A systematic review of client’s perspectives on the cultural and racial awareness and responsiveness of mental health practitioners

Abstract

Culturally and racially responsive practice continues to be a common challenge among Mental Health Practitioners (MHPs). To the authors’ knowledge, this systematic review was the first to collate and synthesize clients’ perspectives of MHPs’ cultural and racial awareness and responsiveness from around the world. Original studies that were published between 2010 and 2021 reporting on qualitative data about clients’ perspectives regarding MHPs’ cultural-racial awareness and responsiveness were included in the review. The studies’ key findings that addressed this review’s question were synthesized and analyzed using reflexive thematic analysis. This review found 48 papers that met inclusion criteria, which represented the views of 652 clients across 10 countries. Three major themes and eight subthemes were established that concerned characteristics of the MHP, the client, and the therapeutic alliance. The results of this review indicate individual and systemic factors that influence mental health access for people from culturally and racially marginalized groups. Ongoing training of MHPs, increased racial and cultural representation among MHPs, inclusive physical settings, and reduced discrimination by MHPs are among the key findings and directions based on the results of this review.

Keywords

Cultural psychology cultural competency diversity and inclusion qualitative research professional development and training racism,bias,and discrimination

Racially and/or culturally marginalized groups often have poorer mental health than privileged groups (e.g., white people from Anglo backgrounds), yet less frequently seek assistance from Mental Health Practitioners (MHPs e.g., psychologists, counselors, social workers; Burkett, 2017; Narendorf et al., 2018). Common mental healthcare access barriers experienced by racially and culturally marginalized people include stigma, low familiarity with services, language barriers, racism, and discrimination (Colucci et al., 2017; Khawaja, 2007; Priebe et al., 2012). Although untreated mental illness alone culminates in complex negative outcomes, additional (common) experiences of racism and discrimination often worsens marginalized people’s mental health, educational, employment, social, and financial outcomes (Maura & Weisman de Mamani, 2017; Skiba et al., 2011). It is therefore vital that researchers and practitioners explore the perspectives of marginalized communities towards MHPs, to understand their healthcare needs and to help circumvent mental healthcare access barriers.

Current evidence suggests many MHPs do not readily recognize they lack the understandings and skills to address the experiences of racially or culturally marginalized people. Specifically, researchers in the USA (Newell et al., 2010) and Australia (Sadusky et al., 2021) have reported a training-practice gap between the amount of multicultural training provided to psychologists and the skills they require to successfully fulfil their role. Moreover, a review of tertiary-level counselling programs revealed that, while elements of multiculturalism are sometimes taught in the curriculum, ethnoracial issues relating to power, oppression, and social injustices are underrepresented across curricula (Motulsky et al., 2014). Consequently, many MHPs are not explicitly trained in the historical and current healthcare structures that have fostered racial supremacy (e.g., whiteness), which continue to hinder racially or culturally marginalized people from accessing adequate care (Gonzalez & Cokley, 2021).

Risk Factors for Poor Mental Health Among Marginalized Groups

Several factors can account for the higher rates of mental illness seen within racially and culturally marginalized groups compared to privileged groups. For example, migrants and refugees often arrive in their new country with a history of colonialism; displacement from family; and/or exposure to conflict, war, or terrorism (George, 2010; Sullivan & Simonson, 2016). These experiences increase the risk of mental illness for these people (Sangalang & Vang, 2017). Moreover, Indigenous people frequently experience higher rates of disadvantage, trauma, discrimination, and racism compared to non-Indigenous people, which negatively impacts their mental health (Herring et al., 2013; Paradies & Cunningham, 2012; Priest et al., 2011; 2013; Watego et al., 2021). Indigenous people have also endured chronic trauma related to colonization; genocide; forcible removal of Indigenous children from their families; the absence of treaties or acknowledgement of the invasion and continued occupation of Indigenous land; and ongoing injustices, systemic discrimination, and racism (Dudgeon et al., 2017; Menzies, 2019). In all, people who culturally and/or racially differ from the dominant (white) group often face many forms of systemic disadvantage which, in turn, fosters mistrust in mental health sectors that are often borne from the customs of the dominant group (Alang, 2019; Hui et al., 2021).

Mental Health Treatment for Marginalized Groups

Racially or culturally marginalized people receive substantially less mental health support than people who comprise the dominant culture. A large study that compared the utilization of mental health services between unaccompanied refugee minors (n = 920) and a Dutch adolescent control sample (n = 1059) found that nearly 60% of the refugee youth sample reported a need for mental health support, compared to only 8.2% of the Dutch sample reporting such needs (Bean et al., 2006). Even when marginalized communities access mental healthcare, the provided support is often of reduced quantity, quality, and/or appropriateness when compared to the care received by culturally or racially dominant group members (Lê Cook et al., 2014). For example, many MHPs utilize treatment protocols that were originally developed for white people (i.e., through Eurocentric and colonial lenses) and therefore can be culturally inappropriate for marginalized groups (Woods-Giscombe et al., 2016). Having negative experiences with mental healthcare services can subsequently reduce marginalized people’s trust in mental healthcare services (Woods-Giscombe et al., 2016) and thus deter them from seeking much needed support, which can exacerbate their mental health conditions (Alang, 2019). Finally, a disparity in the types of offered mental healthcare treatment has been observed (Holden et al., 2013). Specifically, marginalized groups tend to be less likely than white people to receive newer and more comprehensive treatment modalities, which can be attributed to racism and a lack of cultural or racial competency across MHPs (Holden et al., 2013). In all, research has repeatedly demonstrated a paucity in practices that are responsive to the needs of culturally and racially marginalized people (Miller & Berger, 2020) which, in turn, perpetuate injustices and disadvantages (Hui et al., 2021).

