Highlights
- • Trainings aiming to develop antiracist competencies are provided to various mental health professionals.
- • Four main components of antiracist competencies addressing racism at different levels were found.
- • Knowledges on social, cultural, historical aspects of racism, awareness of own biases, non-oppressive approaches contribute to provide antiracist care.
- • Evaluated programs showed that trainings on antiracist competencies contribute to decrease biases, negative stereotypes and racial microaggressions, and to have better therapeutic alliance with patients.
Abstract
Racism has been shown to be directly deleterious to the mental health care received by minoritized peoples. In response, some mental health institutions have pledged to provide antiracist mental health care, which includes training mental health care professionals in this approach. This scoping review aimed to synthesize the existing published material on antiracist training programs among mental health care professionals. To identify studies, a comprehensive search strategy was developed and executed by a research librarian in October 2022 across seven databases (APA PsycInfo, Education Source, Embase, ERIC, MEDLINE, CINAHL, and Web of Science). Subject headings and keywords relating to antiracist training as well as to mental health professionals were used and combined. There were 7186 studies generated by the initial search and 377 by the update search, 30 were retained and included. Findings revealed four main antiracist competencies to develop in mental health professionals: importance of understanding the cultural, social, and historical context at the root of the mental health problems; developing awareness of individual biases, self-identity and privilege; recognizing oppressive and racism-sustaining behaviors in mental health care settings; and, employing antiracist competencies in therapy. Professionals who have taken trainings having the main components have developed skills on the interconnectedness between racialized groups’ mental health and the cultural, religious, social, historical, economic, and political issues surrounding race, necessary for successful clinical practice and for providing anti-racist mental health care. This scoping review presents a summary of the essential antiracist competencies drawn from the literature which must be applied in a mental health care setting, to improve help seeking behaviors, and reduce distrust in mental health care professionals and settings.
Keywords
Antiracist training, Mental health care, Mental health professionals, Antiracist competences
1. Introduction
The protests following the murder of George Floyd and other Black people in the United States (USA) and the racial disparities in health outcomes observed during the COVID-19 pandemic led various regulatory bodies of the mental health professions in the USA, United Kingdom (UK), Canada, New Zealand to take positions condemning systemic, structural, institutional and interpersonal racism (Ahuriri-Driscoll, Lovell, Te Kawa, MacDonald, & Mathias, 2022; American Psychological Association, 2020; Barber, 2020; Mensah, Ogbu-Nwobodo, & Shim, 2021; Tedam & Cane, 2022). A call to action included better education of mental health professionals and students about racial disparities in mental health, raising awareness of racism at different levels in their respective fields, and providing concrete steps to address the consequences of racism in the provision of care to achieve mental health equity (Mensah et al., 2021). Racial discrimination is associated with complex consequences for the health and lives of racialized people (Barber, 2020; Mensah et al., 2021). However, mental health practitioners (psychiatrists, psychologists, and others) are generally not adequately trained to address the consequences of racism, to treat the specific needs of racialized people, or to provide culturally appropriate and antiracist mental health care (Cénat, 2023; Mensah et al., 2021).
Lack of antiracist training among health professionals contributes to the perpetuation of racism and the colorblind approach in mental health care (Mensah et al., 2021). Colorblindness is a racial ideology that postulates that the best way to end racism is to treat individuals as equally as possible, regardless of their racial, cultural or ethnic background (Bonilla-Silva, 2017; Williams, 2011). It is recognized as a racist approach in the sense that it ignores the racist experiences of racialized people, which nonetheless impact their physical and mental health, as well as their social wellbeing (Cénat et al., 2022; Cénat, 2023). Studies conducted in the USA, Canada, UK and elsewhere reveal that most Black, Indigenous, and other People of color (BIPOC) have experienced racial discrimination in healthcare settings (Cénat et al., 2022; Gagné & Veenstra, 2017; Stern, Barbarin, & Cassidy, 2022; Taylor & Richards, 2019; Veenstra, 2012). Without antiracist training, mental health professionals are also ill prepared to address racial trauma, which has significant impacts on physical and mental health, family, social, occupational, and economic aspects of the lives of racialized people (Cénat, 2023; Williams, Khanna Roy, MacIntyre, & Faber, 2022). Racial trauma, defined as the harmful mental and emotional injury caused by experiences related to threats, harm, shame, humiliation, and guilt associated with various types of racial prejudices and discrimination, needs to be recognized and addressed in clinical settings as evidenced, for both direct victims and witnesses (Cénat, 2023). For example, a study revealed that Black participants who experienced high levels of race-based discrimination were 36.4 times more likely to experience severe depressive symptoms compared to those who experienced low levels of racial discrimination (Cénat et al., 2021). The long-term effects of racism are numerous, including hypervigilance, chronic stress, depression, anxiety, PTSD, but also hypertension, diabetes, heart diseases, and premature death (Cénat et al., 2021; Cénat, Dalexis, Darius, Kogan, & Guerrier, 2023; Cénat, Farahi, & Dalexis, 2023; Gagné & Veenstra, 2017; Kogan, Noorishad, Ndengeyingoma, Guerrier, & Cénat, 2022; Veenstra, 2012).
Inadequate training in caring for racialized people creates barriers for accessing care, including discontinuity of care, lack of trust in health care providers and services, over-medication, as well as use of inappropriate and Eurocentric treatments (Alang, 2019; Cénat et al., 2024; Faber, Khanna Roy, Michaels, & Williams, 2023; Hickling, 2012; Planey, Smith, Moore, & Walker, 2019). Thus, it is relevant, and urgent to analyze existing antiracist mental health training programs to examine whether the goals and competencies targeted improve the skills of mental health care practitioners and the care received by patients.
1.1. The present study and objectives
Recognizing the deleterious effects posed by racially inappropriate care as well as the problem of the color-blind approach on mental health treatment for racialized people, research has increasingly focused on developing antiracist training programs (Mensah et al., 2021; Tedam & Cane, 2022). However, the existing training programs cover varied content, components, and targets for skills and competencies development. Importantly, their effectiveness remains unknown (Mensah et al., 2021; Tedam & Cane, 2022). Considering the diversity of training programs, target audiences and competencies, the purpose of this scoping review is to examine existing antiracist mental health care training programs, present their goals, contents, components, and the competencies they aim to develop in professionals, and assess their efficacy in helping professionals develop antiracist skills and provide antiracist care to racialized patients.
2. Methods
2.1. Search strategy
This review sought to identify studies describing antiracist training opportunities and programs created for or offered to mental health professionals. A research librarian with experience in planning systematic reviews drafted, developed, and implemented a search strategy to find relevant published articles in APA PsycInfo (Ovid), Education Source (EBSCOhost), Embase (Ovid), ERIC (Ovid), MEDLINE (Ovid), CINAHL (EBSCOhost), and Web of Science (Clarivate). The strategy was informed by ones conducted in previous reviews on antiracist, diversity or cultural sensitivity training (Benuto, Casas, & O’Donohue, 2018; Hassen et al., 2021; Wang, Shlobin, DiCesare, Holly, & Liau, 2022) and on mental health professionals and practitioners (Banwell, Humphrey, & Qualter, 2021; Brown, Kucharska, & Marczak, 2018; Sandford, Kirtley, Thwaites, & O’Connor, 2021). A draft strategy, which included subject headings and keywords, was developed for APA PsycInfo (Ovid) by the research librarian and feedback was obtained from other review team members. The strategy was also peer-reviewed by another librarian following the Peer-Review of Electronic Search Strategy guidelines (McGowan et al., 2016). The final strategy was executed on October 20, 2022 and updated on July 18, 2023. The search did not use any database limits related to language, date, or other options. The complete search strategy is available in Supplementary File 1. Citations found through the database searches were imported into Covidence, an online tool used to manage various steps of a systematic review’s screening phases. Duplicate references were identified and removed once imported into Covidence.
2.2. Steps for selection
As shown in the PRISMA flow diagram (Fig. 1), a total of 10,602 studies were imported into Covidence for screening. After duplicates were removed, 6 Authors (CB, FMB, GU, OO, SM, SEF) completed the title and abstract screening of 7186 articles (October 20, 2022) for the first search and 373 for the updated search on July 18, 2023. A total of 163 articles were assessed for eligibility and 133 were excluded for various reasons (45 did not include antiracist care; 45 were books, dissertations, scoping reviews, meta-analyses, literature reviews; 14 were not among healthcare professionals; 11 measured mental health care professionals’ aptitudes only; 8 measured/focused on the client’s opinion only; see Fig. 1 for all the details). Each step was conducted by a group of two and all the conflicts were resolved by 4 authors (CB, OO, SM, SEF). A total of 34 were retained for extraction, but after discussing extracted data, only 30 were included in the current study.
2.3. Selection criteria
Studies that were included met the following criteria: 1) Describes an antiracist training intervention in a mental health care setting; 2) Describes a program implementing antiracist mental health care among mental health professionals; 3) Describes the evaluation of a program aimed at implementing an antiracist mental care training; 4) Includes a training meant to address racial trauma; 5) Written in French or English.
2.4. Data extraction
The 6 authors extracted data from the 30 articles using a Microsoft Office Excel template. Data extracted from the included articles were: study characteristics (authors, publication date, country), training description or approach, study purpose, study design, sample characteristics, context, efficacy measure and main findings and recommendations (Table 2) (Cénat et al., 2022).
3. Results
3.1. Study characteristics
Table 1 describes the characteristics of the studies. A total of 30 studies were included, 20 were qualitative (Branco & Jones, 2021; Bryson et al., 1974; Bussey et al., 2022;Cénat, 2020; Corvin & Wiggins, 1989; Fix et al., 2022; Fox, 1983; Leuwerke, 2005; Malott, Paone, Schaefle, & Gao, 2015; Mattar, 2011; McCorvey, 2020; Pieterse, 2009; Ponterotto, 1988; Porter, 1994; Richardson et al., 2017; Ridley et al., 2000; Simmons, Mafile’o, Webster, Jakobs, & Thomas, 2008; Smith & Mak, 2022; Tuckwell, 2003; Woodley, 2021), six were quantitative (Bennett & Keating, 2008; Boyer, Rice, Sorrell, & Spurling, 2019; Brown et al., 1996; Lenes et al., 2020; Santhanam-Martin et al., 2017; Triplett et al., 2023) and three were mixed methods (Kanter et al., 2020; Kuo & Arcuri, 2014; Vega, Tabbah, & Monserrate, 2018; Wade & Bernstein, 1991). Of the 30 studies, 22 studies were conducted in the USA (Boyer et al., 2019; Branco & Jones, 2021; Brown et al., 1996; Bryson et al., 1974; Bussey et al., 2022; Corvin & Wiggins, 1989; Fix et al., 2022; Fox, 1983; Lenes et al., 2020; Leuwerke, 2005; Malott et al., 2015; Mattar, 2011; McCorvey, 2020; Pieterse, 2009; Ponterotto, 1988; Porter, 1994; Ridley et al., 2000; Smith & Mak, 2022; Triplett et al., 2023; Tuckwell, 2003; Vega et al., 2018; Wade & Bernstein, 1991), four in Canada (Cénat, 2020; Kanter et al., 2020; Kuo & Arcuri, 2014; Richardson et al., 2017) and the remaining four studies were conducted in the United Kingdom (Bennett & Keating, 2008; Woodley, 2021), New Zealand (Simmons et al., 2008), and Australia (Santhanam-Martin et al., 2017). The studies were published between 1974 and 2023, with 14 being published in the last 5 years (Boyer et al., 2019; Branco & Jones, 2021; Bussey et al., 2022; Cénat, 2020; Fix et al., 2022; Kanter et al., 2020; Lenes et al., 2020; McCorvey, 2020; Richardson et al., 2017; Santhanam-Martin et al., 2017; Smith & Mak, 2022; Triplett et al., 2023; Vega et al., 2018; Woodley, 2021).
