Keywords

The current zeitgeist in applied psychology training portrays the development of cultural competence as a necessary and highly valued component of clinical training (DeAngelis, 2015; Mena & Rogers, 2017). This has prompted the American Psychological Association (APA) to create guidelines for multicultural education, training, research, practice, and organizational change for psychologists (APA, 2002), as well as mandate culturally competent behavior in its Ethical Principles of Psychologists and Code of Conduct (APA, 2017). If students attending applied psychology training programs are expected to develop cultural competencies, then they must be exposed to structured experiences designed to assist them in this goal. Such experiences include, but certainly are not limited to, didactic classroom instruction. It is also not clear whether practicing professionals require additional training as they face new situations (e.g., their caseload includes a minority group for which they have little experience), or need “refresher” courses because either their skills might decay, or because the field may advance. Interestingly, professional scholarly opinion as to the feasibility of teaching cultural competence training (across a variety of sources both within and outside of applied psychology) tends to vary considerably. These differences of opinion can be subdivided into three broad categories, which acknowledges that subcategories within each of these broad categories also exist.

The first category includes writers who support commonly given justifications as to the need for cultural competence, accept implicitly how the construct has been defined, and support the urgency for developing cultural competence as a permanent and ongoing professional trait in future practitioners. Some advocates within this first category see the construct of cultural competence in strictly moral terms – believing that the teaching of cultural competence is necessary in order to help learners understand the impact of social structures on power, privilege, and oppression (e.g., see Cultural Competence Training in the Context of Civil Liberties chapter, this text; Robinson, Cross-Denny, Lee, Rozas, & Yamada, 2015) – or rid learners of conscious or unconscious moral evils (e.g., “racism”). According to Torino (2015), for example, cultural competence is increased when White counseling trainees develop a “non-racist White racial identity” through teaching that helps them to examine their biases and explore their White privilege.

Other writers believe implicitly that cultural differences result in chasms of misunderstanding between individuals that are so difficult to bridge, that intensive special training is needed to bridge the gap. Priya (2017) opined that “all psychotherapy is cross-cultural, as even a clinician and a patient from similar socio-demographic backgrounds may have widely differing constructs of mental health, relationships, and indeed of the psychotherapeutic process itself” (p. 55).

She argues that a culturally competent supervisor provides teaching strategies for supervisees that enables them to “navigate . . . intersecting cultural forces” in psychotherapy (p. 55). Leonard and Plotnikoff (2000) assert that “although knowledge of many cultures is impossible, [the] willingness to learn about, respect, and work with persons from different backgrounds is critical to providing culturally competent care” (p. 51).

Although these writers opine that “correct attitudes” are the fundamental ingredient for developing cultural competence, other writers believe that cultural competence is fully attainable with the right “toolkit.” The toolkit approach essentially argues that if consumers are provided with explicit and concrete step-by-step procedures to implement in practical settings, a comprehensive array of hands-on materials that can be used in practice (e.g., treatment guides for specific cultural populations [Benuto, 2017; Benuto & Leany, 2017], assessment guides [Benuto, 2013a, 2013b], etc.), reproducible instruments to use for evaluation of training outcomes, easy access to outside informational resources for networking/partnership opportunities and continuing education, appropriate case study materials that explore a wide variety of diversity issues (e.g., Benuto & Bennett, 2015), and links to published studies which presumably provide research support for an intervention – that cultural competence is fully achievable. As one example of this approach, Jeffreys (2015) describes the benefits of a recent textbook for developing cultural competence in nursing and health-care professionals:

These hands-on, user-friendly resources reveal a systematic seven-step approach that takes nurses, educators, administrators, professional association leaders, managers . . . students, and other health care providers from their own starting points toward the pinnacle – optimal cultural competence. (p. xv)

In short, trainers whose views most closely align with this first category seem relatively unconcerned about questioning the legitimacy and validity of the cultural competence construct. What seems most important to these advocates is for audiences to (1) recognize its importance and (2) do whatever is necessary for practitioners to “get it.” In addition, they seem to adhere to what Kiesler (1971) has classically called “client uniformity myths.” The problematic idea in this is that trainees are so uniform that some standard training will result in the same positive effects for all. Of course, this is more than a little ironic given the general diversity ideology of this training. Important empirical questions remain regarding the extent to which these cultural trainings are effective at producing cultural competence (whatever this may mean) and the extent to which trainee variables interact with trainings to produce differential outcomes.