Mental Healthcare Professions and Marginalized Communities

The mental health profession has a long history of systemic racism (e.g., eugenics practices, race/IQ assertions) that likely contributes to its inadequacy in servicing marginalized communities, and in a psychologically safe or trauma-informed manner (American Psychiatric Association, 2022; Buchanan et al., 2021; Kinouani., 2021; Mensah et al., 2021; Roberts et al., 2020; Tinsley-Jones, 2001). The extent of systemic racism, discrimination, and stigma endured by marginalized people within the mental healthcare system has been publicly acknowledged, and apologized for, by authoritative psychology organizations including the American Psychological Association (APA, 2021; 2022) and the Australian Psychological Society (APS, 2016). MHPs, some of whom have been harmed by systemic racism themselves, have mixed reviews regarding the authenticity of these apologies but mostly agree that true reconciliation requires actions beyond apologies to help rectify the harm caused within mental health-related research and practice (Association of Black Psychologists [ABPsi], 2021; Buchanan et al., 2021; Carey et al., 2017; Dudgeon et al., 2017; Roberts et al., 2020; Tinsley-Jones, 2001). This highlights that more needs to be done in the mental health sector to increase access and delivery of appropriate services and treatment to racially and culturally marginalized people, towards eliminating oppression within the field.

Review Aims

As far as the authors are aware, there have been no systematic reviews that have collated and synthesized clients’ perceptions regarding MHPs’ cultural and racial awareness and responsiveness. The key limitations of research in this area have been that sample sizes are too small and/or findings cannot be extended beyond the race or culture that was examined. Thus, this systematic review aimed to collate clients’ voices, around the world, with the primary purpose of informing general global guidelines for how to develop and deliver appropriate mental healthcare services to culturally and marginalized people, and in ways that prioritize emancipation from hegemonic and hierarchical ideologies.

Employed Definitions in this Study

For this study, marginalized people was defined as “those excluded from mainstream social, economic, educational, and/or cultural life” due to racism, discrimination, and other forms of systemic oppression (Sevelius et al., 2020, p. 2009). Marginalization cannot happen without macrosystems that disproportionately advantage only certain groups (Nixon, 2019). Race was considered a non-biological, socially-constructed status (that often perpetuates white hegemony in society; Watego et al., 2021). Culture was defined as a dynamic and complex interaction between the acquisition and transmission of group knowledge, norms, and behaviors across time and context/s (Smedley & Smedley, 2005). Importantly, stable definitions for race and culture across the literature are elusive due to the plethora of experiences that can define these constructs in idiosyncratic ways (e.g., some people experience these constructs interconnectedly while others do not; Yared et al., 2020).

Method

This systematic review was conducted in the following order: database search, title and abstract screening, full text screening, data extraction, quality checking, data analysis, and reporting of the results. The protocol of this systematic review was registered in PROSPERO on 12 June, 2021 (for details, see https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021252705).

Database Search Strategy

Compared with quantitative research methods, qualitative methods better capture the experiences and perceptions of individuals in descriptive, in-depth, and exploratory ways (Cooke et al., 2012). Thus, given the phenomenological nature of this review’s aim, only qualitative studies were of interest. The SPIDER database search strategy was implemented because it enables the synthesis of qualitative research within a systematic review (Cooke et al., 2012). Database searches were conducted in April and May 2021 across five databases: PsycINFO, PubMed, Scopus, CINAHL plus, and ERIC. References were transferred into the Covidence Systematic Review platform (Veritas Health Innovation, 2015) for data screening and quality appraisal. Table 1 shows the terms used to search the databases.

Table 1.

Search strategy and terms.

Sequence	Search terms/directive
S1	(Psychologist* or psychiatrist* or psychotherapist* or counsellor* or counselor) OR (mental health or psychiatric or social or school) adj (therapist or clinician* or nurse* or practitioner* or professional* or worker* or counsellor* or counselor*)
S2	(Cultur* or multicultur* or multi-cultur* or transcultur* or trans-cultur* or crosscultur* or cross-cultur* or accultur* or race* or racial* or ethnic* or ethno) AND (aware or respons* or competenc* or sensitiv* or toleran* or practice* or practise* or skill* or abilit* or capabilit* or bias* or discriminat* or equalit* or inequalit* or inequit* or iniquitor disparit or prejudice* or racis* or stereotyp* or microaggressi* or micro-aggressi*)
S3	S1 AND S2
S4	(Service user* or client* or patient* or consumer* or student* or child* or adolescent* or youth* or young people* or immigrant* or lived experience) AND (perspective* or perception* or impression* or sense* or opinion* or judgement* or viewpoint* or insight* or experience*)
S5	S3 AND S4
S6	Limit search S5: Publication year: 2010–2021; English language; publication type: Doctoral Dissertation, journal article; human

Inclusion and Exclusion Criteria

This review sought to include qualitative literature addressing the experiences and perceptions of clients regarding MHPs’ cultural and racial awareness and responsiveness. Qualitative literature was defined as studies that included outcomes from interviews, focus groups, open-ended survey responses, or case study analyses of clients’ experiences of MHP’s cultural and racial awareness and responsiveness. No restrictions were placed on the country of origin for the included studies and this review did not use criteria for defining racially and culturally marginalized groups. A date range of articles published between 2010 and 2021 was used to ensure inclusion of current evidence. Only studies published in English were included in this review due to translation barriers. MHPs were defined as any professional providing mental healthcare services to clients, including psychologists, psychiatrists, counselors, and social workers. Table 2 shows the utilized inclusion and exclusion search criteria in full.

Table 2.

SPIDER inclusion/exclusion criteria.