Table 1. Key characteristics of included studies and main findings.
Authors (Year) | Country | Training description / type of approach | Study purpose | Study design | Sample characteristics (and type of healthcare professional) | Context | Efficacy measure | Main findings and recommendations |
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Kanter et al. (2020) | Canada | The workshop had “one introduction and didactic on health disparities, stereotypes, microaggressions, interracial provider-patient interactions and racism”. A mindfulness exercise was conducted with guided interracial eye-contact, and mindful acceptance of subtle expression of bias that occur in interracial interaction. Followed by mixed-race groups where participants were asked to practice the mindfulness exercises and reciprocally share and respond with empathy to life histories and personal narratives of loss and or betrayal. The last part of the workshop consisted of an explicit practice component, where participants were separated in groups and conducted role-plays scenarios, with feedback on their skills. Standardized patient interactions to assess the hypotheses were conducted with a Black actor after receiving a training by a patient coordinator. The racial challenge instruction were scripted. Each video-recorded standardized patient interaction were evaluated by two sets of independent assessors. They evaluated overall emotional rapport-building, and other trained assessors evaluated microaggressions and responsiveness to the presentation of the racial challenge. | The intervention was meant to decrease health care practitioner’s likelihood of expressing biases and negative stereotypes with patients of color. Specifically in moments where patients mentioned experiences of discrimination. | Pilot randomized trial of a clinical workshop which used a theoretical model from social and behavioral sciences. One intervention group received the workshop, and one non-intervention group was the control group. All participants completed a questionnaire at screening, baseline and two standardized patient interactions. The intervention group received the workshop the day after, followed by two other standardized patient interactions for all participants two days after. | Medical students and recent graduates who received previous training in ____ and were delivering primary care services at the teaching clinic. Sample size: 25. | Awareness of racial bias in medical care. Training is needed to reduce microaggressions and improve and increase communication and rapport with racialized patients in medical encounters. | Everyday Multicultural Competencies/Revised Scale of Ethnocultural Empathy (EMC/RSEE) Working Alliance Inventory (WAI) Inclusion of the Other in the Self (IOS) | A significant interaction was found for: – Emotional rapport building (p = .001, η2 = 0.40), with Intervention participants demonstrating a significant improvement from pre-intervention to post-intervention (p < .001, Cohen’s d = 1.67) – For responsiveness to racial challenges,(p = .016, η2 = 0.23), with Intervention participants demonstrating a significant improvement from pre-intervention to post-intervention (p = .005, d = 1.78) – For provider recommendations (p = .005, η2 = 0.29), with Intervention participants demonstrating a significant and large improvement from pre-intervention to post-intervention (p < .001, d = 2.04) – Providers demonstrated greater improvements in build- ing emotional rapport, evidenced by their increased use of statements of concern, validation, and empathy. – Specifically respond well to the patients in racially charged moments when providers are likely to struggle and engage in behaviors experienced as microaggressive by patients |
Porter (1994) | USA | Clinical supervision model to implement culturally responsive therapy. Stage 1: Increase awareness of the supervisee, on ethnic diversity and on how it forms beliefs, social structures and behavior; conceptual framework is provided, psychosocial alternatives to diagnostic and treatment approaches are provided; emphasis on research and relevant literature. Stage 2: Link between mental health and sociocultural factors such as racism and other forms of oppression. Social, historical, and cultural shape of behavior. Place the individual’s own experience in a societal context. Relevant literature is recommended at this stage. Empathy is important. Stage 3: The supervisee explores his/her own racism biases/attitudes to see their effects on therapy. Explores the concept of “counter transparence”. Explores perceptions and responses/actions to ethnic minority groups. Monitoring of the therapist’s session is important (taping and observation), focusing on verbal and non-verbal responses. Stage 4: Trainee encourages the supervisee to look beyond psychological intervention to collective solutions and social actions. Looking at alternatives including community participation, support, social perspective. Supervisees are encouraged to get involved themselves in “collective and social action groups.” -Safe and trustworthy supervisory environment are necessary. The supervisor needs to exhibit these cultural therapeutic qualities as well | -describes a model meant for clinical supervisee, to increase their cultural competence and awareness and to deliver antiracists approaches, to train culturally responsive therapy approaches and psychotherapists | Qualitative Overview / Description of a model of a culturally responsive supervision model | Internships of Latino and white supervisees. University of New Mexico. -Supervision and consultation by Latino mental health professionals | Not enough research and data on providing culturally responsive therapy to racialized communities. Educating therapist to deliver culturally responsive therapy approaches. This model is part of a training program in the psychology internship in the Division of Child and Adolescent Psychiatry at the University of New Mexico. | N/A | This article described a model of supervision among psychotherapists, in developing culturally responsive therapeutics approaches. The stages are fluid and supervisees might process content quicker than other. |
Richardson, Carriere, and Boldo (2017) | Canada | Five days training for practitioners about history of colonialism and indigenous suffering and inequalities, through learning circles to discuss the history of colonial adoption. Based on the training of response-based practices, which focuses on “accurate use of language and on how collective positive social responses can assist people Offered opportunities for discussions, sharing, acceptance and integration of new knowledge. At the end, participants participated in ceremonies to make peace with the past and include social structure into consideration in their work | Presentation of a pedagogy program meant for child and youth mental health practitioners, Indigenous cultural sensitization training. Response-Based practice, emphasizing the accurate use of language and words and positive social responses to help recovery. They share their stories and experiences through the lens of celebrating life | Qualitative Overview of the training | Mental health practitioners in British Colombia | Indigenous pedagogical process, space co-created by the facilitator and participants, where everyone can share their experiences and offer support. Various approaches related to cultural safety were included | N/A | This setting allows participants and facilitators to have a structure to share the stories and conversations that are necessary “to integrate the reality of Canada’s colonial violence” in the curriculum of students |
Ridley, Chih, and Olivera (2000) | USA | Training in cultural schemas: These help identifying, organizing, interpreting, and integrating cultural data into clinical practice. 3 steps in applying cultural schemas in therapy: -Clinicians have to become aware of their own cultural schemas, if not they might project on the patient. -Have to be receptive to stimuli relevant to the patient’s cultural schema -Clinicians can become more familiar with a client’s cultural schema, they can help them develop different ones | Description and recommendation of applying Cultural Schemas to help improving multicultural competence among practitioners | Qualitative Overview and recommendation of cultural Schemas training | Training professional practitioners overcome unintentional racism in clinical practice | Cultural schemas training for practitioners. Schema are cognitive structures through which individuals acquire information divided between 4 types, person self-role and event schemas. Cultural schemas | N/A | Endorsing concept of cultural schemas allows clinicians to be more receptive, perceptive in the interpretation of cultural data and it can help them overcome unintentional racism in clinical practices. |
Santhanam-Martin, Fraser, Jenkins, and Tuncer (2017) | Australia | Evaluation of 12 consultations that were conducted over a 12-month period. Secondary consultations took place at public mental health services. Description of the secondary consultation: -Case discussion using a semi structured format. -Confidentiality is explained, then a case summary is given. -Presentation and discussion of cultural insights, attendees all participate. -The facilitator brings up different themes such as racism, poverty, issues of gender, stigma, religion etc. to enhance the complexity of culture. The secondary consultation process is evaluated through feedback right after and up to 6 months after (self-report questionnaire-usefulness of the session, what influences their practices with clients since) | Description of a transcultural secondary consultation model. It aims to promote cultural responsiveness in partnership with mental health services. | Quantitative; survey and qualitative content analysis of feedback data Description of a Pilot transcultural service consultation program | The secondary consultation team had clinical psychologists, nurses, psychiatrists, occupational therapists. | Debate on the best approach to psychiatric care for culturally diverse patients. | In term of usefulness, 54% (44/82) of the participants rated the secondary consultation session as highly useful; 37% (30/82) quite useful; 8% (7/82) moderately useful; 1% (1/82) a little useful; and 0 not at all useful. | 54% (44 of 82 participants) thought this session was useful. 3 concepts were considered having an influence on their work: 1) culture specific = greater comprehension of the history of ethnic groups, traditional practices, sociopolitical factors, and religious aspects. 2) Client specific = content addressing “management of the presenting problem and client-related issues” EX: “knowing more about migration law and interaction with mental illness” 3) System-specific = content related to the “process itself as related to the organisation or to broader systems”. EX: “highlights of challenges faced with cultural issues when doing care plans in a service context” From the follow up interviews: Of 12, 10 were recontacted for a follow up interview; 9 mentioned positive views on the whole process and content. = Their feedback included: -Concepts that influenced their work: better knowledge on how to ask questions about culture; on background details about political situations; learned about new support services, greater knowledge on culture and migration to better help clients -Influenced their work with the family: learning about family through a cultural angle to better help clients -Recommendations that they were able to put in place: connecting the patient to a role model in the community; involving all family members in the care; increasing cultural supports and decreasing medication. |
Simmons, Mafile’o, Webster, Jakobs and Thomas (2008) | New Zealand | Workshop during the second year with students. 50 h in a community social service agency. -Workshop is co facilitated by a Maori and non-Maori member. -Starts with a Maori welcome procedure with greetings and prayers. 4 stages: 1) Locating ourselves: identification of life and social structures. Reflection of the student’s own culture through making collages. 2) Naming the issue: Look at pre-treaty history and the treaty document. They learned about past events in a sequence to understand colonisation and oppression. 3)Analyzing the issue: Look at the impact of history and current context via the use of human sculptures (used in family therapy) 4) Developing strategies for change: based on their prior discussions and new knowledge, discuss section of the Bicultural Code of Practice (which aims to promote indigenous identity). Students use a checklist to reflect of themselves and think of what they could do next to move forward 5) Conclusion: prayers and songs, | Goal is to develop an anti-racist and anti-oppressive social and community work practice. A workshop is described among students. | Structural analysis model | Social workers, community worker, social educators | Anti-racist training in Aoteara in New Zealand is provided at the Massey University in the Bachelor of Social Work program framed by the Treaty of Waitangi between Maori chiefs and the British crown giving spiritual, religious freedom, rights, and more. The antiracist training takes place as part of the communal effort to have society better understand the treaty. | N/A | For non-Maori students: pleasantly surprised enjoyed the day, learned a lot about themselves. It has been rated the most beneficial workshops for the past 3 years. Maori Evaluations: Maori students have had initial apprehension on being put on the spot, but good to share their experience with everyone and learning from one another. |
Smith and Mak (2022) | USA | In this Trajectory of awareness Model: courses Clinicians are led to recognize the experience of internalized racial oppression and to understand the psychological processes involved for them and their clients Phases of awareness on the trajectory (coming to awareness and reckoning with awareness). 1)Coming into awareness. 2)Emerging into awareness. 3)Reckoning with awareness. 3 different courses following that model: Course 1: students focus on assessing the client’s concerns at the individual and family levels. Ways for assessment of internalized racial oppression as a main factor for the client’s mental health problems, are presented. Identifying dynamic systemic factors at work in the client’s environment and context. Case vignette of clients describing discrimination or colorism. Course 2: List of multimedia resources, showing examples of racial injustice, chose two and provided a definition of anti-Black racism, provided example on how they thought anti-Black racism could be internalized. They were taught on how internalized racial oppression is described and experiences and discussed how socialization perpetuates racism and creates the internalization process. Course 3: client’s cases from students ‘field placements. In their assessment students were asked to add questions related to the model. Encouraged thinking about micro intervention, mezzo intervention, and macro intervention. | Theoretical framework on internalized racial oppression and looking at how Black women psychotherapist understand the phenomenon | Qualitative Theoretical framework | Social work students | Not enough literature on how to teach about internalized racial oppression to social workers using the trajectory of awareness. Important to teach and learn about anti-Black racism, to dismantle structures of oppression and move to racial equity and recognizing intersectional identities. | N/A | Conceptually, students think about the impact of internalized racial oppression on their Black clients. Developmentally, experiential and application-based learning is demonstrated and help students to take a closer look at the characteristics of internalized racial oppression. |
