Beyond multicultural competency: a scoping review of multicultural orientation in psychotherapy and clinical supervision
| Date | 28 February 2024 |
| Pages | 1095-1119 |
| DOI | https://doi.org/10.1108/MHSI-01-2024-0012 |
| Published date | 28 February 2024 |
| Subject Matter | Health & social care,Mental health,Social inclusion |
| Author | Daryl Mahon |
Beyond multicultural competency: a
scoping review of multicultural orientation
in psychotherapy and clinical supervision
Daryl Mahon
Abstract
Purpose –Psychotherapy and clinical supervision outcomes are influenced by client and supervisee
factors, one of which is culturalidentity. Those with diverse racial and ethnic minoritised identities often
experience disparities in therapy outcomes. Therapists and supervisors need to be responsive to the
identity of those they support. The multicultural orientation (MCO) frameworkis an emerging concept in
psychotherapyand clinical supervision that may offerthese practitioners a framework to be responsive.
Design/methodology/approach –A preferred reporting items for systematic reviews and meta-
analyses extension for scoping reviews was conducted. Six databases, PubMed, Scopus, Embase,
Academic SearchComplete, Web of Science and PsychInfo, weresearched for peer-reviewed literature
publishedin English between the years 2000 and2023.
Findings –A total of 1,553 sources wereidentified, of which (n¼42) are included in this review. Findings
suggest that MCOis still in its infancy as applied to therapy and clinical supervision.Most of the research
has been conducted in America, using quantitative methodologies with white western populations.
Culturalhumility is the most studied MCO pillar, and variables suchas reductions in psychological stress,
the working alliance and microaggressions are reported on as outcomes. MCO applied to the group
therapy process is an emerging finding of interest. However, more research is needed, especially
experientialdesigns across different and diverse populationsand contexts.
Originality/value –MCO is an emerging therapy and clinicalsupervision process that has the potential
to improve the outcomes for therapy clients and supervisees. Further research is needed to replicate
current studies, and further research with diverse populations, countries and contexts should be
undertakenas a priority.
Keywords Multicultural orientation framework, MCO, Cultural humility, Multicultural competency,
Multicultural supervision, Culturally sensitive
Paper type Literature review
1. Introduction
As societies become increasingly less homogenous, there is an awareness of the need for
behavioural health care to be more responsive to different cultural needs (Stanford, 2020;
Truong et al., 2014;Ziegler et al.,2022). Psychotherapeutic interventions are a key first-line
intervention in many countries. However, research underpinning these evidence-based
practices is largely Euro/American centric (Arnett, 2008;Huey et al., 2014;Koc¸ and Kafa,
2019;Sue and Sue, 2013). Using homogenous samples can pose threats to the external
validity of interventions, meaning such interventions may not be as effective for those with
diverse identities. According to Mahon and Jeawon (2022), “cultural responsiveness is the
process by which individuals and systems respond respectfully and effectively to the
diversity within individuals from all cultural backgrounds, embracing differences across
language, gender, religion, spiritual tradition, disability and socioeconomic or ethnic
backgrounds”.
Daryl Mahon is based at the
Outcomes Matter, Wicklow,
Ireland.
DOI 10.1108/MHSI-01-2024-0012 VOL. 28 NO. 6 2024, pp. 1095-1119, ©Emerald Publishing Limited, ISSN 2042-8308 jMENTAL HEALTH AND SOCIAL INCLUSION jPAGE 1095
Practitioners are increasingly working with individuals from diverse backgrounds and need
to have strategies to support those who may have different explanatory health models
based on different cultural values and beliefs (Benish et al.,2011). Indeed, research
documents disparities in psychotherapy outcomes for ethnic minoritised clients, with white
clients tending to benefit more from therapy (Drinane et al., 2016;Hayes et al.,2015;Imel
et al.,2011
). It is not just the outcome of care that is impacted on. How individuals access
and interact with behavioural health care is influenced by culture and the cultural sensitivity
of the service provider (Jeawon and Mahon,2023).
There is an increasing awareness of disparities in mental health outcomes among
marginalised groups. Those of different ethnic and minoritised identities often access care
less when compared to natives, and when they do, outcomes tend to be of a lesser quality
(Cook et al., 2017;Lee-Tauler et al.,2018). For example, systematic review and meta-
analyses demonstrate that refugees present with elevated levels of post-traumatic stress,
anxiety and depression (Bustamante et al., 2017;Bogic et al.,2015;Henkelmann et al.,
2020;Morina et al., 2018). Moreover, various factors influence not just prevalence of mental
health but also maintenance and recovery, meaning refugees often have worse mental
health outcomes (Nowak et al.,2023;S
aet al.,2022). Similarly, those with diverse sexual
identities also suffer from disparitiesin accessing behavioural health care and mental health
outcomes (Malik et al.,2023).
One approach put forward to work more effectively with diversity is the multicultural
competency framework (MCC) (Sue et al.,1992;Sue and Sue, 2013). The tripartite model of
MCC put forward by Sue and Sue (2013) identifies cultural competency as being made up
of:
䊏awareness of one’s own personal beliefs, values, biases and attitudes;
䊏awareness and knowledge of the worldview of culturally diverse individuals and
groups; and
䊏utilisation of culturally appropriate intervention skills and strategies.
Later research built on Sue et al. (1992) model by exploring methods of adapting
psychotherapy treatment to various demographics through cultural adaptations. Bernal
et al. (1995) suggested adapting aspects of therapy such as language, persons,
metaphors, content, concepts, goals,methods and context. Several meta-analyses provide
evidence for the effectiveness of adapting psychotherapy to culturally diverse populations
(Benish et al.,2011;Davis et al.,2016;Griner and Smith, 2006;Taoet al., 2018; Soto et al.,
2018;Smith et al., 2011, 2010), with some of these outcomes mediated through the
therapeutic alliance. Indeed, Tao et al. (2015) meta-analysis suggests that client ratings of
practitioners’ MCC account for approximately 37% of the variance in the therapeutic
alliance and 52% of the variance in client satisfaction. This is an important finding
considering the predictive nature of the therapeutic alliance on treatment outcomes (Mahon
et al.,2023
).
However, the MCC framework has been critiqued as having various limitations in
operationalisation, measurement and outcomes (Drinane et al., 2016;Hook et al., 2013;
Huey et al.,2014;Owen et al., 2011). Other research suggests that cultural competency
training has limited utility on health-care service user satisfaction or recovery outcomes
(Beach et al., 2005;Truong et al., 2014;Lekas et al., 2020) make the case that cultural
competency approaches have the potential to stigmatise and stereotype individuals, while
also not taking account of intersectionality. Intersectionality is a theoretical framework for
describing how aspects of a person’s social and political identities combine to create
different modes of discrimination and privilege. For example, sex, gender, race, sexuality,
class, religion, disability and physical appearance (Crenshaw, 1991). As such, therapists
focusing on using cultural competencyto intervene in one aspect of a person’s identity may
PAGE 1096 jMENTAL HEALTH AND SOCIAL INCLUSION jVOL. 28 NO. 6 2024
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