Criteria	Inclusion(s)	Exclusion(s)
Sample	Recipients of mental health services	Non-recipients e.g., practitioners, general community’s perspectives
Phenomenon of interest	Recipients’ perspectives* regarding MHPs’ cultural-racial awareness and responsiveness *Based on lived or perceived experiences	Non-recipients’ perspectives
Design	Qualitative, mixed methods	Quantitative only
Evaluation	Identified themes (derived from interviews, focus groups, open-ended questions) that relate to the phenomenon of interest	Quantitative data, qualitative data that do not related to the research questions/Phenomenon of interest
Research type	Original peer-reviewed empirical studies e.g., journal articles, dissertations, theses	Grey literature (e.g., book chapters), synthesized/unoriginal works (e.g., meta-analyses, reviews)

Screening Strategy

All four authors participated in title and abstract screening and full text screening. During both the title and abstract, and full text screening phases (1) each author screened approximately a quarter of the papers, and (2) each paper was screened by two authors before proceeding to the next stage or being excluded. Where conflicts over inclusion/exclusion decisions occurred, a third author independently reviewed the paper in question (i.e., without feedback from the two authors who initially screened the record) and made the final inclusion/exclusion decision. Figure 1 illustrates how many papers progressed through each stage of the review.

Figure 1.

Covidence PRISMA flowchart of review Progression.

Quality Appraisal

The Critical Appraisal Skills Programme (Critical Appraisal Skills, 2019) Checklist for Qualitative research was used to assess the credibility, dependability, and confirmability of the included studies. This process involved evaluating the papers’ articulated aims, design, method, considerations of ethical issues, management of researcher-participant relationships, analyses, and findings. Each CASP criterion is rated “Yes” or “No” to indicate whether it has been satisfied or unsatisfied, respectively. All authors were involved in the quality appraisal stage: each paper was appraised independently by two authors within Covidence. Conflicts in quality appraisal ratings were resolved through discussion between the original raters. The CASP checklist does not use a scoring matrix and there are no cut-off points to determine what constitutes low/medium/high quality. Consequently, the authors collated the frequencies that each of the CASP checklist’s nine criteria were satisfied by the 48 papers (see Table 3). As shown by Table 3, eight out of the nine CASP criteria were satisfied by at least 75% of the included studies.

Table 3.

Satisfactory CASP quality appraisal ratings (“Yes”) of included studies (n = 48).

CASP criterion	Criteria met (n)
1. Research aims are clearly stated	48
2. Qualitative methodology is appropriate	48
3. Research design appropriately addresses research aims	45
4. Recruitment strategy appropriately addresses research aims	45
5. Data collection strategy appropriately addresses research aims/issues	44
6. Researcher-participant(s) relationship is adequately considered	20
7. Ethical issues are considered	36
8. Data analysis is sufficiently rigorous	29
9. Findings are clearly stated	47

Note: The tenth CASP question required the authors to provide commentary about the value and contributions the study makes to pre-existing knowledge. All included studies were deemed appropriately valuable because they added new insights about a different cultural-racial population’s perspectives and/or considered the implications of these perspectives for accessing non-discriminatory psychological services.

Data Extraction

Three authors (AS, HY, and PP) and a research assistant (KO) each extracted approximately one-quarter of the included papers’ data into a shared spreadsheet. Each spreadsheet row represented one included paper, while each column contained a different type of extracted information. The data that was extracted from the papers included:

• Demographics about the studies (e.g., country and participant/MHP characteristics; see Tables 4 and 5).

• Key findings that related to this review’s research questions (i.e., the extractors’ initial coding efforts).

• Excerpts and quotes that illustrated each study’s key findings.

Table 4.

Paper demographics.

