78.4%), and client interactions (e.g., therapeutic alliance, 75.7%). Discrimination and prejudice (54.1%) was the least discussed topic. Most curricula used a live, expert-led format (91.9%). Curricula were delivered in a course (n = 21) or workshop (n = 17) format. One curriculum was tested in both a course and workshop format. The most common instructional strategies were didactic lectures (89.2%) and group discussions (86.5%). Assignments (e.g., presentations, 59.5%) and exercises (e.g., privilege walk, 59.5%) were also commonly used strategies, while receiving feedback (e.g., after a roleplay, 24.3%), providing clinical services to clients (16.2%), and modeling (13.5%) were used less often.

Table 3.

Curricula Content, Methods, and Outcome Domains.

		Curricula Characteristics by Outcome Domain
Category – Subcategory	All Curricula (n = 37)	Attitudes (n = 17)	Knowledge (n = 15)	Skills (n = 15)
Content – Cultures
Race/Ethnicity	24 (64.9%)	11 (64.7%)	8 (53.3%)	8 (53.3%)
Sexual Orientation	17 (45.9%)	6 (35.3%)	8 (53.3%)	8 (53.3%)
General Multiculturalism	16 (43.2%)	6 (35.3%)	7 (46.7%)	7 (46.7%)
Gender	8 (21.6%)	2 (11.8%)	2 (13.3%)	2 (13.3%)
Religion	6 (16.2%)	2 (11.8%)	2 (13.3%)	2 (13.3%)
Ability Status	5 (13.5%)	1 (5.9%)	2 (13.3%)	2 (13.3%)
Socioeconomic Status	5 (13.5%)	1 (5.9%)	1 (6.7%)	1 (6.7%)
Immigration Status	5 (13.5%)	1 (5.9%)	1 (6.7%)	2 (13.3%)
Linguistic Ability	4 (10.8%)	1 (5.9%)	1 (6.7%)	1 (6.7%)
Content – Topics
Sociocultural/Historical Info	33 (89.2%)	16 (94.1%)	14 (93.3%)	13 (86.7%)
Identity	29 (78.4%)	14 (82.4%)	12 (80.0%)	12 (80.0%)
Client Interaction	28 (75.7%)	14 (82.4%)	11 (73.3%)	11 (73.3%)
Stereotype	26 (70.3%)	14 (82.4%)	11 (73.3%)	9 (60.0%)
Mental Health	23 (62.2%)	10 (58.8%)	10 (66.7%)	10 (66.7%)
Heritage	23 (62.2%)	12 (70.6%)	10 (66.7%)	9 (60.0%)
Theory	22 (59.5%)	11 (64.7%)	11 (73.3%)	10 (66.7%)
Discrimination/Prejudice	20 (54.1%)	11 (64.7%)	8 (53.3%)	7 (46.7%)
Method – Formats
Live, Expert-led	34 (91.9%)	16 (94.1%)	14 (93.3%)	14 (93.3%)
Virtual, Expert-led	2 (5.4%)	1 (5.9%)	1 (6.7%)	1 (6.7%)
Live, Collaborative	1 (2.7%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Method – Strategies
Lecture	33 (89.2%)	17 (100.0%)	14 (93.3%)	13 (86.7%)
Discussion	32 (86.5%)	13 (76.5%)	12 (80.0%)	12 (80.0%)
Multimedia	27 (73.0%)	12 (70.6%)	8 (53.3%)	8 (53.3%)
Reading	26 (70.3%)	10 (58.8%)	9 (60.0%)	8 (53.3%)
Assignment	22 (59.5%)	9 (52.9%)	10 (66.7%)	9 (60.0%)
Exercise	22 (59.5%)	10 (58.8%)	11 (73.3%)	8 (53.3%)
Reflection	19 (51.4%)	6 (35.3%)	7 (46.7%)	7 (46.7%)
Direct Contact	19 (51.4%)	7 (41.2%)	5 (33.3%)	6 (40.0%)
Role Play	16 (43.2%)	6 (35.3%)	5 (33.3%)	7 (46.7%)
Case Scenario	15 (40.5%)	9 (52.9%)	9 (60.0%)	7 (46.7%)
Experiential Immersion	10 (27.0%)	5 (29.4%)	3 (20.0%)	4 (26.7%)
Feedback	9 (24.3%)	3 (17.6%)	2 (13.3%)	3 (20.0%)
Clinical Experience	6 (16.2%)	1 (5.9%)	2 (13.3%)	3 (20.0%)
Model	5 (13.5%)	2 (11.8%)	1 (6.7%)	1 (6.7%)

Note. For each domain, the n reported represents the number of curricula that yielded statistically significant changes in outcomes for that domain.

Outcome Measurement.