A sizable number of writers, while asserting that cultural competence is widely considered to be an important component of practitioner training – also concede that cultural competence remains challenging, if not difficult, to operationalize clearly (Frisby, 2009; O’Donohue & Benuto, 2010; Priya, 2017; Sue, Zane, Hall, & Berger, 2009). Other writers are bothered by what is perceived to be an overly simplistic manner in which the term is defined and understood conceptually (Kleinman & Benson, 2006), its tendency to occasionally lead audiences into faulty assumptions about clients that should be avoided in practice (Stuart, 2004), the observation that cultural competence has not been adequately differentiated from similar psychological constructs (Frisby, 2009), the perception that cultural competence is more discussed than it is empirically investigated in the professional literature (Worthington, Soth-McNett, & Moreno, 2007), and the lack of evidence of its predictive validity in real-life contexts – especially if it is positively correlated with client outcomes (Braden & Shah, 2005).

These and other writers comprise a second category, which sees value in pursuing the positive features of the cultural competence construct that are conceptually and empirically defensible – while at the same time recognizing (and seeking to correct) its conceptual and empirical shortcomings. It is reasonable to assume that these scholars would include important caveats and safeguards in the teaching of cultural competence.

A third category of scholars have serious concerns about the cultural competence construct – and by extension its ability to be successfully taught to students. These concerns focus on the ideological, definitional, and/or empirical problems that are deeply intertwined within the cultural competence construct. Some writers essentially argue that the biased sociopolitical and ideological roots of cultural competence advocacy have poisoned the scientific and professional integrity of the movement. For example, Weinrach and Thomas (2004) opine that the Association for Multicultural Counseling and Development’s (AMCD) multicultural counseling competencies are essentially “political . . . in nature,” and their tone and style are more consistent with a “manifesto” designed to establish a “political identity to the groups that issue them” (p. 85). They observe that anyone who disagrees with any aspect of how cultural competence is defined is routinely demeaned by militant cultural competence advocates (at least within the counseling psychology profession) as “racist,” “ethnocentric,” “Eurocentric,” and suffering from “White privilege” or “White supremacy.”

Other scholars essentially argue that audiences are prone to overlook significant difficulties in the cultural competence movement’s fundamental definitional and conceptual assumptions. For example, O’Donohue and Benuto (2010) point out serious problems with the lack of clarity in defining “culture” and “sensitivity,” as well as problems in defining what elements of a treatment need to be culturally tailored for a particular cultural group (Benuto & O’Donohue, 2015). Patterson (2004) argued that there is a faulty assumption in the literature whereby counseling or psychotherapy is a simple matter comprised solely of information, knowledge, practices, skills, or techniques. Patterson also questioned the assumption that differences between the clinician and the client outweigh the importance of similarities. Patterson suggested that a focus on similarities between the client and clinician could lead to improved rapport.

Finally, many writers argue that the cultural competence movement is lacking a solid empirical base that justifies specific practice recommendations. At the time of their writing, for example, Atkinson and Israel (2003) argued that very little research supported the validity of multicultural counseling competencies promoted by professional organizations or policy changes that have been implemented by the APA and other professional organizations related to the promotion of multicultural counseling competencies. Patterson (2004) concluded that there is no evidence for the appropriateness or effectiveness of specific methods, techniques, or skills for working with multicultural clients. Moreover, research findings indicate that little professional consensus exists among experts as to the nature of cultural competence and its components (Cunningham, Foster, & Henggeler, 2002), and clients do not rate therapists with specialized training superior to those without (Stanhope et al., 2008). As a result of disappointing findings from a study designed to identify consensus among family caregivers, family advocates, administrators, and community stakeholders in the children’s mental health system, Davis (2004) concluded:

. . . the dearth of empirical support for culturally related concepts and practice models raises troubling questions about the foundations upon which social work students are being educated about culturally responsive practice. (p. 220)

Reviews of Cultural Competency Training

Using meta-analytic techniques, Smith, Constantine, Dunn, Dinehart, and Montoya (2006) concluded that multicultural education interventions were typically associated with increased cultural competency largely assessed through the administration of self-reported questionnaires across a wide variety of participants and study characteristics. In addition, they found that multicultural education interventions which were explicitly founded on research-based principles of multicultural competence (and included theory-based curricula) yielded outcomes nearly twice as beneficial as those that were not.