Tuckwell (2003) | USA | Therapists must ask themselves how they can: -through their lack of awareness on their own identity, block themselves from looking at racial identity issues with their clients. -deliver a narrow therapeutic perspective, not considering racial factors at work in psychological and social functioning – focusing only on psychological aspects instead of focusing on socio-political implication of race. -Therapists need to recognize their own stereotypes, beliefs and attitudes that could result in patronizing their clients, show insensitivity, disbelief. -They need to manage their emotional reactions; pay attention to internal dynamics, must express conflict between intellectual ideas on racial justice and racial equality and uncomfortable emotional responses; not use a colorblind approach -Acknowledge the shared common humanity of a personal encounter, with acknowledging that race is present. Therapists need to be aware of their own racial identity and as racially positioned in society Communicating, recognizing processes of racism and oppression -understand and recognize how silence about racism and oppression marginalises, acknowledging power in the therapeutic relationship. White therapists have to recognize their position in the social and racial hierarchy and faced their own biases and internalized beliefs of superiority in the therapy -important to make referrals if needed, recognizing the language of oppression in the client’s story -recognizing internalized racial oppression and how they can appear in the client’s behaviors and attitudes -examining the therapist-client relationship and if they relate to each other as if they were victim or perpetrator of oppression | To challenge all white therapists to become aware of how being white influences therapy, particularly with black clients. | Qualitative Editorial opinion essay Commentary, article | Meant for white therapists | White therapists need to be aware of how being white influences their therapy with Black clients, race needs to be considered from a socio-political point of view allowing therapists and clients to engage more freely about race in the therapeutic setting and talk on the negative consequences of oppression, racism and its effect on mental health. | N/A | N/A |
Vega et al. (2018) | USA | Multicultural school psychology course. Twice a week for 5 weeks, lectures, class discussions, small group discussions, activities, films, guest speakers. -Each class had a different topic like: history of multicultural psychology, concepts of racisms/privilege/race, cultural ethnicities, disproportionality, assessment of diverse students and gender identity and sexual orientation. -Focus on awareness and knowledge. -Assignments such as reflection paper on the concept of privilege, cultural autobiography to think about one’s own values, cultural identity, family history. -There were interviews with people of different culture, group assignment with a class discussion on a present event; cultural immersion activity and a reflection paper. | Multicultural course and outcomes on student’s feelings of empathy and sensitivity for members of racial communities. Evaluation of the student’s perception of how it influenced their future practices | Mixed methods study Quantitative (questionnaires) and Qualitative (content analysis) Mixed method exploratory study | 15 Psychology students, enrolled in a multicultural course 3 students identified as male and 12 as female. The ages ranged from 22 to 35 years old (mean age = 25.7); one did not provide their age. 7 identified as White, 7 as Latina/o/Hispanic, and 1 as African American. 14 were born in the United States. | Important to look at outcomes of participation in multicultural training experiences, of a 5-week multicultural course. | Quantitative: lower ethnic identity scores for white people. After the course students showed higher levels of understanding/feeling of other groups’ experiences. Qualitative: importance of a safe learning environment (feeling comfortable to share, open atmosphere, sharing one’s beliefs), increased multicultural awareness (learned a lot about the depth of the content, about history, about current events of oppression, of privilege, comprehension of different cultures), putting theory into practice (becoming aware of one’s biases, insight of the experience of other cultural groups, better understanding of cultural differences, taking racial and economic divide into consideration). | |
Wade and Bernstein (1991) | USA | 4 h of culture sensitivity training. -overview of issues and concerns brought by racialized individuals. -Group discussion on the counselor’s self-awareness and the minority client. -skills training based on a triad model of cross-cultural counseling: 1)see the client’s problems within its cultural framework 2)take into consideration the client’s resistance and know how to manage it 3)recovering from mistakes that took place during the counseling. -Practice sessions where counselors were told to be aware of: a) the patient’s suspiciousness of the social system and how it may affect its perception of the counselor; b) the difference between the patient and counselor of race and class; c) how the client’s own perception of being black could affect the counseling process. | Brief culture sensitivity training and its effect. They also looked at the effect of counselor’s race on Black women’s perception of the counselor’s attributes. They also focused on the traininaction of the client with his counseling session | Quantitative and qualitative | Counselors 4 Black and 4 White females And 80 black women as clients | Looking at the effect of counselor’s race on the client’s perception of the therapeutic process hasn’t been investigated enough and the doubt must if non-minority counselors are able to provide appropriate counseling for Black clients has been raised | Statistically significant main effect for culture sensitivity training for the first counseling sessions, F(l, 70) = 12.36, p < .001, the second counseling session, F(∼I, 69) = 18.49, p < .001, and the third counseling sessions, F(7, 67) = 18.77, p < .001. | Counselors who have done the training received higher ratings in terms of expertness, trustworthiness, attractiveness, unconditional regard, and empathy. Clients that were assigned with counselors who received the training, were more likely to come back for a follow up session and reported higher satisfaction with their counselor. Racial similarity between the client and the counselor decreased client attrition but did not have an effect on the client’s perception and on the counseling process. |
Woodley (2021) | England | Education for Mental Health Practitioners (EMPH): Evidence based intervention for low level anxiety or depression. For the evaluation of the EMHP training, 4 elements were considered: -Community context = understanding the school population in the context of the local area -Cultural characteristic of local population = understanding varying cultural views of mental health well being -Organizational infrastructure = understanding how schools and national health services operate -Direct service support = understanding how to engage with parents/carers about evidence-based practice | Reflection on the first wave of training Education Mental Health Practitioners (EMHPs), this study focuses on the training and its support for children and young people with low and moderate mental health needs (among Black, Asian, Minority Ethnic refugees). | Qualitative General Overview of the study | N/A | 30 trainees, mostly white British individuals | N/A | The EMHPs trainees can benefit from understanding the minority groups of CYP attending schools in the area covered by their Mental Health Support Team (MHST). It is important for the MHST to build relationships with minority groups early in the MHST formation. Some recommendations include: the adaptation of the EMHP curriculum at a local level, including specific training on the needs of minority groups. The development of relationships between schools and the communities they engage with locally is a must for continued success. Training that are specific to the needs of minority groups in their MHST areas should be ongoing. |
Fix, Testa, Thurston, Gray, and Russell (2022) | United States | The STYLE framework is composed of five parts. (1) Self-awareness is key. Meant to increase awareness about racism and how it manifests in their practice. Encouraged to seek educational opportunities. They recommended using the ADDRESSING framework could be helpful for clinicals to understand their own identities and privileges/oppressions. (2) Terminology is important to speak effectively about racism (Talk about community-police relations and racism). They call to use Systems-Centered Language which allows the separation of the person from their oppressive experiences; it seeks to end the dehumanization of people by not reducing them to their oppressive experience. There is also an encouragement to read and seek out anti-racist trainings. Understand how experiences with police are different between BIPOC and white communities. (3) Yield space and time to anti-racism work Making the time and space for anti-racism work must be done. This also means working with law enforcement officers and offering and conducting trainings with them. This is a way they can advocated on behalf of their patients and families who have had negative experiences with LEOs (law-enforcement officials). Provide clinical care to children who have been exposed to LEOs and commit to engaging in anti-racist work. (4) Learn about how structural racism impacts child health – It is important to teach yourself about the outstanding problem of structural racism in your community and the disparities between BIPOC health and the health of white citizens. (5) Evaluate policies and practices through an anti-racism lens – Think critically of the structures in place and how the justice system may disadvantage marginalized youth. The STYLE principle can be used to evaluate policies and practices. | STYLE framework is an anti-racist strategy that uses the ecological systems theory in order to expand the skillset of pediatric psychologists when working with their BIPOC clients, especially with those who had negative experiences with the police. | Qualitative, conceptual | No sample. This was designed for pediatric psychologist. | Due to the negative experiences that BIPOC community members under 18 face, STYLE is introduced to give pediatric psychologist anti-racism training. | None mentioned. | The authors noted that some of barriers pediatric psychologist face during anti-racism work include a lack of access and awareness to materials and resources for anti-racism work. Many don’t seem to prioritize this work. There is a lack of insight that they can play a pivotal role when working with BIPOC children who have had negative experiences with law enforcement and also a lack of knowledge as to how they can work with the police force to prevent these circumstances from reoccurring. |
Fox (1983) | United States | The guidelines that Terry proposed for racism courses. 1. The course must be required. The course instructors must be diverse. 2. The student group must also be diverse. 3. All material must be presented in depth (no superficial glance over certain groups) 4. Content should be empirically oriented, focusing on the realities of marginalized groups 5. Experiential learning is preferred over literary sources. 6. There should be different perspectives of racism brought to students 7. Students can have a “racial autobiography” that they start writing at the beginning of the course and keep till the end. 8. The structure of the course should be informal, where there is free exchange and learning from one another 9. Students should be involved in the syllabus making 10. Awareness and recognition that we can improve in many different areas. The racism course that is proposed has a central portion dedicated to a field exercise, which offers experiential learning to the students. And, the other suggests that it should be mandatory. This would involve students maybe working in a traditional social service agency, in a family home in need of counseling, with an ambulance team responding to economically devastated community, etc. | This provides a conceptual analysis for courses that deliver anti-racism education. | Terry has provided 10 guidelines for the course. He mentioned that the course should be required, and the field course should be required as well to receive the credit. | No sample It seems to be intended for social workers | None mentioned | To maximize the learning potential of the field course, there could be a written reflection portion which students share with one another about their experience. The author provided 8 different questions that can be asked. | |
Kuo and Arcuri (2014) | Canada | Name of course: The Multicultural Counseling and Psychotherapy with Refugees Practicum Structure: 2-semesters; 8 months (Sept-April), plus an in-house practicum that would be done with psychological services on their university campus. This practicum will be available to clinical psychology doctoral students (years 4–6) at the University of Windsor. The prerequisite for the course is Couse of didactic multicultural and diversity course. The first 7 weeks of the course is composed of pretherapy didactic seminars. Students are given a reading list and must present topical issues when working with refugee survivors clinically. This part also teaches trainees how to work with language interpreters within therapy. Weeks 8–24 are composed of the actual practicum. In week 5, the trainees will visit and have orientation at the Multicultural Council. The practicum supervisor liaises with the council to screen criterial for appropriate matches of clients and trainees. Trainees are linked with their client, and they have a maximum of 17 weeks to deliver treatment. These sessions are scheduled for 90 min to ensure that working with an interpreter does not cut into actual therapy time. The therapists are to work collaboratively with the client’s case manager who will advocate for the individual’s needs. This is how trainees learn about social advocacy work. Included, there is a 2-h group supervision to ensure professional development for the trainees and appropriate care for the client. | To describe a model of multicultural therapy practicum available at the University of Windsor which uses collaboration between university and community to educate doctoral clinical psychology students. | Mixed methods | Doctoral Clinical students. Not an experiment. | They presented an ongoing practicum at the University of Windsor and described its structure. The students were evaluated before and after of their multicultural competence. Then, the authors presented a case study of their practicum in action with an unnamed student and his client during his practicum. | The participants were given the Multicultural Counseling Inventory, Multicultural self-efficacy Scale-Racial Diversity form and a demographic sheet pre and post-practicum. This summed up the quantitative results. The qualitative assessment was done through weekly “Critical Incident Journal” which was required after each therapy session with their client. | |