#	Study	Type	Country	MHP roles	Aim (to explore/identify/collect…)
1	Alajlan (2016)	T	USA	NK	Psychological attitudes of Saudi Arabian international students toward mental health services
2	Al-Roubaiy (2013)	T	Sweden	CO, PSYC, PSYT	How counselling and psychotherapay can address the post migration stress that adult male Iraqi refugees can experience in the later stages of exile
3	Blake et al. (2017)	PA	UK	SW, carer workers, social care managers	Underlying reasons for the expression of dissatisfaction with services among Bangladeshi and Pakistani social care users in England and how these could be addressed
4	Boghosian (2011)	T	USA	NK	Mental health attitudes and psychotherapy experiences of clients of middle Eastern descent
5	Browne-James (2018)	T	USA	NK	Lived experiences of Black individuals who have encountered racial microaggressions and learn their perspectives on what counselors can do to help them in counseling
6	Bushey (2018)	T	USA	NK	Native Americans perceptions of mental health service experiences, and of the intake process in particular
7	Carpenter-Song et al. (2010)	PA	USA	NK	How understandings of mental illness and responses to mental health services vary along ethnoracial lines
8	Chang (2021)	T	USA	CO	Female Chinese immigrants’ perceptions of why they are reluctant to seek mental health services
9	Conner et al. (2010)	PA	USA	CO	Drug counselor preferences of older adult methadone maintenance clients
10	Crans (2013)	T	USA	NK	How race, ethnicity, and socioeconomic status influenced the experiences of adolescent clients in counseling relationships
11	Dorsainvil (2015)	T	USA	CO	Students' perceptions of high school counselors' role (and multicultural competence) and its effect on student academic, career, and personal, social development
12	Gouveia & Zanello (2019)	PA	Brazil	P/T	Narratives of black persons regarding their experiences of racism in daily life and how they were listened to in a biracial dyad in psychotherapy with white psychotherapists
13	Gundel (2016)	T	USA	NK	Lived psychological experiences of sudanese refugees and the meanings members of this group have ascribed to Western models of mental health care
14	Gundel et al. (2020)	PA	USA	PSYC	Experience of multicultural processes in a cross-cultural counseling dyad in the lived experiences of a client and a clinician
15	Hack et al. (2014)	PA	USA	NK	Clients’ cultural connection to their racial identity and to understand what impact their American Indian identity had on their mental health care experiences
16	Harms et al. (2011)	PA	Australia	SW	Educational preparation and social work practice approaches that may lead to more effective relationships and positive outcomes, particularly from an Aboriginal perspective
17	Hepworth et al. (2015)	PA	Australia	MD, PSYC, SW, Aboriginal health worker, dietician, nurses, receptionists	Impact of integrating mental health care service delivery into an urban Aboriginal and Torres Strait Islander primary health care service
18	Hunter (2011)	T	Canada	CO, PSYC, PSYT, P/T, SW	Counselling needs of the growing population of older adults, including clients' perspectives in enhancing multicultural competence of counsellors
19	Joharchi (2017)	T	USA	MHC	Experiences of deaf and hard of hearing individuals from immigrant backgrounds, as well as those of the mental health clinicians who serve these individuals
20	Kassan & Sinacore (2016)	PA	Canada	CO	Experiences of young women who attended counselling during their adolescence, focusing on their perceptions of their counsellors multicultural counselling competencies and the cultural factors deemed important to them in counselling
21	Kour et al. (2020)	PA	Norway	NK	Treatment experiences of immigrant men living with co-occurring mental health disorder and substance-use disorder in Norwegian mental health and addiction services
22	Lanesskog et al. (2019)	PA	USA	SW	Spanish speaking clients’ and workers’ perceptions of their relationships and the barriers and facilitators of their work together
23	Liu et al. (2020)	PA	USA	CO	Experiences of East Asian international students who had sought mental health counseling in the United States
24	Manalo (2011)	T	USA	CO	Counseling needs and resilient strategies of Hmong students living in the southeast across elementary, middle and high school levels, as perceived by school employees and Hmong students
25	McCullough et al. (2017)	PA	USA	CO, PSYC, P/T, SW	Counseling experiences of transgender and gender nonconforming individuals
26	McGee (2013)	T	USA	Community mental health workers	African American women’s perceptions of community mental health interventions
27	Moleiro et al. (2013)	PA	Portugal	NK	Experiences of individuals of ethnic minority groups regarding their access to the Portuguese healthcare system (both physical and psychological) and to identify the multicultural competencies of the clinicians (as perceived by the clients) which would be required to improve culturally sensitive treatments
28	Munoz (2014)	T	USA	NK	How the role of language influences hispanics perception of mental health and their judgment toward receiving treatment
29	Pejic et al. (2019)	PA	USA	NK	Training experience of psychiatry residents working with refugees and assess the level of satisfaction of refugees, most of whom are Iraqi, who seek psychological treatment at a refugee mental health program
30	Peña & Rhoads, 2019	PA	USA	CO	Latino male students and first-year experience programs aimed at promoting student transfer
31	Rogers-Sirin et al. (2015)	PA	USA	CO, MHC, PSYC, SW, doctor (PhD)	Immigrants' perceptions of their therapists’ cultural competence
32	Romero (2018)	T	USA	CO, MHC	Personal life experiences of undocumented, central American Latino immigrants to highlight barriers and challenges that these persons face; and how these may have adverse impacts on physical health, mental health, access to health care and healthcare professionals; and how these persons cope with the enormous stresses and pressures of immigration and acculturation
33	Rowe (2014)	PA	Australia	CO	The ways in which counsellors at a specialist alcohol and other drugs service balance cultural relevance with fidelity to various psychosocial interventions
34	Sambrano & Cox (2013)	PA	Australia	NK	How three Indigenous people experienced the controversial practice of seclusion
35	Smith (2012)	T	USA	NK	Attitudes of a select group of muslim Arab Americans toward psychotherapy and explore their beliefs as to why members of this group of Americans tend not to use mental health services
36	Sun et al. (2014)	PA	USA	MD, P/N, SW, program administrator	Perceptions of service barriers as seen by Chinese American family caregivers and the service professionals in the phoenix metropolitan area
37	Tor & Tan (2015)	PA	Singapore	PSYT	Differences between patients and psychiatrists regarding the qualities of a good psychiatrist
38	Tsai et al. (2017)	PA	USA	CO	Attitudes towards prenatal genetics among Southeast and East Asian women living in the United States and to explore sociocultural factors influencing those attitudes
39	Tse et al. (2010)	PA	New Zealand	NK	Use of the strengths model as a recovery intervention with Chinese people with mental illness in New Zealand
40	Turkes-Habibovic (2011)	T	USA	NK	Muslim women’s attitudes towards counseling and utilization of counseling services
41	Valibhoy, Kaplan, and Szwarc (2017)	PA	Australia	NK	Young refugees' experiences regarding how they accessed mental health services, their feelings about disclosing personal problems, what promoted and what discouraged engagement with services and practitioners, what assisted them, and what they recommended to improve services
42	Valibhoy, Szwarc, and Kaplan (2017)	PA	Australia	NK	To examine barriers to accessing mental health services, from the perspective of young people of refugee background who have been service users, and to suggest strategies to improve access to mental health services
43	Venner & Welfare (2019)	PA	USA	NK	Lived experiences of Black Caribbean immigrants as they access mental health treatment in the United States
44	Weich et al. (2010)	PA	UK	NK	Service users’ and carers’ accounts of recent episodes of severe mental illness and of the care received in a multi-cultural inner city, as well as factors impacting on these experiences (including whether and how users and carers felt that their experiences were mediated by ethnicity)
45	Wilson (2010)	PA	USA	Psychiatric nurses	Whether African American clients with mental illness think that psychiatric nursing care is effective in meeting their cultural needs, and if psychiatric nurses think that they provide culturally competent psychiatric nursing care
46	Wright (2020)	T	USA	NK	Lived experiences of Black women who voluntarily engaged in mental health services
47	Yalamanchili (2014)	T	USA	NK	Cultural competence through the perceptions of minority clients with disabilities seeking vocational rehabilitation counseling services
48	Ye et al. (2012)	PA	USA	PSYT	Extent to which Korean patients accept telepsychiatry services

Note: T = Thesis/dissertation. PA = Peer-reviewed journal article.

