(WITHDRAWN) A Critical Review on Cross-Cultural Clinical Practice: Toward Reducing Cultural Inequality in Mental Health Knowledge Production

Background: This critical review provides an overview of key themes and methodologies in the cross-cultural clinical practice literature. This study seeks to fill a gap in review literature that tends to favour therapist perspectives, is largely based on majority therapist-minority client dyads, and excludes factors beyond race and ethnicity when conceptualizing the therapeutic relationship in cross-cultural encounters. Specifically, this review explored the types of cross-cultural clinical encounters that have been studied related to multicultural and cross-cultural competencies, cross-cultural clinical processes, and various sociocultural differences including race, ethnicity, sexual and gender orientations, class, age, nationality, (dis)ability, and cultural values.

 

Methods: A critical review method allows researchers to “take stock” (Grant & Booth, 2009, p. 93) of the state of literature and its contributions to the field (Grant & Booth, 2009). This method focuses on the conceptual contribution of existing research and identification of opportunities for future research. Inclusion criteria of the current study was all forms of cross-cultural clinical practice from 1980-2018 that involved a clinician (of any professional background such as social work, psychology, counseling, psychiatry). Exclusion criteria involved studies related to biomedical care such as non-psychotherapy-oriented physician-patient cross-cultural practice and public health practices. Analysis involved extraction of key information from each study that was then critically analyzed for content, theoretical framework, characteristics of participants or population, and gaps. A final sample included 70 articles composed of 10 quantitative, eight reviews, 19 qualitative, 14 case studies, 18 theoretical/commentary, and one mixed methods article.

Results: Results yielded a large body of research founded on Sue and colleagues’ (1992) model of Multicultural Competencies (MCC). This research focused on (1) correlations between aspects of MCC and therapy outcomes; (2) how MCC has been fostered through professional training and practice; and (3) the impact of client-therapist racial matching and culturally adapted therapeutic interventions. The next primary theme focused on therapeutic processes within the cross-cultural dyad. These included processes of both transference and countertransference as well as the use of conversation analysis techniques to capture negotiations and tacit demonstrations of cultural themes arising within clinical sessions. These themes were similar in various cross-cultural dyads including cross-gender, sexual orientation, class, and ability dyads beyond cross-racial or cross-ethnic studies.

 

Conclusions and Implications: This review yielded a wide variety of content and methodologies within the cross-cultural literature. Due to diverse approaches, methodologies, and goals of therapy, there are apparent challenges in developing an operationalized definition of culturally responsive, competent, and safe practice. Sue and colleagues’ original MCC framework, while foundational in the field, is limited to four racial and ethnic minority groups and excludes alternative dyads outside of a Eurocentric context. Research that essentializes minority clients also limits opportunities to understand key dyadic processes that impact clinical experiences of both therapists and clients of either majority or minority backgrounds. Literature would also benefit from a stronger link between therapeutic processes and broader sociocultural factors to empower clients and resist existing systemic barriers faced outside the clinical encounter.