Lenes et al. (2020) | United States | It was multimodal training with mindfulness practices. The training included four 3-h components with content focused on (a) foundations of intersectionality, multiculturalism, color-blind racial attitudes, and mindfulness; (b) privilege, cultural bias, socialization, and mindful communication; (c) inner and outer awareness of reactions and responses to cultural conflict or hate crimes, and meta meditation; and (d) institutional awareness, implications for counseling, mindful movement, and action steps With every multicultural activity it was paired with a mindfulness practice. | Examine the effectiveness of a Color-Conscious Multicultural Mindfulness (CCMM) training | Longitudinal/Quantitative | N = 39 (18 in training, 21 in control group) Asian – 7.69% Black – 10.26% Hispanic – 12.82% White – 69.23% Cis man – 10.26% Cis woman – 89.74% Study was conducted on prelicensed counselors and graduate level counselors. | There was a control group and training group. A need exists for a counseling curriculum that is race-conscious and based on social justice principle. Previous literature lacked random assignment and did not focus on color-blind racial attitudes (which this study wanted to explore). Color-blind racial attitudes refer to beliefs that race should not and does not matter. | Multicultural Awareness, Knowledge, and Skills Survey– Counselor Edition–Revised (MAKSS-CE-R) And Color-Blind Racial Attitudes Scale (CoBRAS) (Neville, Lilly, Duran, Lee, & Browne, 2000) And, Five-Facet Mindfulness Questionnaire (FFMQ) (Baer et al., 2008 ) | The interaction between groups and changes between the pretest and posttest was statistically significant for MAKSSCE-R total score, F(1, 35) = 34.17, p < .001, ηp 2 = 0.494 The interaction between groups and changes of CoBRAS total score between pretest and posttest was statistically significant, F(1, 35) = 61.51, p < .001, ηp 2 = 0.637 Recommendations: larger samples, more POC representation in sample, interviews and supervisor evaluations instead of self report. People who completed the training had a statistically significant increase in their mindfulness and decrease in the color-blind racial attitudes. As they used race/ethnicity as a covariate, they were also able to demonstrate that White people had rated themselves with lower multicultural competence than POC. For multicultural competence, they recommend having an intensive training (2-day workshop or 4-week training) as opposed to a tradition college course format. |
Leuwerke (2005) | United States | The author conducted a literature review presenting different existing models for race conceptualization for white persons. From there, he made recommendations for different practitioners in the field, which are outlined below. He encourages practitioners to take a graduate level course surrounding diversity, multiculturalism, and cross-cultural counseling, attend workshops in the similar vain. They should seek life experiences that can expand their knowledge of culturally different groups. Seek supervision and consultation when working with a client of a different background. For counselors in training, he recommends watching a particular film and have a discussion with faculty and classmates. They should seek practicums where they will be able to work with different culture population groups. If their school doesn’t offer a multicultural course, they can seek one at a different institution. They should be encouraged to attend conferences and workshops that tone in on diversity and multicultural counseling. They can join research groups and functions that focus on marginalized communities. They can engage themselves in discussions with classmates about diversity and also in self-reflection where they also seek feedback from their supervisors. Supervisors and educators also play a role as they prepare each year a new cohort of counselors. They should engage students in self-exploration of race and ethnicity and encourage class discussions on these topics. All courses can have some of these issues highlighted to a degree. They can also take initiative and develop a multicultural counseling course if it doesn’t exist at their institution, where they can also actively engage their students in reflective learning which can increase their self-awareness. They can also invite experts that can join their class as speakers to educate their students. They may also share some of their own experiences with racial identity development. | Offers raining ation and development models for white identifying counselors to work with culturally different clients. | Qualitative | No sample. The author address recommendations for practitioners, counselors in training and their supervisors. | The author had his own experience in the development of racial identity awareness and noticed the need for many other counselors, as they are called to work with culturally different clients. | None | |
Malott, Paone, Schaefle and Gao (2015) | United States | Activity 1: “Is it racist? This activity is used to increase awareness and recognition of microaggressions and understand the underlying meanings and the consequences it has on the recipients. The activity requires students to create teams and place the microaggression in the right category (microinsult, microassault, microinvalidation). The instructor must have explanation prepared to explain why each comment fits into a different category. Activity 2: “Hassle lines” It is an activity where one student says a racist remark and the other is responding to this remark. The activity is to have a non-violent response to this remark. | The study purpose is to provide counselor educators with activities they can implement which sheds light on microaggressions and its different forms. Through role play and theory, they can hopefully address these issues with their clients and avoid certain statements that may harm their clients. | Qualitative | NO sample, This training is for counselor educators | Contemporary racism is no longer as common in terms of blatant acts, however it still persists in manners that are more subtle. This activity is to prepare students for speaking about race and shed light on the experiences of some minorities. | None | Instructors who give this course must have a clear understanding of their own racial identity, so that they don’t shy away from negative learner reactions. In terms of managing feelings of guilt, this could be helpful to be able to model discussions. |
Mattar (2011) | United States | 1. Development of trauma psychology curricula and training practices which give a throughout account of cultural factors – To operationalize culture in terms of race and culture in the curriculum and add these topics to the curriculum. To offer cultural training to professional to develop practical skills when dealing with the racial trauma of clients such as trauma interventions and engaging clients in trauma treatment. 2. The meaningful inclusion of cultural context in trauma psychology research – A lot of researchers are offering effective treatment outcomes using research evidence for treating their clients, though there is concern for the generalizability of results to racial groups in evidence-based practices that may affect the efficacy of the treatment. Further research including diverse populations is necessary. 3. The promotion of organizational structures and culture within psychology that support cultural competence – The development of a culturally competent education requires culture and race to be included at an institutional level, such as in the diversity of the student body and the curriculum. Through this you can hope to reshape the culture surrounding racial issues and the environment of the students in trauma psychology. | The authors mention that trauma psychology has often used a scientific lens to understand it and create a sole concept of trauma and its expression, without regarding culture. Suggest 3 possible practices that will educate mental health professionals in the field of cultural competence in trauma psychology. | Qualitative | NO samples | The author describes the need for teaching trauma psychology for the following reasons: The high rate of trauma and PTSD among those who are diagnosed with severe mental illnesses. PTSD might be more common to certain groups belonging to specific racial and ethnic cultural groups. One’s cultural context might impact the subjective reactions to trauma. | None. | N/A |
McCorvey (2020) | United States | There were some principles and guidelines that were offered: a) Therapists can seek to engage themselves into ongoing education in order to practice anti-racist and culturally sensitive therapy. b) Invite discussion about race Make race a normal topic for you and your client to help them feel comfortable discussing the topic if they want. Discuss race without waiting for something in the news to appear which breaks the ice. c) Talk about race even outside of the therapy room (best to be practiced before – learn how to sit with the possible discomfort) d) Accept the mistakes you are likely to make on the way and apologize. Use as learning experience. Change the perspective of your BIPOC client as a victim and instead as a person who has survived many injustices; work with them to find healing. | Offers approaches to white therapists to properly address race and racial issues with their clients of color. | Qualitative, Column article in magazine/newspaper | NA | Many therapists have had very minimal education as to how to work with diverse clients. As a result, many BIPOC clients seek clinicians that look like them, but white therapists represent a much greater percentage of therapists available. Most therapy programs discuss race issues briefly or in passing. If you are white, you may not fully understand your own privilege or how to communicate with BIPOC clients. | NA | NA |
Pieterse (2009) | United States | As an attempt to decrease the potential for resistance and defensiveness and to establish the classroom as a place in which students could explore their experiences without fear of judgment or negative reactions, five core concepts were identified to serve as the framework in which the learning would take place. – Constructivism – Knowledge and scholarship – Reflective learning – Systemic focus – Process To increase the accessibility of the course content, various teaching strategies were used – The three-part series Race: The Power of an Illusion – Readings were offered to supplement the video series and included selections from Prejudice and Racism Every class session included a group process in which students could process their reactions to the readings and the video series. A reflection paper provided the opportunity for students to grapple with their personal awareness of and accountability for individual and systemic racism. Reading materials and video series. Collectively, student responses to the readings and video series reflected a sense of being overwhelmed, surprised, and angry. Racial–cultural interview. The interview served as the primary experiential component for the course. Students met in instructor-facilitated groups consisting of four individuals and engaged in 3-h sessions that were focused on talking about their feelings and socialization experiences associated with their racial group membership. Advocacy papers and individual presentations. For the papers and individual presentations, students were requested to write and present on one aspect of institutional racism in which they participated or by which they were affected. | (a) developing in students a heightened awareness of the manner in which racism exists and is maintained in society, (b) increasing an awareness of ways in which students both as individuals and as racial group members contribute to racism, and (c) facilitating in students an individual accountability and responsibility for antiracism practice | Qualitative | NA | The course highlighted in this article was structured as a one-credit elective course for graduate students enrolled in a counseling and development program. The course consisted of five 3-h class sessions with both didactic and experiential components (e.g., lectures, video material, small-group discussion, and individually based racial–cultural interviews). All components provided opportunities for group-level reflection and debriefing | None | Students provided several observations: an increase in knowledge about racism, a beginning understanding of self as a racial being, a desire to implement social change, and a sense of having experienced personal growth. Students requested that the class be transformed to a three credit course and that it be recommended as a requirement for the program |
Ponterotto (1988) | United States | The author created a stage theory to develop racial consciousness among white counselor trainees through 4 stages: pre-exposure, exposure, Zealot-Defensive and integration. The Pre-exposure stage is when the person is not aware of their racial identity and the impact it has made in their life and the life of others. The exposure stage exposes students to realities of racism and prejudice. This also forces them to examine what their role might be as a White member in society. This might be where guilt and anger may build among some students. The Zealot-Defensive stage presents the student with two options: dive headfirst into the issues that minorities face or to retreat from discussing and looking into all kinds of multicultural issues. The integration stage is the last stage which “parallels closely the Internalization stage of the Cross model (Cross, 1979) and the Autonomy stage of the Helms model.” (Ponterotto, Alexander, & Hinkston, 1988) | Purpose is to bring forth a stage model for the conceptualization and development of the racial identity of white counselor trainees. | Qualitative Review | NA | N/A | NA | Research should focus on breaking down the racial identity development process. They should focus on strategies and learning environments that encourage students to move through the stages successfully |