CO = Counsellors. MD = Medical doctor (e.g., general practitioner, physician). MHC = Mental health clinicians. PSYC = Psychologists. PSYT = Psychiatrists. P/T = Psychotherapists/therapists (unspecified). SW = Social workers. NK = Not known.

Table 5.

Sample Demographics (n Represents Non-Professionals).

#	n	Culture/Race/Ethnicity of service users	Age	Gender (m/f)	Data collection	Data analysis
1	35	Saudi Arabian	19–45	19/16	Survey	CA, HP
2	10	Iraqi	21–38	10/0	SSI	IPA
3	63	Bangladeshi, Pakistani, white British	18–60+	28/35	SSI	PA
4	13	Middle Eastern	NK	5/8	SSI	TA
5	7	African American, Caribbean	25–65	3/4	SSI	IPA
6	6	Native Americans	23–75	1/5	SSI	IPA
7	25	African American, Euro-American, Latino/Latina	26–69	13/12	Unstructured interview	Iterative qualitative analysis (unclear)
8	6	Chinese	70+	0/6	FG	GT
9	24	African American, Caucasian American	50–66+	10/14	SSI	CA
10	8	American, African, African-American, Alaskan native, hispanic, Mexican, Mexican-American, native-American, puerto rican-American, Spanish, white	16–20	4/4	SSI	IPA
11	7	Black, hispanic	17–19	4/3	SSI	TA
12	7	Black	22–30	0/7	SSI	CA
13	9	Sudanese	19+	NK	SSI	PA
14	1	African American, muslim	NK	0/1	SSI	Stake’s (1995) four-phase analysis
15	14	American-Indian, Black, multiracial, white	M = 48, SD = 11	3/11	SSI	CQR
16	30	Aboriginal Australian	NK	5/25	FG	TA
17	12	Aboriginal and Torres Strait Islander	6–67^a	4/8	SSI, FG	TA
18	10	Egyptian, English-Canadian, French-Canadian, German, Indian, Jewish-American, Jewish-Canadian	67–89	4/6	SSI	Narrative analysis
19	3	Eastern European, South American, Southeast Asian	24–39	1/2	SSI	GT
20	20	White, “ethnic minority” (unspecified)	18–23	0/20	SSI	PA
21	10	African, Asian, middle Eastern	25–53	10/0	SSI	Systematic text condensation
22	3	Latino	NK	NK	SSI	PA
23	9	Chinese, Korean	21–28	2/3	SSI	IPA
24	7	Hmong American	10–20	2/5	SSI	GT
25	13	Black/African American, Latino, multiethnic, multiracial, white	21–54	See note^b	SSI	IPA
26	6	African American	19–62	6	FG, SSI, observations	TA
27	40	African, Brazilian, European	18–50+	10/30	FG	TA, CQR
28	8	Spanish	NK	2/6	SSI	PA
29	10	Iraqi	5–60^a	4/6	SSI	TA
30	16	Chicano, hispanic, Latino	18–24	16/0	SSI, document analysis, observations	TA
31	10	Belizean, Chinese, Columbian, Italian, Korean, Lebanese, Russian, Senegalese, Trinidadian	19–42	3/7	SSI	CQR
32	8	Central American	30–69	5/3	SSI	IPA
33	24	Not Anglo-Australian	NK	NK	SSI	Qualitative data analysis (unclear)
34	3	Aboriginal, Torres Strait Islander	18+	2/1	SSI	HP
35	14	Muslim-Arab-American	18–65	4/10	FG	IPA
36	6	Chinese American	18+	1/5	FG	TA
37	21	Caucasian, Chinese, Indian, Malay	M = 39.5, SD =12.3	11/10	SSI	GT
38	23	Chinese, Filipino, Hong Kongese, Indonesian, Japanese, Malaysian, Singaporean, South Korean, Taiwanese, Vietnamese	22–70	0/23	SSI	TA
39	35	Chinese	16+	NK	FG, SSI	General inductive approach (unclear)
40	10	Arab, Asian, Black, hispanic/Latina, white	26–49	0/10	SSI	IPA
41	16	Afghan, Congolese, ethiopian, Iranian, Iraqi, Ivorian Cote d'Ivoire, Pakistani, sudanese, Tanzanian	18–25	7/9	SSI	TA
42					SSI	TA
43	8	Black Caribbean (African American, Black, Caribbean, Caribbean American, Jamaican, mixed race, Trinidadian)	40–59	NK	SSI	PA
44	40	Black (Black African, Black British, Black-Carribbean, mixed), South Asian (Bangladeshi, Indian, Pakestani), white (white British, white Irish, other)	18–65	22/18	SSI	TA
45	15	African American	18–65	NK	SSI, survey	TA
46	8	Black	35–62	0/6	SSI	IPA
47	8	African American, Black, native American, native American/Mexican/Puerto rican, Black, native American/Hispanic, native American/Mexican, mixed race, white	18+	NK	SSI	PA
48	16	Korean	18–65	5/11	Survey	TA

Note: Labels for the racial and cultural identities reflects what the authors originally used.

FG = Focus groups. SSI = Semi-structured (individual) interviews. NK = Not known.

CA = Content analysis. CQR = Consensual qualitative research. GT = Grounded theory. HP = Hermeneutic phenomenalogy. IPA = Interpretative phenomenological analysis. PA = Phenomenological analysis. TA = Thematic analysis.