However, Smith et al. (2006) failed to define what exactly was meant by “research-based principles” and “theory-based curricula,” in addition to noting other problems in the studies they reviewed (e.g., see Benuto, Casas, & O’Donohue, 2018 for additional details). Lie, Lee-Rey, Gomez, Bereknyei, and Braddock (2011) reviewed seven studies involving health professionals that focused specifically on the positive relationship between cultural competency and patient outcomes but did not expressly focus on mental health professionals. Most recently, Smith and Trimble (2016) conducted a meta-analysis of surveys and outcome studies with the aim of assessing the extent to which multicultural training improved therapists’ ability to effectively serve diverse clients. Unfortunately, their review was not published in a peer-reviewed journal, and as such the review did not undergo a peer-reviewed evaluation process. In addition, a substantial proportion of studies they reviewed included samples of undergraduate students (i.e., not professional therapists), and there is a large degree of variability across helping professions with respect to the types of services delivered and the type of training that is mandated by the associated professional organization (e.g., the American Psychological Association vs. American Association for Marriage and Family Therapists).

Mills et al. (2016) used a pre- vs. posttest questionnaire to assess the effects of a 1 h didactic teaching session on the DSM-V cultural formulation interview with psychiatry residents and found that mean scores changed significantly (in a positive direction) as a result of the intervention. Although they noted important limitations in these results, they concluded that “psychiatry residents’ cultural competence scores improved” (p. 829) as a result of the training. This conclusion stays close to the data; however, the overall title of the research article does not – which reads, in part: Training on the DSM-5 Cultural Formulation Interview Improves Cultural Competence in General Psychiatry Residents. Here, increases in scores on a self-report paper and pencil instrument do not necessarily reflect actual changes in cultural competence as generally demonstrated in an actual work setting (Frisby, 2009).

Current Review of Cultural Competency Training Goals

Benuto et al. (2018) conducted a systematic review of how psychologists are trained for cultural competence. They addressed the following specific questions :

  1. 1.

    What research methodologies are employed to examine the effects of cultural competency training?

  2. 2.

    How are psychologists trained to be culturally competent, including what are the specific goals of cultural competency training?

  3. 3.

    How are training outcomes assessed (i.e., what are the expected outcomes of cultural competency trainings)?

  4. 4.

    What are the outcomes of cultural competency training?

Benuto et al. (2018) searched several different databases (PsycARTICLES, PsycCRITIQUES, PsycINFO, Social Work Abstracts) through March 15, 2017, using different combinations of the following key terms: “cultural competence,” “cultural sensitivity,” “training,” “psychology,” “mental health,” “multicultural,” “education,” “psychotherapy,” “psychotherapists,” and “psychologists.” After omitting duplicates, book chapters, and nonempirical dissertations and peer-reviewed manuscripts, the final pool for analysis consisted of 563 dissertations and peer-reviewed manuscripts.

These 563 abstracts were reviewed by two independent raters to determine which sources examined cultural competency training outcomes using clinical or counseling psychologists/trainees in the United States or Canada. From the abstracts that were reviewed, a total of 17 training outcome studies (published between 1984 and 2014) ultimately met the inclusion criteria.

According to Benuto et al. (2018), 82% of the outcome studies used a between-group design with a control group, with graduate students (including interns) constituting the majority of participants. The majority of the studies reviewed provided little or extremely limited information about curricular content. Of the information that was provided, the following subset of topics were covered: racism and discrimination, worldviews, cultural identity, general concepts about culture, biases, information about specific cultural groups, and information about the clinical/client interaction as it related to cultural competency or diversity. Even when attempts were made to describe curricular content, Benuto et al. (2018) opined that descriptions of curricular content were often vague (e.g., the amount of time spent on each topic was unclear; topic material covered was unclear; and particular cultural groups covered was often not clearly specified) and trainings were not manualized (for details as to curricular methods used, see Benuto et al., 2018).

The majority of studies reviewed by Benuto et al. (2018) used questionnaires to assess knowledge and awareness rather than actual concrete skill development relevant for professional practice (for details of instruments used, see Benuto et al., 2018). The majority of the studies reviewed by Benuto et al. (2018) indicated positive changes with regard to knowledge; however, outcomes related to attitudes, awareness, and self-report of skills were mixed (i.e., some studies indicated positive changes after training and other studies resulting in no significant changes). For a more detailed explanation of findings, see Benuto et al. (2018). However, again, it is still unclear whether such positive knowledge gains reach some cutoff for “cultural competence.” Again, it is also unclear if such a generic construct make sense or whether cultural competence is tied to a specific cultural group, e.g., cultural competence in treating African-Americans or cultural competence is assessing Latinos.