Bennett and Keating (2008) | England | Study itself did not provide training but rather sent out a survey to see the current training available from all NHS mental health trusts, PCTs and independent inpatient mental health service providers in England in addition to 90 providers of race equality training. The list of trainings included: diversity, cultural awareness, cultural sensitivity, racism awareness and anti-racism. | To map the current training on race equality in the mental health sector | Quantitative study / Survey | Employees of the NHS, PCTs and independent inpatient mental health service providers. No specifics were mentioned about types of professionals or their demographics | Report investigating David Bennett’s death found institutional racism in the NHS and recommended training to combat this racism. As a response to this, the government the department of health put forth the Delivering Race Equality action plan. One of the goals included was to first map out the current education and training, hence this study. | The survey sent out found participants to be either satisfied or very satisfied with the quality of trainers (78%), length of training (70%), mix of participants (69%), aims and objectives of the training (76%) and support received after training (30%). Just over 35% of the independent service providers evaluated their training. The commissioners evaluating the training felt the trainings had a very positive impact (9%), some positive impact (23%), had mixed feelings about the impact (9%) while 23% said it was too soon to tell and 30% were unable to comment | The current training in England focuses too much on learning about the race and culture of other people while they should be focusing on specific inequalities in mental health services such as diagnosis and compulsory detention. The trainings should allow these organizations to look at their own specific context and own issues. |
Boyer, Rice, Sorrell and Spurling (2019) | United States | Students first completed a course (phase 1) on culturally competent care where they were evaluated both at the beginning and at the end of the course in their ability to be racially/ethnically sensitive providers. After completion of this course, their clinical coursework (phase 2) began where preceptors measured their racially/ethnically sensitive behaviors and interactions with patients. Some of these students were assigned to underserved sites whereas others were not in order to examine the difference that experience in underserved communities make. It’s important to note that the students doing the Advanced Clinical Coursework were not exposed to the training in the first section. | To provide and evaluate racial/ethnic & cultural sensitivity training of psychiatric mental health nurse practitioner students | Quantitative evaluations (both by self and evaluator) of sensitivity. | Psychiatric mental health nurse practitioner students. Phase 1 (course): 88.46% female, 76.92% non-Hispanic white, 7.69% Hispanic, 3.85% Asian American, 7.69% Black/African American, and 3.85% American Indian. Avg Age: 40.73 for fall semester/37.8 for winter semester (not significant different). Phase 2 (clinical): 91.67% female, 86.11% non-Hispanic White, 5.56% Black/African American, 5.56% Asian American, and 2.78% Hispanic. Avg age: 39.69 years (SD = 8.76). | There are significant disparities in the mental health treatment of minorities. The burden that a lack of racial/ethnic and culture sensitive care is disproportionate weighing heavily on minority populations which results in more unmet mental health needs. | Measured using 24-item Ethnic Sensitive Inventory. Phase 1: Racial/ethnic sensitivity increase significantly in non-Hispanic white students from the start (M = 3.86, SD = 0.36) to the end (M = 4.32, SD = 0.36) of the course but not much in racial/ethnic minority students from the start (M = 4.15, SD = 0.62) to the end (M = 4.17, SD = 0.35) of the course. Phase 2: Advanced students had higher self and preceptor evaluations of racial/ethnic and cultural sensitivity than Novice students. Novice students in urban settings significantly improved in racial/ ethnic and cultural sensitivity from midterm (M = 2.88) to final (M = 3.55; t = −2.483, p = .019). Novice students in underserved settings improved from midterm (M = 3.78) to final (M = 3.88). The settings made no significant difference for the Novice students (t = −0.477, p = .635). | Working with patients increases racial/ethnic and cultural sensitivity and both training and experience in underserved settings increases this sensitivity. Although placement settings were not significant different, placement in underserved sites affected change in behavior (sensitivity) more over time so longer studies with larger samples are required for the future. |
Branco and Jones (2021) | United States | The training provided here applies critical race theory in counselor education and offers counselor educators and supervisors several “micro interventions” or way of addressing microaggressions as counselor skills to their students. In the training provided, they use 3 of the 4 responsive strategies by Sue and colleagues (Sue et al., 2019): 1. Make the invisible visible. 2. Disable the microaggression. 3. Educate the offender. 1. Make the invisible visible examples: -Undermine the metacommunication. -Make the metacommunication explicit. -Ask for clarification. 2. Disarm the microaggression examples: -Set limits -Interrupt and redirect 3. Educate the offender examples: -Promote empathy -Point out the commonality The training combines these microinterventions with commonly used counseling skills in order to come up with a response that both addresses microaggressions and preserves the counselor-client relationship. Common counseling skills: -Reflection of content -Open-ended question for clarification -Self-disclosure -Information sharing Table 1 of the article goes through all of these with an example of a response in a case vignette. I will provide one of the examples here: The client talks to the Hispanic counselor over the phone to set up an initial meeting. The counselor thinks this went well. However, when they meet before the session starts the client asks if the counselor has a work permit.as the client doesn’t want to risk their security clearance by working with someone who cannot legally work in the U.S. The counselor in response combines the first microintervention with commonly used counseling skills of a) reflection of content and b) open-ended question for clarification: a) “You are interested to know if I have documentation to legally work in the United States, as you want to preserve your security clearance. This sounds quite important to you.” B) “What concerns you about my legal status?” The final microintervention which is not really adapted into the training but is mentioned again in later recommendations is 4. Seek external validation. The article recommends clinical supervision as an important source of external validation for counselors to process their experiences with microaggressions. | To offer training/guidance to counselor educators and supervisors that they can use to teach their BIPOC students how to deal with microaggressions from the clients. | Qualitative Overview | BIPOC counselors | Microaggressions in counseling have gotten a lot of recent attention with research showing: 1. Counselor initiated microaggressions negatively impact the counselor-client relationship and contribute to poorer client outcomes. 2. Counselors of color suffer through microaggressions to maintain so they can preserve the counselor-client relationship. 3. Little guidance/training has been offered to BIPOC counselors to address client-initiated microaggressions. | No | There is a gap in practice literature on how counselors can deal with microaggressions, and racism directed at them by the clients and the MCI framework can help BIPOC counselors in these situations. Future research is needed to see the helpfulness of the MCI framework |
Brown, Parham, and Yonker (1996) | United States | Weekly 3-h class every week for a 16-week course divided into 3 phases: 1. Self-awareness 2. Knowledge of five ethnocultural populations (African American, Asian, Latino, Native American and European American) 3. Development of preliminary skills to counsel diverse clients. Phase 1 encouraged students to explore themselves, their prejudices and biases and how these can impact others through discussions and experiments like the “blue-eyed brown-eyed experiment” designed to separate students in to two groups and have them treated very differently then come back and discuss feelings etc. in addition to other social experiments. Phase 2 was met by different guest speakers and discussions on culture specific issues and “worldview constructs” related to the aforementioned five ethnocultural groups. The students would also prepare beforehand via texts and other sources provided about the specific group. Presenters were instructed to create presentations that were “didactive and experiential in nature”. Phase 3 was designed to develop culturally competent skills such as identification and interpretation of verbal and nonverbal communication, minority and majority stages of racial identity development and cultural biased assumptions and their impact on personal and traditional counseling theory. | To investigate changes that cross-cultural training has on racial identity attitudes of white graduate counselors. | Quantitative study using WRIAS | White graduate counselors in training. 10 men, 25 women. | Culturally diverse clients also require and seek mental health care. This has challenged service providers, especially counselors in training whether they are ready to properly help someone who is culturally different than them as their race-based experiences would vastly differ. | Measured using White Racial Identity Attitude Scale. Racial Identity Subscale changes: Contact went from M: 3.14 (SD: 0.30) to 3.06 (0.28) for women and 3.03 (0.26) to 3.09 (0.37) for men. Disintegration went from 2.18 (0.44) to 2.07 (0.44) for women and 1.84 (0.48) to 1.83 (0.32). Reintegration went from 2.07 (0.42) to 1.97 (0.40) for women and 1.88 (0.40) to 1.95 (0.44) for men. Pseudoindepence went from 3.50 (0.27) to 3.77 (0.20) for women and 3.79 (0.29) to 3.85 (0.40) for men. Autonomy went from 3.74 (0.31) to 3.75 (0.30) for women and 3.82 (0.27) to 4.04 (0.30) for men. Meaning of each scale is included in the main findings section. | Racial identity of white students are significantly affected by a cross cultural course. All students can (a) psychologically accept racial differences, (b) appreciate the potential impact of racial attitudes on people of color, and (c) exhibit less racist behaviors. Women had higher Pseudoindependence scores. This group tends to be made up of Whites who believes assimilation is key and may still believe White culture is best. Men had higher Autonomy scores and are therefore working to refine their identity. The study recommends to document more populations on their racial identity attitudes and research the impact of specific methods of teaching such as experiential exercises vs reading vs lectures etc. Its implications for training is to increase comfort with diversity through contact with diverse populations and to increase students self-awareness of self as a racial-being. |
Bryson, Renzaglia, and Danish (1974) | United States 1974 | The training provided here is focused around using stimulus films. The stimulus film contains a series of simulated emotional vignettes where a Black actor roleplays a prescribed reaction to the helping other (i.e. the trainees). The actors deliver a particular emotion (rejection, fear of rejection, intimacy given and fear of intimacy) in a brief monologue to the camera. The feelings were chosen as they are believed to be the most experienced feelings in counseling relationships. The actors also express these feelings to different levels of affect, from subtle to very hostile. These films are primarily used in group settings with participants from various stages of their career (example: counseling practicum students to teachers working with disadvantaged population). These participants are then instructed to act as if the role-player in the film is their client and to respond to them empathetically. Following a sequence, each member discusses their reaction to the films which can focus on 1. Emotions expressed by the role-player 2. Their feelings and reactions to the simulated client and 3. Their response to the client. This exercise helps amplify the participants sense of self by making them aware of their feelings and reactions and can use the group members and the facilitator to become more “comfortable and aware with their racial feelings and attitudes.” Group members may also assume the role of the client to continue the act in real time in response to another group member’s response where then it is possible for group discussion to focus on alternative responses to what the black actor may say in a counseling session. This type of procedure is a form of “behavioral rehearsal.” | To share a training procedure to help counselors in training and other social workers to successfully work with Black clients. | More of an overview | Doesn’t have a specific sample, the training is intended for counselors in training and other human service workers. | There are several suggestions made by Ayers which can be used to alter racial attitudes of people in human service sectors to better relate to Black clients and build better interpersonal relationships (Ayers, 1969, Ayers, 1969). However, some of these suggestions are too demanding and people may not follow such recommendations. The article here provides a concept and training which has recently started to be used as a less demanding alternative for improving skills of trainees in biracial counseling relationships. | No | The model here allows individuals to become more self-aware regarding racial attitudes and can help them practice and develop more effective behaviors/responses when working with Blacks. There is still lots to be done however, as more films are needed to include more scenarios and work needs to be done to assess these training systemically and empirically. |
Bussey, Thompson, and Poliandro (2022) | United States 2022 | Training with multiple components and exercises with the aim of participants understanding self-biases, being able to identify false dominant socio-political narratives, have techniques to mitigate such narratives, recognize role of social work in addressing inequalities, understand how they can bring change and intervene when they recognize biases in colleagues’ behaviors. The training included multiple experiential exercises such as the power shuffle and power chair exercise. | Looking at antiracists training for social workers | Qualitative | 25 social workers | Racial conflicts in the United States have created divide and such divide has increased the frequency of far-right narratives. Anti-bias training for social workers is important as they are positioned to lead the systems they work in toward antiracist, anti-bias and equitable policies and practices. | No | The conversations held during training were sometimes emotional and flexibility was needed to deal with charges of emotions, however, when views collided it provided for a great opportunity to discuss both view points and foster deeper relations between colleagues. More research is needed research is required to understand the full effects of the training. |