Across the 37 curricula, outcomes were primarily measured using self-assessments (73.0%). Open-response questions (37.8%), journal entries (16.2%), exams (10.8%), behavioral observation (10.8%), and client-reported assessments of provider competence (2.7%) were also used. Common standardized measures included the Multicultural Counseling Inventory (Sodowsky et al., 1994), Multicultural Awareness Knowledge and Skills Survey (D’Andrea et al., 1991), Sexual Orientation Counselor Competency Scale (Bidell, 2005), Lesbian, Gay, and Bisexual Affirmative Counselling Self-Efficacy Inventory (Dillon & Worthington, 2003), and the White Racial Identity Attitudes Scale (Helms & Carter, 1990).

Content and Methods Common to Effective Trainings

The second aim of this review was to describe content and methods that were common in curricula that showed positive outcomes to the provider. To accomplish this, we first identified the studies that demonstrated positive outcomes on measures of attitudes, knowledge, or skills following the training. Then, we examined patterns of the content and methods of these curricula by outcome domain.

Attitudes.

Of the three domains of cultural competence outcomes, cultural attitudes were most frequently assessed (n = 33, 89.2%). Quantitative cultural attitudes outcomes were assessed in 22 (66.7%) of these 33 curricula. Of this number, seventeen (77.5%) curricula saw statistically significant impacts in the desired direction on providers’ attitudes and thus served as the sample for our examination of curricular content and methods (Table 3, “Attitudes” column). Among these effective curricula, race/ethnicity was the most frequently discussed cultural identity (64.7%) and all other cultural identity categories were discussed in approximately less than a third of curricula. Four topics (i.e., sociocultural/historical information, identity, client interaction, stereotypes) were discussed in over 80% of curricula that saw changes in cultural attitudes. Mental health diagnosis and treatment was the least common topic (58.8%). Didactic lectures appeared in every curriculum (100.0%) that found significant provider outcomes in attitudes.

Knowledge.

Cultural knowledge outcomes were assessed in 30 (81.1%) of the curricula. Quantitative knowledge outcomes were assessed in 18 (60.0%) of the 30 curricula, of which 15 (83.5%) yielded statistically significant increases in providers’ cultural knowledge (Table 3, “Knowledge” column). Among these 15 curricula, race/ethnicity (53.3%), sexual orientation (53.3%), and general multiculturalism (46.7%) were the most frequently discussed cultural identities. All other identities were discussed in less than 15% of curricula. Most topics, including theory, stereotypes, and client interactions, were discussed in over two-thirds of trainings, with the most common topic being sociocultural/historical information (93.3%). The least common topic discussed was discrimination and prejudice (53.3%). Lectures (93.3%) and discussion (80.0%) were the two most common instructional strategy used. Exercises (73.3%), assignments (66.7%), readings, and case scenarios were strategies that were also frequently used in curricula that saw positive outcomes in cultural knowledge. More behavioral strategies such as exposure to others with certain cultural identities (33.3%), role play (33.3%), and modeling (6.7%) were used less often.

Skills.

Cultural skills outcomes were assessed the least frequently (n = 25, 67.6%) among curricula. Quantitative outcomes were assessed in 19 (76.0%) of the 25 curricula that measured cultural skills. Of this, fifteen (78.9%) curricula found statistically significant increases in providers’ skills (Table 3, “Skills” column). Race/ethnicity (53.3%), sexual orientation (53.3%), and general multicultural identities (46.7%) were discussed in approximately half of curricula. All other cultural identities were discussed with lower frequency. In addition to sociocultural/historical information and identity, client interactions (73.3%), theory (66.7%), and mental health (66.7%) were discussed in curricula that found significant knowledge outcomes. Lectures (86.7%) and discussion (80.0%) were the two most common instructional strategies. Roleplays (46.7%) and reflections were used in approximately half of curricula, while other strategies related to skill acquisition such as feedback (20.0%) and modeling (6.7%) were used less often.

Discussion

This systematic review aimed to characterize cultural competence trainings delivered to mental health providers in terms of their features, content, methods, and outcome measurement. In addition, this review aimed to identify curricula content and methods that were common in trainings that showed positive outcomes in each cultural competence outcome domain (i.e., attitudes, knowledge, skills). We examined 37 unique training curricula from 40 published articles and have highlighted our findings to make recommendations for future trainings.