^aIncludes one parent interviewed about a child participant.

^b 6 m/FTM, 2 FTM, 1 m, 1 GQ/GF, 1 GQ/I/FTM, 1 T-S/M. (FTM = Female-to-male. T-S = Two-spirit. GQ = Genderqueer. GF = Gender fluid. I = Intersex).

Data Analysis

Authors AS and PP conducted the data analysis using Clarke and Braun’s (2013) reflexive thematic analysis method. Data analysis was split into three phases: independent analysis by AS and PP, collaborative analysis between the two authors, and lastly team-based verification by AS, PP, HY and EB. Themes were discussed first between AS and PP and then between the entire authorship team until consensus was reached around the final set of themes and subthemes. Where necessary, the authors referred to original papers to assist them in making decisions about the inclusion and/or structure of themes and subthemes. Details about process used to derive themes, across all data analysis stages, are in the Appendix.

Authors’ Positionalities

All authors were involved in conducting this review and interpreting and reporting its findings. As such, it is important to highlight their positionalities in relation to this research, which may influence their perceptions of the results.

All of the authors are registered psychologists with the Board of Australia and practice on the unceded lands of the Kulin Nation. Their positionalities in relation to this investigation were as follows:

Andrea Sadusky (Author 1) identifies as a white, able-bodied woman and mother. She is Australian-born and has a Cypriot Greek ethnic background. Her relevant research knowledge includes critical disability studies which critique macrosystem-level oppressions that are parallel to those explored in this study.

Hannah Yared (Author 2) identifies as a second-generation Eritrean cisgender woman whose research explores race and racism within education and psychology. Her research is shaped by this Black settler/African-diaspora positionality.

Pamela Patrick (Author 3) identifies as an Indian, able-bodied cisgender woman who was born in Singapore. Her research expertise is in intergenerational transmission of mental illness. She currently counsels high school students from various cultural and ethnic backgrounds.

Emily Berger (Author 4) is a white Senior Lecturer with over 14 years’ research experience. She was born in Australia and comes from European ancestry. She has worked as a child and family psychologist in a variety of settings and with people from a variety of backgrounds and cultural groups for 8 years.

Results

Paper Demographics

Of the 48 papers included in the review, the majority (66.67% n = 32) were conducted in the USA and/or were peer-reviewed articles (60.42% n = 29). For details about each studies’ demographics (location, publication type, MHP types discussed, aims), see Table 4. Two included papers represented the same sample (i.e., Valibhoy, Kaplan, & Szwarc, 2017; Valibhoy, Szwarc, & Kaplan, 2017) but addressed separate research questions. If it is assumed that only Valibhoy, Kaplan, and Szwarc (2017) and Valibhoy, Szwarc, and Kaplan (2017) represented the same participants, and no other participant-overlap occurred between other studies, then this review synthesized the views of 652 clients across 10 countries. Except for one participant who described their 6-year-old child’s interactions with MHPs (Hepworth et al., 2015), all clients represented in this review were aged at least 16-years-old. Moreover, only five studies reported views of youth aged 17 years and younger. Table 5 details each study’s (1) participants’ demographics and (2) data collection and analyses methods.

The outcomes of the reflexive thematic analysis in this review resulted in three broad themes and eight subthemes. In describing the theme structure, a theme summary has been provided before details of each subtheme and representative quotes from participants. To accurately report the results, we have used the same terms as the original papers to describe participants’ racial, cultural, ethnic, or sexual identities; and/or the aims and outcomes. However, they acknowledge that preferences for terminology can vary between individuals and the original terminology adopted may not suit all people’s preferences.

Theme 1: MHP Factors – Knowledge, Skills, and Competencies

Many clients’ views about MHPs’ cultural and racial responsiveness were specific to behaviors manifested by MHPs. A sentiment commonly shared by clients was the need for MHPs to undergo training to enhance their cultural and racial awareness. MHPs who appeared to overestimate their knowledge about different cultural or racial groups tended to rupture the therapeutic alliance. Clients considered MHPs’ openness and willingness to listen as pivotal for the provision of culturally and racially responsive therapy.

Lack of Cultural and Racial Awareness and/or Training

Clients highlighted how some MHPs lacked the appropriate information to behave in a culturally safe manner. They often emphasized the need for MHPs to be educated about how various cultures and racial groups perceive mental healthcare services, and for these services to be tailored accordingly to meet clients’ needs:

then I went to a psychiatrist … and it was amazing! It was the opposite of the first psychiatrist … in addition to paying attention to my current situation, she was also concerned with my situation here as an immigrant. – client’s race was unclear (Moleiro, 2013, p. 89, p. 89)

I don’t think they [MHPs] had any clue of my background or anything like that or understanding Armenians or Lebanese … They don’t really have a clue of how many cultures really come from the Middle East, how many different backgrounds or religions or ways the cultures come from that area. I never felt any kind of understanding of that. – Armenian client from Lebanon (Boghosian, 2011, p. 70)

Some MHPs showed limited ability to be culturally responsive, such as not adjusting how directive they were when guiding clients. While some clients appreciated a non-directive approach, others expected a top-down approach whereby MHPs are viewed as experts who provide clients with explicit instructions:

If the patient knows what to do, they wouldn’t come to you … they are more scared to make a decision than being told what to do because they don’t know what decision to make, [whether] it will be right or wrong. They don’t know, they don’t have the professional training. –East Asian client living in the USA (Tsai et al., 2017, p. 1045, p. 1045)

Overestimating One’s Cultural and Racial Knowledge

Several clients also noted how MHPs seemed to overestimate their cultural or racial knowledge, which was experienced as alienating and dismissive. For example, clients noted that some MHPs quickly assumed characteristics about them based on their cultural or ethnic background. This idea was articulated well by a Lebanese client whose MHP made homogenizing assumptions about clients from different cultural and ethnic backgrounds:

She said she had a client who was Egyptian so I got a sense she knew she had dealt with this difference before. She didn’t make me feel like ‘Oh I understand,’ she kind of was just like ‘oh I heard this before, I’ve touched upon this before with another client.’ – Lebanese female client in the USA (Rogers-Sirin et al., 2015, p. 262, p. 262)

Openness to Listen

Clients did not expect their MHPs to know everything about their culture or race but appreciated it when practitioners acknowledged their limited understanding and invested effort into listening more about the client’s background. When MHPs expressed curiosity and openness to listen about their client’s cultural or racial backgrounds, clients reported feeling seen, respected, and validated as unique individuals:

[My counselor is] open to my beliefs. And without her open to my beliefs it would make an impact on my mental health care. So it does make a big difference how I believe and how she views that. Like if she didn’t believe it, then that would create a big gap in our communication. And I’m afraid that it would affect it so much that I’d probably either have to go to somebody else or someone that did believe in what I believe in. – American Indian client (Hack et al., 2014, p. 72, p. 72)

Theme 2: Client Factors – Apprehension Towards MHPs

Clients’ perceptions of MHPs’ cultural and racial awareness were further shaped by their preconceived notions and/or lived experiences concerning mental healthcare services. These indirect and direct experiences of MHPs subsequently influenced clients’ willingness to engage in therapy. Specifically, clients who held negative views about MHPs felt apprehensive about engaging in mental healthcare services due to fears of being stigmatized, discriminated against, and otherwise further marginalized due to racism.

Preconceptions about MHPs

Preconceived fears and assumptions about what mental healthcare services entail shaped clients’ willingness to engage in therapy. Some of these preconceptions were culturally-derived, as illuminated by a refugee who stated, ‘‘it’s deeply rooted in our society that if you see a psychologist you’re crazy’’ (Valibhoy, Kaplan, & Szwarc, 2017, p. 28). Moreover, many clients viewed therapy as a Western practice (for white people) and preferred other methods for navigating hardships that were more responsive to their needs (e.g., seeking the advice of religious leaders). These concerns were not always based on first-hand experiences but, instead, the experiences of others in their community and/or media representations of MHPs:

I’d rather go to the Imam because he knows more than me about my religion, and I want him to give me a solution about what my religion tells me is better for me, that’s what I think, not to go to the counselor. – Nigerian Muslim client (Turkes-Habibovic, 2011, p. 125, p. 125)

[Y]ou get most of your ideas from the media . . . The idea of you sitting down, you’re laying down on a bed and there is a person who just sits there like a statue recording what you say . . . I came in—with those ideas about mental health—and how it just seems like a very silly profession that would not help you at all. – Client who is a refugee living in Australia (Valibhoy, Kaplan, & Szwarc, 2017, p. 28).

I already had this preconceived notion … I came in like ‘you don’t understand me … I was cautious. I already had a wall up. I already figured she wasn’t going to understand me. – Native American Indian client describing their experience with a non-Native counselor (Bushey, 2018, p. 67, p. 67)

Direct Experiences with MHPs

Some clients had experiences of feeling judged and misunderstood on the grounds of their cultural or racial identity. In some instances, clients perceived MHPs’ negative judgments through their body language and facial expressions:

…made him make a face at me and I didn’t see that that was very polite way to go

about that. I kinda thought that was rude, but he just made it obvious how he felt

about that. – Mexican-American client (Crans, 2013, p. 70, p. 70)

In other instances, clients’ feelings of being misunderstood emanated from MHPs being unaware of their positionality and power imbalances in the counseling dynamic and the experiences of their clients that are shaped by historical and current systems of oppression. This is illuminated by a Black woman describing her white counselor:

Because as a white woman, first of all, she didn’t understand where I was coming from. So, to me, it’s a waste of time-I totally hated it! White women always had a stigma against Black women. (McGee, 2013, p. 67, p. 67)

Importantly, not all clients’ experiences of MHPs’ reactions to their cultural customs resulted in negative outcomes. In these instances, circumventing unpleasant client experiences appeared to be due to the MHPs’ willingness to listen and the establishment of a strong therapeutic alliance:

She was definitely shocked to hear about um my family’s tradition of marriage … but she didn’t she didn’t let it affect uh, she just mostly expressed interest in what I had to say, it didn’t seem like she was disapproving. – Mexican-American client Crans, 2013, p. 73, p. 73)

Theme 3: Inter-Relational Factors – Therapeutic Enablers

Several factors shared between MHP and clients were perceived by clients to augment the therapeutic alliance and were experienced by clients as culturally and racially responsive practices. These included the physical environment, clients having a shared identity with the MHP, and the MHP showing unconditional positive regard for clients from racially and culturally marginalized backgrounds.

Physical Environment

Clients reported that the physical environments of MHPs’ consultation rooms were important for acknowledging and welcoming their cultural and racial identities. In turn, clients felt represented and validated within the therapeutic space. Latino/Latina students discussed the importance of “various displays and objects on the walls and around the offices” (Peña & Rhoads, 2019, p. 197) that were important in validating the cultural and racial identity of students. Others pointed at the presence of pictorial representations, such as images of diversity and flags of various countries, as well as the pride flag, as being significant markers of fostering an inclusive and welcoming space. Furthermore, a culturally and racially safe environment was also regarded as important in enhancing participation and adherence to therapy.