Cénat (2020) | Canada 2020 | Offers guidelines of how to provide anti-racist mental health which addresses the needs of professionals and students in the trainings they should get. The guidelines contain four key components: 1. An awareness of racial issues 2. An assessment adapted to the real needs of Black individuals 3. A humanistic approach to medication 4. A treatment approach that addresses the real needs and issues related to racism experienced by Black individuals Each component contains several guidelines on how to adhere to anti-racist practice. | To provide guidelines on how to provide anti-racist mental health care | Commentary | No sample, the guidelines are meant for mental health care professionals | The American Psychological Association has labelled racism as a pandemic due to recent backlash against police brutality against Black communities. This, along with disparities of mental health in Black communities and the negative perceptions they may have of mental health services and professionals need to be addressed. | No | The author says that these guidelines can help 1. “improve human interactions between healthcare systems, mental health” professionals and Black patients 2. Get rid of mistrust and fear of professionals, health care systems and of the care provided 3. “Establish equity in care by reducing disparities, building confidence in care systems, humanising care and restoring hope to people from Black communities.” |
Corvin & Wiggins, 1989 | USA | The article explains an antiracism training model based on the characteristics of White identity development. The White identity development stages described here include 4: 1. Acceptance: Denial of race problem, unconscious assumption of Whiteness as “the norm,” “want to be seen as a non-racist but believe that minorities should assimilate to White values.” 2. Resistance: Recognition of racism in society, may actively demonstrate against this oppression, sees the problem as a White problem but fails to see their own racism 3. Redefinition: focus on building toward White identity and a White culture without racism. Recognizes Whites should be addressing racism and may build alliances with other Whites in same stage. Self-exploration allows re-evaluation of personal values and goals. 4: Internalization: understands varying levels of racial consciousness, works with other Whites for change. “Improve appreciation for diversity as they internalize their existence in multiculturism. This stage represents the integration of the White person’s race into their identity. The rainingg process focuses on having goals and activities for each of these stages. In stage 1, they focus on increasing their awareness as a White race member and what it means to be White in America while recognizing cultural differences. Activities here focus on racial self-awareness and employ questions asking how they were taught to interact with people of other racial groups or what ideas they were encouraged to believe about their racial group. In stage 2, they focus on identifying their own racist attitudes and behaviors while working through resistance and feelings of futility to build hope and power for change. Activities like watching and discussing films that talk about issues of racism or generating stereotypes they have heard and how they may have perpetuated such stereotypes are used. They note that it’s important to instill hope here to avoid “learned helplessness.” In stage 3, the goals are to become more aware of their own racism and sensitive to racism as both a White problem and one’s own problem while re-evaluating personal values, behaviors and attitudes. Along with this they will also being to make strategies for changing racist systems and to increase awareness of White identity. Activities here focus on participants dealing with their Whiteness by exploring the importance and luxuries and advantages of being White. Activities focus on “value clarification” which include discussion of current events involving racism, affirmative action issues and personal experiences with racism. In stage 4, the goals are to integrate their racial identity into their personal identity, get rid of oppressive and exploitative attitudes and behaviors as well as internalize a multicultural perspective while implement action strategies for change. The activities here focus on helping participants develop action plans to combat racism on personal, institutional and cultural levels by working together or individually to identity a specific racist system they want to face. The authors state that this model can be implemented as a workshop format or as an “agency’s in-house professional staff development activities.” | To provide an antiracism training based on White Identity Development in order to address the issues in multicultural training of White professionals. | Overview | No sample, meant for White professionals counselors it seems as it focuses on developing their White racial identity. | Multicultural counseling and training concerns have prompted training models. However, these models do not address the White trainee’s need for self-exploration as a White race member in order to examine their own racism thus the authors provide a model which instills multicultural and anti-racist values while allowing the trainee to examine themselves and develop their White racial identity. | No | It’s important that White trainees in counselor preparation programs explore their White identity and think about racism in their personal and professional life. The model proposed here can be used a diagnostic tool to see where one is in their White identity development and where they must go to employ anti-racist behavior. |
Triplett et al. (2023) | USA | The training integrated theater-based methods within CBT training for children. Before the actual training began, participants watched a series of recorded therapist-client interactions. These videos were scripted based on the initial survey the team had circulated and analyzed. These two videos included a white therapist and a black male adolescent for the first video and the second – a black female adolescent. The videos show the therapist’s response/engagement in discussion about race. In the videos, the therapist avoids the conversation about black current events. The clinicians watching these videos are asked to make suggestions for the therapist as to how they could engage in conversations about such topics. After this, the training began. All trainings were facilitated by Zoom and lasted 4 h. The training was divided into different sections: – The first portion included didactics introducing the systemic barrier black communities’ face, alongside mental health inequities and more. They also reviewed barrier and facilitators when discussing race from their previous prject. They also reviewed training goals of cultural humility and a framework encouraging learning and self-reflection. – The second part included reviewing the videos and comments from the videos the clinicians watched before the training. The black clinician leaders facilitating the event gave their own suggestions as to how the therapist could have better interacted with the client. – The third part included the theater component: improvisation. There were actors that acted out the pretraining video, but, this time, they incorporated the suggestions the clinicians in training had suggested before the training. In addition, then the actors started adding in some of the new suggestions that were coming through the chat box from the clinicians in training. – The fourth part consisted of break out rooms led by the black clinician leaders. This allowed for debrief, discussion and practice of similar conversations about race and racism with black adolescents. – The final wrap up consisted of the group coming back together and sharing their takeaways from the training. | This specific project focused on the integration of theater-based methods within the child-focused CBT training for clinicians. More specifically, they sought to evaluate the feasibility and acceptability of their theater based anti-racist clinical training for the development of clinician’s cultural humility. They also looked at the likelihood that the clinician’s engagement in conversations about subjects like race and racism with their clients. Ultimately, they wanted to understand if an interdisciplinary approach using theater-based methods can actually train clinicians and be used in other settings as well. | Quantitative and qualitative (but qualitative data was not presented) | Clinicians came from a CBT training initiative in Washington. Total number of clinicians: 16 Total number of supervisors: 7 Total participants: 23 Some demographics: 10/11 clinicians were White 1/11 clinician was multiracial 9/11 clinicians were female | This study focused on both drama therapy and community theater as an intervention technique for development, such as positive changes in relations and emotions. The team had previously conducted a survey of clinicians’ perception of barrier and facilitators during conversations about race and racism. They used the data to inform the scripts for their anti-racist clinical training. There has been a lot of publicizied killings of Black people in media (e.g. George Floyd) which has contributed to the worsening mental health of Black Americans. Black Youth aged 12–17 have seen an increase in depressive episodes and suicidal thoughts/attempts. Part of combating this includes ensuring high-quality mental health care for Black Americans that are culturally responsive to help them cope with present experiences of racism. | There were different measures used: 1. Acceptability of intervention Measure (AIM; 2017) This post training measure was used to survey the clinicians in training perception of appropriateness of the training. 2. Clinicians’ multicultural counseling Self-Efficacy Scale- Racial Diversity (MCSE-RD; 2007) This was used pre- and post-training and it examined the clinicians in training self-perceived capabilities when counseling racially diverse clients. 3. Concerns About Counseling Racial Minority Clients (CCRMC; 2012) Assessed clinicians’ concerns when working with clients of color. This was used pre and post-training. 4. 15-item scale that assessed the clinician’s intentions when discussing race and racism with their BIPOC client (Woodard et. Al., in preparation – it was a new scale at the time). This was collected pre- and post-training. | The results showed that the AIM score for the training was 4.69 out of 5, meaning that participants found there was a high degree of appropriateness in the training. The results of MCSE-RD sat at 6.21 (out of 9) pre-test, which suggests participants were confident in their self-perceived capabilities counseling racially diverse clients in multicultural settings. The post-training average score was 7.55, indicated an increase in clinicians’ self-perceived capabilities. The results of CCRMC pre-test were 3.29 (out of 5), suggesting that the participants had some concerns when working with BIPOC clients. At post-training, it was 2.51, meaning there was a decrease in concerns after the training. Finally, the results of the final 15-item scale assessing the clinicians’ intentions to discussing race indicated a slight increase in intentions to discuss race and racism with all BIPOC, but only for supervisors. The clinician participants did not notice and significant improvements. As the goal was mainly to increase clinicians’ intentions to discuss race and racism with their BIPOC clients, the authors understand that there may also be hesitancy for BIPOC clients to discuss these issues with a white therapist. That being said, the authors speak about the importance of acknowledging the powerful relationships therapists hold with their clients whether they choose to have this conversation or not. |
3.2. Populations studied
Studies included participants from different fields: five were conducted among social workers or students in social work (Bussey et al., 2022; Corvin & Wiggins, 1989; Fox, 1983; Simmons et al., 2008; Smith & Mak, 2022); 6 among counselors (Branco & Jones, 2021; Brown et al., 1996; Bryson et al., 1974; Lenes et al., 2020; Malott et al., 2015; Wade & Bernstein, 1991); four among counseling trainees (Leuwerke, 2005; Pieterse, 2009; Ponterotto, 1988; Woodley, 2021); 11 included various mental health practitioners (Bennett & Keating, 2008; Cénat, 2020; Fix et al., 2022; Mattar, 2011; McCorvey, 2020; Porter, 1994; Richardson et al., 2017; Ridley et al., 2000; Santhanam-Martin et al., 2017; Triplett et al., 2023; Tuckwell, 2003), 3 among students in psychology (Kuo & Arcuri, 2014; Vega et al., 2018), mental health nursing practice (Boyer et al., 2019), and in medical studies (mobilizing social and contextual behavioral sciences) (Kanter et al., 2020). When reported, training took place at universities and colleges (Boyer et al., 2019; Brown et al., 1996; Kuo & Arcuri, 2014; Pieterse, 2009; Porter, 1994; Smith & Mak, 2022; Vega et al., 2018), public mental health services (Santhanam-Martin et al., 2017), or community social service agencies (Simmons et al., 2008; Triplett et al., 2023).
3.3. Training and interventions
3.3.1. Format
Training was offered through formal courses (Boyer et al., 2019; Brown et al., 1996; Kuo & Arcuri, 2014; Malott et al., 2015; Pieterse, 2009; Smith & Mak, 2022; Vega et al., 2018), teaching program with cultural sensitization training (Richardson et al., 2017); theoretical frameworks and models (Bussey et al., 2022; Corvin & Wiggins, 1989; Fix et al., 2022; Mattar, 2011; Ponterotto, 1988; Porter, 1994; Ridley et al., 2000); workshops (Branco & Jones, 2021; Bryson et al., 1974; Corvin & Wiggins, 1989; Kanter et al., 2020; Lenes et al., 2020; Santhanam-Martin et al., 2017; Simmons et al., 2008; Wade & Bernstein, 1991; Woodley, 2021); training booklets (Bennett & Keating, 2008; Cénat, 2020; Fox, 1983; Leuwerke, 2005; McCorvey, 2020; Tuckwell, 2003). Different methods and tools were used during the training programs such as group and case discussions (Brown et al., 1996; Santhanam-Martin et al., 2017), interviews and films (Leuwerke, 2005; Triplett et al., 2023), experiential exercises such as “power shuffle”, “power chair” or “role plays” (Bryson et al., 1974; Bussey et al., 2022). The courses had lectures, class and group discussions (Brown et al., 1996; Smith & Mak, 2022; Vega et al., 2018; Wade & Bernstein, 1991), activities and films (Bryson et al., 1974; Triplett et al., 2023), theater (Triplett et al., 2023), and guest speakers, assignments, and interviews (Pieterse, 2009; Vega et al., 2018).