As previous reviews on cultural competence trainings have focused primarily on race/ethnicity, we assessed a broad range of cultural identities and topics in our review. One of the most important findings from this study is that the cultural identities represented in the curricula in our review were not equally distributed. Notably, most curricula focused on race/ethnicity, sexual orientation, gender, or general multicultural identities. This presents the question whether mental health providers have the necessary training to effectively serve individuals who come from other cultural backgrounds that are not well represented in the literature, a concern that reflects APA Ethical Standards 2.01a and 2.01b. Importantly, this review also found that discrimination and prejudice was the least discussed topic in curricula. This is concerning as marginalized individuals frequently experience discrimination in services, with studies finding that up to 81% of clients experience at least one microaggression in therapy (Hook et al., 2016). Given that microaggressions in therapy have been associated with weaker therapeutic alliance and poorer client outcomes (Owen et al., 2017), addressing not only how discrimination affects clients’ lived experiences, but also how providers can reduce discriminatory behaviors may create a downstream effect of positive outcomes. Importantly, addressing bias and discrimination in standard workforce training aligns with policy and practice recommendations to ameliorate structural racism in mental health service systems (Alvarez et al., 2021).

Another important set of findings involved content and methods of effective curricula. Effective curricula, as defined by significant changes in the desired direction, across all outcomes included sociocultural/historical information, cultural identity, and client interactions with high frequency. Curricula that yielded positive outcomes on cultural knowledge and cultural skills also included theory as a common topic. This aligns with the literature on training adults, which suggests that discussing how theoretical knowledge may enhance providers’ understanding or practical application of cultural competence is key to include in curricula (Yannacci et al., 2006). For curricula that found positive outcomes on cultural attitudes and knowledge, assignments, exercises, readings, and case scenarios were often used, in addition to lectures and discussions. Moreover, while some behavioral strategies appeared in curricula that found significant outcomes in cultural skills, there were opportunities to leverage more of these strategies to align with the adult learning and skill acquisition literature.

Overall, these findings are similar to those from previous reviews, in which didactic strategies were the most commonly used methods and active learning strategies, specifically modeling, immediate feedback, and direct clinical experiences, were used less often (e.g., Beach et al., 2005; Benuto et al., 2018). While didactic strategies are effective for increasing certain outcomes such as declarative knowledge (Bennett-Levy et al., 2009), they are not recommended by the adult learning literature to be used in isolation or over more active learning strategies. Active strategies such as role plays, feedback, and coaching have been found to be most effective in the training of mental health professionals (Beidas & Kendall, 2010). The active process of critical reflection, which was found in about half of curricula, has also been posed as particularly relevant for adult learners (Mezirow, 1991). Future research should examine whether cultural competence trainings that capitalize on active learning strategies such as modeling, role playing, reflections, and receiving corrective feedback might be even more effective than those that rely on didactic instruction, or whether the effects of active learning strategies might be differentially related to outcomes at post-training or more enduring effects over time.

Most studies in the present review used a single group pre-post study design. While randomized controlled trial designs have high value to understand the impact of trainings, we recognize that these rigorous designs may not be feasible for all training developers and for every context and that it is possible to collect useful training data using other methods (e.g., pre-post design with multiple outcome domains, including client perspectives). Relatedly, we found that training length varied drastically, ranging from a single-day 45-minute workshop to a nine-month biweekly commitment. While some literature suggests single-day workshops alone are ineffective at building mental health providers’ competencies (Beidas et al., 2012), the studies in this review demonstrated that both brief and longer trainings were successful at improving provider outcomes. This calls the field to consider how trainings can be designed to best match the contexts where mental health providers work, such as by adjusting the training duration. Other scholars have also advocated for trainings supplemented with ongoing contextual support such as consultation and supervision to consolidate learning from training (Frank et al., 2020).

Additionally, we found that self-assessment measures were the most common method of evaluating the impact of training on providers. While many measures have been validated, self-assessment evaluations of cultural competence do not necessarily reflect actual behavior and have been associated with social desirability (Constantine & Ladany, 2000). Future research could examine whether other methods, such as knowledge tests or behavioral observation of skills might provide different assessments of training outcomes (Kalinoski et al., 2013). It is also important to examine whether training improves client engagement and treatment outcomes (Lie et al., 2011). This may be informed by a meta-analysis or by examining client perspectives on the cultural competence of training participants.

In addition, we found that the population represented in most trainings were master’s-level graduate students. It is very positive that cultural competence is getting attention in the field at the pre-licensure level when professional habits are being established. Examining graduate school curricula and comparing curriculum requirements to cultural competence standards may inform our understanding of the role of education and training in developing cultural competence. At the same time, practicing professionals were represented in less than one-third of trainings in this review. Given that post-graduate mental health professionals report that training can facilitate engagement with underserved populations (Park et al., 2019), it is important to develop and support providers’ cultural competence after their training and formal education. Thus, agencies may consider how to promote and foster ongoing development of cultural competence for practicing professionals through providing and rewarding attendance of cultural competence training opportunities. Governing associations or accrediting bodies may also play a role in requiring regular cultural competence training (e.g., continuing education requirements).