According to Benuto et al. (2018), 9 of the 17 studies that were identified in this systemic review of the literature also employed qualitative methodologies including 6 studies that employed mixed methodology and an additional 3 studies that employed exclusively qualitative methodology. Results from the studies that examined qualitative data as a mechanism for assessing training outcomes included studies that evaluated feedback from trainees. One study reviewed used course evaluations which revealed that trainers should consider the cultural background of the trainees [when preparing training material]. According to Benuto et al. (2018), this was consistent with Klausner’s (1997) finding that instructor characteristics are important to training experiences. Specifically, instructor characteristics that were rated positive included those who fostered personal safety in the classroom for sharing life experiences, feelings, and beliefs; were open and receptive to students’ comments, questions, and concerns; were provocative and challenging; and appropriately shared relevant, personal experiences. According to Benuto et al. (2018), results from Tomlinson-Clarke’s (2000) study indicated that trainees felt that the diversity of the trainees and the interactions among trainees were a strength of the training and enhanced multicultural learning.

Benuto et al. (2018) summarized trainees’ comments as to aspects of cultural competence training that they found most useful. Their review revealed the following trainee observations: course readings were useful, but additional discussion regarding the readings would have been helpful; students did not find presenting about their own culture or keeping a journal during the course to be particularly useful, but indicated a desire to learn factual information about different cultural groups; guest speaker presentations, cultural exploration, and cross-cultural contact were found to be most important; and exposure to different people, readings, films, lectures, and panels helped to develop multicultural awareness (see Benuto et al., 2018 for additional details). However, again, it must be noted that trainees finding material useful is not the same as data indicating that such trainings actually produced culturally competent practice.

Benuto et al. (2018) discussed three studies that used service learning (i.e., multicultural training that allows trainees to learn about culture in context through various types of community service activities) as a training platform. One study (Roysircar, Ortega, Hubbell, & Gard, 2005) had trainees mentor ESL students as part of the training. When trainees’ narrative reflections were analyzed, trainees identified concepts of relationship and alliance building (i.e., differences being integrated, cultural empathy, affective empathy), intra- and interpersonal dynamics (i.e., counselor self-disclosure and self-reflection), and cultural norms, values, and practices (i.e., unintegrated differences, stereotypes, and overgeneralization of similarities). Benuto et al. discussed one study that had trainees write reflections about their experience with service learning (Lee, Rosen, & McWhirter, 2014). When reflections were analyzed for themes, trainees appreciated the importance of building rapport and connecting with others (in this case the students that they were working with). Benuto et al. (2018) discussed one study that examined the experiences and outcomes (via interviews) of trainees after they completed a service-learning course based on social justice principles in Belize (Koch, Ross, Wendell, & Aleksandrova-Howell, 2014). Findings indicated that trainees experienced a change in diversity attitudes; growth in their self-rated multicultural counseling competence, counseling skills, and leadership skills; an increased awareness of the need for multicultural competency; increased knowledge; and an increased appreciation of individuals who are different.

Benuto et al. (2018) concluded that the training studies had many methodological flaws, lacked information regarding the specifics of training, the implications for trainee benefits were unclear, and there has been no demonstration that cultural competency trainings resulted in improvements for clients. The authors give recommendations for future research as a result of their findings. In their view, future research needs to (1) employ more rigorous methodology (i.e., RCTs, dismantling designs) to move the field toward developing evidence-based training practices; (2) authors should provide their training manual as online supplemental material as a way to promote accessibility to training materials (and allow for replication); and (3) develop an improved understanding of what elements (i.e., trainer characteristics, training methods, etc.) are related to the outcomes of cultural competency trainings.

While the APA (2002) created guidelines for multicultural education and training (and research, practice, and organizational change) for psychologists, these guidelines provide information regarding the necessity of multicultural education and training for psychologists but do not provide specifics regarding how this training should be delivered. As such, it is not surprising that the existing research on training psychologists to be culturally competent practitioners is sparse, varies substantially, and comes with many methodological flaws. As suggested by Benuto et al. (2018):

Because there is not sufficient information to suggest that specific curricular methods or content produce strong outcomes, the field should reconsider the foundation of cultural competency training using psychological science as a basis. This may include an examination of the empirical literature regarding what clinician characteristics and behaviors are linked to poor or positive client outcomes [for diverse clients] and a review of the strategies that have documented success in changing problematic clinician characteristics (i.e., attitudes, biases, and stereotypes) and behaviors. With this behavioral focus, evaluating skills (and possibly client outcomes) would be appropriate.

The field as it stands is ripe for the development of evidence-based trainings, which as suggested above, can be developed using a clinical science model.