3.3.2. Training objectives
The training programs aimed to develop different approaches such as culturally responsive therapy, cultural competence and sensitivity (Boyer et al., 2019; Brown et al., 1996; Mattar, 2011; Porter, 1994; Richardson et al., 2017; Santhanam-Martin et al., 2017; Wade & Bernstein, 1991); multicultural competence (Kuo & Arcuri, 2014; Lenes et al., 2020; Ridley et al., 2000; Vega et al., 2018); antiracist strategy and education, and anti-oppressive interventions (Bennett & Keating, 2008; Branco & Jones, 2021; Bussey et al., 2022; Cénat, 2020; Corvin & Wiggins, 1989; Fix et al., 2022; Fox, 1983; Kanter et al., 2020; Simmons et al., 2008; Triplett et al., 2023; Woodley, 2021); and awareness to help mental health practitioners to recognize their own biases and intersectional identities (Bryson et al., 1974; Leuwerke, 2005; Malott et al., 2015; McCorvey, 2020; Pieterse, 2009; Ponterotto, 1988; Smith & Mak, 2022; Tuckwell, 2003).
3.3.3. Components highlighted in antiracist care
Panel 1 lists the different target knowledge, abilities and skills that were described as part of the training programs in the included studies. The following sections provide an overview of the key results of the studies.
Understanding the cultural, social, and historical context of mental health problems. Many studies emphasized the need to increase health practitioners’ knowledge of ethnic diversity and the history of oppression and racism (Pieterse, 2009; Porter, 1994; Richardson et al., 2017). One study focused on increasing knowledge on how racism is maintained in society and how students, as individuals and members of different racial groups, contribute to racism (Pieterse, 2009). Another study emphasized the importance of learning about the history of ethnic diversity, understanding traditional practices, socio-political factors, and religion to place the patient’s or client’s experience in a societal context (Porter, 1994). In addition to general knowledge about racism and ethnic diversity, the programs developed in some studies describe the need for mental health practitioners to understand the link between mental health and socio-cultural factors such as racism, discrimination and racial profiling (Cénat, 2020; Porter, 1994). Some studies showed that these factors can have a negative impact on mental health and therefore, mental health practitioners should be aware of racial and intergenerational trauma and systemic disparities (Corvin & Wiggins, 1989; Leuwerke, 2005). One training program targeted dominant socio-political false narratives and techniques to mitigate these narratives and address inequalities through various experiential exercises such as the “power shuffle” and “power chair” (Bussey et al., 2022).
Developing awareness on self-identity and privilege. Many studies emphasized the importance of increasing mental health care practitioners’ self-examination to increase awareness of self-identity and privilege (Brown et al., 1996; Bussey et al., 2022; Cénat, 2020; Corvin & Wiggins, 1989; Fix et al., 2022; Ponterotto, 1988; Porter, 1994; Ridley et al., 2000; Simmons et al., 2008; Williams, Faber, & Duniya, 2022). Studies highlighted the importance of White therapists recognizing themselves in society as racially positioned individuals and being aware of their own racial identity and cultural background. (Cénat, 2020; Corvin & Wiggins, 1989; Tuckwell, 2003). Ponterotto (1988) developed a four-stage theoretical model for developing racial awareness among White counselors-in-training. In one study, trainees, who were unaware of their racial identity, were provided information about racism and prejudice, allowing them to confront their roles as White members of society, and finally discuss and learn about multicultural issues to integrate them (Ponterotto, 1988).
Recognizing oppressive behaviors. Studies mentioned that mental health professionals should confront their own conscious and unconscious biases and beliefs, as well as their own stereotypes and attitudes that can lead them to belittle their patients, be insensitive, and prevent them from considering racial factors and the socio-political implications of race in the provision of services (Tuckwell, 2003). A formal course for social work students focused on recognizing the experience of internalized oppression and analyzing the mental processes involved (Smith & Mak, 2022). Examples of anti-Black racism and how it can be internalized (by those subjected to it) were used to illustrate internalized racial oppression and how socialization perpetuates racism and creates the process of internalization (Smith & Mak, 2022). Studies used activities and workshops designed to raise awareness of the recognition of microaggressions and their underlying consequences, through role-plays (Kanter et al., 2020; Malott et al., 2015) and definitions of microaggressions through different categories (“micro-insult, micro-assault, micro-invalidation”) (Malott et al., 2015) or through mindfulness exercises with guided interracial eye-contact (Kanter et al., 2020). This enabled mental health practitioners to address these issues with their clients and avoid using harmful statements in therapy. Finally, studies underlined that colorblind attitudes should be addressed and mental health care practitioners should favor a color-conscious approach where race is acknowledged and discussed in therapy and where disparities are taken into account (Lenes et al., 2020; McCorvey, 2020). This was meant to prevent victim-blaming or minimizing the experience of people from a different racial group, as emphasized in different studies (Cénat, 2020; Lenes et al., 2020). Other studies suggested that mental health practitioners should explore their own perceptions and responses to BIPOC (Porter, 1994) and should seek knowledge on how these can impact others through education and experiences (Sherlon Brown et al., 1996).
Antiracist competence in therapy and alternative approaches. Many studies suggested offering alternative treatment plans and proposed recommendations for doing so (Brown et al., 1996; Cénat, 2020; Mattar, 2011; Porter, 1994). One study showed the importance of developing a trauma psychology program that is culturally sensitive and does not examine trauma solely from a scientific perspective (Mattar, 2011). The importance of looking beyond psychological intervention to more collective and social approaches was described (Porter, 1994). The study indicated that community-based approaches should be explored, supporting a social perspective, as well as involvement in “collective and social action groups”, to create an environment where the mental health practitioner demonstrates culturally-sensitive therapeutic skills. Another study showed that multicultural therapeutic skills need to be developed, and should focus on identification and interpretation of verbal and nonverbal communication, stages of racial identity development, and culturally-biased assumptions and their impact on personal and traditional counseling theory (Brown et al., 1996). In another study, mental health practitioners were urged to inquire about the patient’s cultural background, racial trauma history, and all aspects related to racial issues and their impact on mental health when conducting an assessment (Cénat, 2020). Another study indicated that when prescribing psychotropic medications, a humanistic approach that avoids overprescribing is needed, as well as an approach that addresses all aspects related to the health effects of racism (Cénat, 2020; Triplett et al., 2023). Table 2 summarises the key findings related to antiracist knowledge, abilities and competences drawn from the included studies.
Table 2. Summary of antiracist knowledge, abilities and competences drawn from the articles.
Components | Knowledge. Abilities and Competences | Objectives |
---|---|---|
1. Knowledge of Cultural, social historical context of mental health problem | • Knowledge of history of racism, ethnic and cultural diversity | • Increasing awareness and knowledge on history of racism and ethnic diversity by learning more about the client’s background • Understanding social and political implications of race |
• Racial discrimination and mental health inequalities | • Mentioning in therapy and understanding racial and intergenerational trauma and how racism and other forms of oppression are central to mental health problems. • Understanding social, historical, and cultural shape of behavior • Placing the individual experience in a societal context • Referring to the relevant literature of cultural and social determinants of health | |
• Client’s internalized racism | • Understand how socialization perpetuates racism and creates the internalization process. • Assess the client’s internalized racial oppression and understand how it is central to the client’s mental health problems | |
2. Self-examination and recognizing oppressive practices | • Identity and privilege | • The mental health care practitioner needs to understand their own racial identity, cultural background, and privileges in society |
• Personal biases and Cultural biases | • Exploring one’s own personal biases and their effect on therapy • Exploring specific stereotypes attached to different groups to identify one’s own • Exploring how assumptions can be a result of certain beliefs which result in certain behaviors in therapy • Explore perceptions and responses/actions to ethnic minority groups • Acknowledge power in the therapeutic relationship | |
• Internalized biases | • Address and confront thoughts, beliefs that might be the result of internalized racism. • Address stereotypes and attitudes that are patronizing the patient and insensitive. | |
• Microaggressions | • Increase awareness of microaggressions • Understand the underlying meanings and consequences it has on the recipients. • Learn to recognize microaggression and its different forms: such as micro insults, micro assault, and micro invalidation • Learn to recognize microaggression and its forms such as micro insults, micro assault, and micro invalidation | |
• Oppressive practices and Color-blind approach | • Using a color-conscious approach instead of color blindness. Color-blind attitudes avoid talking about race, racism, institutional discrimination, and white privilege. • Explore racial identity issues with the client and have open conversations about race | |
3. Antiracist competences in therapy and alternative treatments | • Verbal and non-verbal competences skills | • Use Verbal and Non-verbal competences with using the accurate use of language • Using the right terminology is important, to end the dehumanization of people by reducing them to their oppressive experience • Recognize the language of oppression in the patient or client’s story |
• Delivering alternative practices | • Offering alternatives to the individual therapy model to collective solutions and social action groups. • Consider trauma with a culturally sensitive approach and social perspective and not only through scientific lenses • Involve the family of the patient through a cultural angle • Increase cultural support and decrease medication • Get involve in collective and social action groups • Make referrals if needed | |
• Exhibiting Multicultural competences | • Awareness and knowledge on history of ethnic group, traditional practices sociopolitical factors and religious aspects • Take intersectionality into account and take the impact of race, gender, social categorization into consideration in therapy • Demonstrate cultural therapeutic skills where the therapy is culture specific, client specific, and system specific. • Seek out antiracist and trauma psychology trainings |
3.4. Evaluation of training programs
Ten studies reported having evaluated their training programs (Bennett & Keating, 2008; Boyer et al., 2019; Kuo & Arcuri, 2014; Lenes et al., 2020; Santhanam-Martin et al., 2017; Simmons et al., 2008; Triplett et al., 2023; Vega et al., 2018; Wade & Bernstein, 1991). Nine were evaluated using self-report questionnaires (Bennett & Keating, 2008; Boyer et al., 2019; Brown et al., 1996; Kanter et al., 2020; Kuo & Arcuri, 2014; Lenes et al., 2020; Triplett et al., 2023; Vega et al., 2018; Wade & Bernstein, 1991); two using written and oral feedback (Santhanam-Martin et al., 2017; Vega et al., 2018). A qualitative study conducted an evaluation of 12 secondary consultations (case discussion by clinical practitioners) to enhance cultural responsiveness among mental health practitioners and found that 54% (44/82) of the participants thought it was useful (Santhanam-Martin et al., 2017). The participants mentioned that they had developed a greater comprehension of sociopolitical factors, religion, history and traditional practices of ethnic groups and their interaction with mental illness (Santhanam-Martin et al., 2017). A quantitative study found that after taking a multicultural course, psychology students showed a greater understanding of other cultural groups’ experiences and greater awareness of the experiences other groups have in society (respectively: Cohen’s d = 0.67, and Cohen’s d = 0.69) (Vega et al., 2018). Counselors who had participated in a 4-h cultural sensitivity training with cross-cultural counseling skills training, were described by patients (compared to the control group), as having more expertise (M = 26.23, SD = 2.63 vs M = 16.43, SD = 5.81), empathy (M = 50.31, SD = 6.57 vs M = 31.93, SD = 9.44), trustworthiness (M = 26.58, SD = 2.70 vs 17.69, SD = 4.95) at the third sessions (Wade and Bernstein, 1991). A training program for counselors, focusing on the foundations of intersectionality, color-blind racial attitudes and privilege, evaluated the changes between pretest and post-test and found statistically significant results for multicultural competence (Awareness, Knowledge and Skills; [F(1, 35) = 34.17, p < .001, η p2 = 0.494) as well as for colorblind racial attitudes [F(1, 35) = 61.51, p < .001, η p2 = 0.637)](Lenes et al., 2020). Before and after receiving racial/ethnic and cultural sensitivity training, psychiatry residents showed a significant increase in racial/ethnic sensitivity (M = 3.86, SD = 0.36 vs M = 4.32, SD = 0.36) and students placed in urban settings significantly improved in racial/ ethnic and cultural sensitivity from midterm (M = 2.88) to final (M = 3.55; t = −2.483, p = .019) (Boyer et al., 2019). Another study found that after participating to a workshop meant to decrease biases and negative stereotypes with patients of color through mindfulness exercises and role plays scenarios, providers (assessed by two independent blind teams of coders) showed greater improvement in showing emotional rapport (p = .001, η2 = 0.40), greater responsiveness to racial challenges (p = .016, η2 = 0.23) post-to-pre intervention (Kanter et al., 2020). Finally, the results of a theater-based training revealed an improvement of multicultural counseling self-efficacy (t[13] = −5.83, p < .001), intentions to discuss race and racism with Black clients (t[13] = −6.11, p < .001) and all clients of color (t[13] = −3.16, p = .008) and a decreased concerns about counseling Black clients (t[13] = −5.83, p < .001) (Triplett et al., 2023). Finally, another evaluated program showed that patients were more likely to come back to a follow-up session after mental health providers have taken the training (Wade & Bernstein, 1991).