Finally, the studies in this review included samples of mental health providers that represented different professional disciplines. Specifically, while counseling and clinical psychology trainees and professionals were often participants, individuals from social work, marriage and family therapy, and allied health professions (e.g., psychiatry, nursing) were also represented in the cultural competence trainings for mental health providers. In addition, more than one-quarter of training samples included individuals from different professional backgrounds. This finding reflects the interdisciplinary nature of mental health services, which is a context valued by the APA (2017a; 2017b) that both requires psychology’s attention and that represents an opportunity for scientific advancement. Although the number of studies that included individuals from professional backgrounds other than counseling and clinical psychology was too small for analytic comparisons with studies of counseling and clinical psychology trainees, our review found some similar results to a previous systematic review that examined trainings in clinical and counseling trainees and psychologists (Benuto et al., 2018), suggesting that the strategies and methods of other fields are not widely different from those of counseling and clinical psychology. It is possible and perhaps desirable for psychologists to borrow from and build upon strategies implemented within psychology and across similar fields. Moreover, as the demands of cultural competency change with time, the cross-fertilization of training ideas across fields can advance the professional practice and research of psychology more rapidly than siloed pursuits to address important issues in our field such as improving the quality of mental health care for culturally underserved communities.

Limitations

There are several limitations of this review to note. First, this review gathered curricula information reported only in published, peer-reviewed manuscripts. Unpublished work and official protocols were not requested from authors, thus presenting the possibility of publication bias and omission of curricula information described elsewhere. Second, novel training approaches, such study abroad programs and specific service-learning programs, were also excluded from this systematic review due to their non-standard formats. The studies and trainings in this review only represent information about cultural competence workshops and courses and therefore exclude curricula information that is potentially different and unique to these non-standard formats. Third, the descriptive nature of this review cannot be used to deduce causal relationships between specific curriculum elements and training outcomes. To make these claims, additional statistical testing is needed. Fourth, there is a potential for bias in the outcomes reported in this review, as most studies relied on self-assessment measures of cultural competence. However, this is a limitation of the methodology used in the field rather than of this specific review. Nevertheless, the patterns from this review provide training developers another source of information from the evidence base to use in designing future trainings.

Implications for Research and Curriculum Development

We identified several opportunities, which we pose as questions for future consideration by researchers/training developers:

1. Could the rigor of the study design be increased to advance our knowledge of cultural competence trainings in a meaningful way? For example, could the study design include a control group or longitudinal/follow up data collection methods? Could the study employ an additive or factorial design to examine the relative contributions of different training methods or content?

2. Could the curricula include theoretical knowledge to set the foundation for learning by emphasizing the relevance of cultural competence to providers and clients alike?

3. Could the curricula expand its focus to identities beyond race/ethnicity, such as cultural identities related to religion or immigration status? What are the principles or procedures that generalize across identities?

4. Could the curricula and training expand to include topics of discrimination and prejudice to gain knowledge about clients’ experiences and also opportunities for reflection about mental health providers’ awareness and ability to address their own discriminatory behaviors, such as microaggressions, and prejudiced beliefs?

5. Could the training incorporate active learning strategies, such as case vignettes, role playing, modeling, and providing feedback, to support practical application, reflection, and growth?

6. Could the study include multi-method (e.g., observation, questionnaire) and multi-informant assessment (e.g., trainee, client, supervisor) to examine how methods and perspectives converge or not?

In summary, this review demonstrates that cultural competence trainings are generally effective at shifting attitudes, increasing knowledge, and developing skills of mental health providers. In considering and applying the mentioned recommendations above, we hope that the science and practice of cultural competence trainings can continue to improve to support the mental health needs of culturally underserved communities.

Public Significance Statement:

This review demonstrates that cultural competence trainings are an effective method of shifting attitudes, increasing knowledge, and developing skills of mental health providers to support the mental health needs of culturally underserved communities. These findings can be used by developers of cultural competence trainings to develop, implement, and assess the outcomes of such trainings.

Biographies

Wendy Chu received her BA in psychology from Macalester College. She is currently a doctoral student in clinical-community psychology at the University of South Carolina. Her research interests explore how mental health providers address culture in treatment with the aim of increasing the access to and quality of mental health services for culturally underserved youth and families. She also examines the dissemination and implementation of evidence-based strategies and practices on treatment engagement in low-resourced school and community contexts.

Guillermo Wippold received his PhD in counseling psychology from the University of Florida. He is a licensed psychologist and an Assistant Professor in the Department of Psychology at the University of South Carolina. His research interests include the concept of health-related quality of life – a multidimensional conceptualization of health that includes psychological, physical, and social functioning. His work uses a community-based participatory research framework to develop, implement, and evaluate health-promoting interventions among at-risk communities.

Kimberly D. Becker received her PhD in psychology from the University of Arizona. She is a licensed psychologist and an Associate Professor in the Department of Psychology at the University of South Carolina. Her research interests include improving the effectiveness of children’s mental health services, with specific interests in clinical decision-making and treatment engagement. She also collaborates with community partners on workforce training and development.