4. Discussion
4.1. Summary of findings
The purpose of this study was to identify the various antiracist mental health care training programs that exist in the published literature, analyze their components and efficacy in developing knowledge, abilities and skills professionals need to provide antiracist care to racialized patients. The findings showed that the antiracist training programs included in this study highlighted four main components of competencies. The first component is the understanding of the cultural, social, and historical context of mental health problems. It provides contents to help professionals understand the cultural, social, and historical context of mental health problems in racialized communities. This is a key component and the most developed aspects of the trainings. Mental health professionals gain knowledge on the history of racism, culture and diversity, and structures of oppression (Malott et al., 2015; Porter, 1994; Richardson et al., 2017). Subsequently, the training programs link mental health problems to sociocultural factors that can negatively impact care (Porter, 1994). The second component is developing awareness on self-identity and privilege. Self-examination allows participants to become aware of their identity (Cénat, 2020; Fix et al., 2022; Ponterotto, 1988; Ridley et al., 2000; Simmons et al., 2008). This assessment helps identify privilege and biases they hold as well as acknowledge their position in society (Brown et al., 1996; Bryson et al., 1974; Corvin & Wiggins, 1989; Lenes et al., 2020). These elements can have a negative impact on health care, in addition to perpetuating overall society-based racial-insensitivity. For example, studies have demonstrated that racial bias contributes to clinicians’ overemphasis of the presence of psychotic symptoms among African Americans (Faber et al., 2023; Gara et al., 2012; Gara, Minsky, Silverstein, Miskimen, & Strakowski, 2019). The third component is recognizing oppressive behaviors. This component helps professionals learn to identify and eliminate color-blind attitudes (Tuckwell, 2003) and move toward a color-conscious approach. It also allows providers to adopt better practices. For instance, some studies have shown that racialized people are more likely to be over-medicated (Segal, Bola, & Watson, 1996), which can reduce these communities’ confidence in health care professionals. For example, African Americans may be more skeptical regarding the use of psychiatric medication and are less willing to use them or administer them to their children (Schnittker, 2003). When a provider is aware of this past oppressive practice, it can allow them to be mindful about certain behaviors such as non-adherence to medications. The fourth component is antiracist competencies in therapy and alternative approaches. Mental health professionals are encouraged to adopt new practices. These include recognizing the language of oppression and microaggressions that can emerge in therapy (Tuckwell, 2003), assessments that include racism as a strong determinant of mental health issues (Porter, 1994), a humanistic approach to medication management (Cénat, 2020), alternative practices such as addressing racism consequences in care (Cénat, 2020), including internalized racism (Smith & Mak, 2022), involving the family in the care (Santhanam-Martin et al., 2017) and continuing education by seeking out additional antiracist trainings (Fix et al., 2022).
4.2. Lessons learned and recommendations for development of future trainings
Some elements are common to all the training programs. These include a module or section that seeks to educate participants on the cultural, social, and historical context of mental health problems (Branco & Jones, 2021; Fox, 1983; Kanter et al., 2020; Leuwerke, 2005; Pieterse, 2009; Richardson et al., 2017; Ridley et al., 2000; Sandford et al., 2021; Tuckwell, 2003). Future trainings should continue to include this component because participants gain valuable knowledge, and it sets the foundation for further portions of the trainings. The training programs contain a variety of content that are inconsistent from one training to another. There are inconsistencies in the prioritization of content in each training. For instance, some training programs included interviews with people of a different culture (Vega et al., 2018), role-playing to practice skills (Malott et al., 2015), and watching stimulus films with simulated emotional vignettes (Bryson et al., 1974). In contrast, others prioritize classroom courses and none integrated a supervised practice after completing the training program. Multiple methods may be used to provide antiracist training, indicating that there isn’t a specific combination of strategies necessary to achieve the end goals of the programs. However, very few of the training courses were evaluated. Therefore, we cannot know if they are all effective in fostering antiracist practices. Also, there is almost no data on the outcomes for clients and their perceptions of the practices. More efforts should be made to implement and validate antiracist trainings among mental health professionals.
Moreover, most trainings focus on the personal racial attitudes of the health care providers and learning about racism. The trainings rarely address therapeutic skills and do not indicate how to address the consequences of racism during care. Future development of anti-racism trainings should consider including content on how providers can address their clients’ experiences of racism in their everyday lives in therapy. Therapists should be able to help clients work toward responding effectively toward racism they experience in their daily lives (Williams, Holmes, Zare, Haeny, & Faber, 2022). Future training programs can be inspired by a module in the ‘How to provide antiracist mental health care’ training that teaches this approach by Cénat and colleagues at the University of Ottawa (Cénat et al., 2020). Also, none of the studies included in the scoping review discuss the importance of utilizing an Afrocentric approach, respecting clients’ beliefs and values or provide concrete ways to deliver non-oppressive (Bartlett, Faber, Williams, & Saxberg, 2022) and culturally appropriate care. These are all crucial elements needed to provide antiracist care and need to be considered when developing new trainings. Further, 22 of 30 of the studies were conducted in the United States and the eight others in Canada, the United Kingdom, Australia, and New Zealand. There is a need to develop similar programs in other countries to include a global perspective that is lacking in the current creation and implementation of these trainings. We need to ensure that future anti-racism trainings are suitable for use with racialized communities all over the world and include cultural humility aspects (Rousseau, Gomez-Carrillo, & Cénat, 2022; Williams, Faber, & Duniya, 2022). Moreover, this study explored the content of these trainings. Future research should examine the structure of the programs such as the length, feasibility, delivery method (ex. in person or virtually) and related costs. These implementation characteristics can serve as a barrier to uptake of these trainings’ programs. They require more investigation and consideration during the development of future trainings. We can compare the content and teaching strategies from these trainings to those used for Indigenous communities in New Zealand, Australia, and Canada because there are similarities. Also, the learning strategies need to include a combination of passive (e.g., knowledge acquisition) and active (e.g., roleplays) strategies with an evaluation that involves a direct observation which is the most relevant way to assess competency.
Finally, different important aspects have not been addressed by the various training programs. We can cite the issue of positionality, the need often expressed by racialized patients to be treated by same-race mental health professionals, issues associated with the treatment of mixed-race patients (often forced by experiences of racism to only acknowledge their Blackness, Asian, Latino, Indigenous or other people of color background and ignore their White heritage), consideration of the intersectionality of potential discrimination (e.g. race, gender, social class, disability), the evaluation of the practical experimentation of training programs among patients, the modification of the practices of established professionals, and the issue of supervised practice following training courses. In addition, none of the training programs were evaluated by the clients themselves to determine whether they perceived an improvement in the care they received before and after the providers completed the training. These are just some of the issues to be addressed in future training courses and studies.
4.3. Limitations
This scoping review has some limitations. First, there is a need to conduct a systematic review on this topic. Although our search strategy was comprehensive, we have not captured relevant grey and unpublished literature in this study. Further research should explore the content from these types of literatures to allow for more diverse evidence sources. Second, we only included articles published in English or French. If we had expanded the language criteria, it could have allowed for more studies to be included in the review. Third, relevant antiracist trainings may have been excluded from this study due to our inclusion criteria. Fourth, the results are not reported in the same way in all the articles. The studies are described and evaluated with no consistent measurement. Therefore, it is possible that some aspects of the findings could be interpreted differently by readers. Finally, the absence of previous review papers limited the ability to observe the evolution of the field. In addition, when considering the different periods of publication since the last 50 years (first publication in 1974 and last publication in 2023), there was no obvious evolution of contents. In fact, the limited implementation of these training programs also limited the evolution of the contents.
5. Conclusions
Existing antiracist training programs are a step in the right direction toward antiracist mental health care that promotes humanistic values. Although more work is needed to quantify the effectiveness of such trainings and the essential components, the results demonstrate that the trainings are useful based on the research to date, and as such they should be a regular part of clinician training. However, there is still work to be done to ensure these training programs are mandatory and provided in all settings. First, hospitals, health centres and all health care services should ensure that all their workers are trained; they are regularly responsible for the care of racialized individuals and need to gain the specific competencies addressed in these antiracist trainings. Second, colleges, associations of psychiatrists, psychologists and other professionals should require all their members to receive training in how to provide antiracist care. These programs need to become a standard for the training of these professions to ensure the best care for individuals of racialized communities. Universities also need to review their programs and assure that students have these competencies at the end of their training. There needs to be a commitment to providing culturally appropriate care in this field, and that begins with the leaders and governing bodies of those professions. Most importantly, universities should ensure that no student exits in a mental health related program without a solid education on anti-racism issues and successful internships on how to provide antiracist care. Academic institutions can no longer neglect to educate their students on antiracist competencies. These courses should become a part of the curriculum, especially in programs where students will be interacting with other people and be responsible for their care. Competencies included in this review will improve the quality of care that students will deliver as students and later in their careers. Institutions can ensure culturally appropriate care becomes the standard by beginning to teach future professionals early in their training.
Contributors
The authors contributed equally performing analyses, drafting, and revising the article. JMC obtained fundings from the Social Sciences and Humanities Research Council (SSHRC) and the Canadian Institutes of Health Research (CIHR).
Data sharing
The data are not publicly available due to privacy and ethical restrictions. They are available on request from the corresponding author.
Role of the funding source
This study was funded by the Social Sciences and Humanities Research Council (SSHRC) and the Canadian Institutes of Health Research (CIHR), Grant #: 1036-2021-00702 and the grant # 4500440446 from the Public Health Agency of Canada (PHAC). The funders were not involved in the design, and interpretation/writing the paper.
Funding
This article was supported by the grant #469050 from the Social Sciences and Humanities Research Council (SSHRC) and Canadian Institutes of Health Research (CIHR) and the grant # 4500440446 from the Public Health Agency of Canada (PHAC).
Declaration of competing interest
There is no conflict of interest for any author.
Acknowledgments
We extended our acknowledgments to Schwab Bakombo and Wina Darius for the coordination role within the Interdisciplinary Centre for Black Health and the Vulnerability, Trauma, Resilience, and Culture Research Laboratory. We would also like to thank Alain El Hofi, Research Librarian at the University of Ottawa Library, who peer-reviewed the APA PsycInfo (Ovid) search strategy using the PRESS guideline for systematic reviews.