Shared Identity with MHP

Some clients reported it was valuable to their therapeutic journey when their MHP had a shared identity to them (e.g., with respect to ethnicity, race, immigration status, and socioeconomic status). Specifically, when MHPs self-disclosed their racial or cultural identities to clients, clients often noticed shared experiences which made them believe their MHP had a better understanding of them and their viewpoints. Moreover, clients felt more personally connected and comfortable with their MHP when they knew they had similar racial or cultural experiences, as articulated by a Latino client:

…maybe they have struggled or they are like me, I feel more connected to them. I actually feel comfortable going to their office and asking for help. (Peña & Rhoads, 2019, p. 197, p. 197)

The importance of a shared identity appeared to extend beyond cultural or racial identity to include intersecting identities such as gender as well:

It was all the more important to be with somebody who is trans and who has struggled

with the different aspects of that experience. – genderqueer/intersex/female-to-male client whose racial and cultural identity was unspecified (McCullough et al., 2017, p. 427, p. 427)

The reverse also applied. That is, when clients perceived MHPs as having dissimilar cultural or racial identities and experiences to them, they felt unconfident or wary that the MHP would not have the capability to comprehend their experiences. Subsequently, some clients expressed disconnection from, or uncertainties towards, MHPs who had a different racial or cultural background to their own:

I thought she seemed a little privileged and she may not understand some of the issues I came in there with … I was thinking, “Well, she has probably never had to deal with that, so she doesn’t know.” … I felt more comfortable with the Native counselor than I did with the non-Native. – Native American Indian client (Bushey, 2018, p. 68, p. 68)

I wanted to practice oral English when seeking counseling...but now, after counseling, I would like to have counselors who are from Chinese or Asian backgrounds. At least we share similar family values, and he/she can understand what I talk about ... this is not usually an option. – Chinese client (Liu et al., 2020, p. 283, p. 283)

I think it would seem likely for me to relate to somebody who was Trinidadian or even a Caribbean professional. I probably would have more likely stayed in counseling or more likely to have discussed more things. – Black client (Venner & Welfare, 2019, p. 652, p. 652)

Therapeutic Alliance

Clients appreciated empathy from MHPs. Specifically, clients reported trust and psychological comfort when MHPs demonstrated unconditional respect, listening, and genuineness. When MHPs were perceived as warm and trustworthy, clients felt more confident to honestly disclose their innermost thoughts and feelings:

he was bright and caring and seemed to take more of an interest in me, and probably all his patients, than I would have thought another therapist would. So I was impressed by his professionalism and I was impressed with his sincerity. – White Jewish client (Hunter, 2011, p. 65, p. 65)

I was talking a lot [while] she was listening. She had a great memory … so she was listening and she was definitely interested … She was warm and kind and … I feel like she wants to help me. – Client from Senegal who migrated to the USA (Rogers-Sirin et al., 2015, p. 264, p. 264)

Discussion

The current study systematically collated clients’ perceptions of MHPs’ cultural and racial awareness and responsiveness from around the world. From the 48 studies conducted across 10 countries, three broad themes and eight subthemes emerged that concerned ‘MHP factors’, ‘client factors’, and their combined interaction, referred to as ‘inter-relational factors’. Our findings overwhelmingly indicated that barriers exist for racially and culturally marginalized people who are accessing mental healthcare. Our findings also highlight some ways that MHPs can begin to engage in practices that are culturally and racially safer by (1) listening to the voices of marginalized clients, (2) engaging in professional development, and (3) showing humility in their level of cultural and racial knowledge. While these practices will not address all the barriers that marginalized people face when accessing mental healthcare services, doing these things will assist in providing safer and more accessible therapeutic spaces for marginalized clients.

Barriers to Cultural Safety

Many clients reported that their MHPs did not understand the nuances of their racial and/or cultural backgrounds. This was evidenced through MHPs having no deep understanding about the cultural or racial backgrounds of their clients and/or making homogenizing and stereotyped assumptions about their clients’ experiences and needs. These assumptions often led to MHPs making racialized comments that negatively impacted their clients’ trust in the therapeutic process and threatened their sense of cultural or racial safety. Moreover, inaccurate and/or stereotypical assumptions appeared more common when MHPs had an inflated sense of cultural or racial competency than when MHPs humbly acknowledged gaps in their knowledge (i.e., showing cultural humility; Tervalon & Murray-García, 1998). This could explain why clients seemed more receptive to therapy when MHPs accepted limitations in their knowledge of different cultural and racial groups and subsequently strove to address these by listening to perhaps learn more about these groups.

This study found that clients’ lived or vicarious experiences of discrimination and maltreatment from MHPs fueled their perceptions that MHPs lacked adequate cultural and/or racial competency. These marginalizing experiences also increased clients’ apprehension towards MHPs and mental healthcare services. This finding aligns with research that shows marginalized clients, especially Indigenous people, experience mental healthcare settings that are often uninviting, impersonal, and culturally unsafe (Curtis et al., 2019; Kendall & Barnett, 2015). Moreover, the present findings suggest that MHPs are capable of being racist or discriminatory toward clients, which has the potential to cause harm and disrupt the therapeutic alliance. This inference is further reinforced by our finding that clients reported feeling safer and more welcomed when therapeutic spaces physically portrayed messages of inclusion and anti-racism. The importance of visual displays in creating a welcoming and accepting environment has been found in earlier research (e,g., Miller & Berger, 2021).

Promoting Cultural and Racial Awareness and Responsiveness

This review found that MHPs who had a shared racial or cultural identity with their clients were perceived to have greater insight into their clients’ experiences of marginalization when compared with MHPs with dissimilar backgrounds. Unsurprisingly, the latter group of MHPs were thus perceived and/or observed to have limited skills for addressing their clients’ needs, which parallels indications that MHPs lack sufficient responsiveness training (Newell et al., 2010; Sadusky et al., 2021). Although identity-matching between clients and MHPs has clear benefits (e.g., increased comfort in accessing mental healthcare), a lack of shared identity does not necessarily inhibit MHPs from working effectively with marginalized clients. Specifically, this review highlighted that genuine empathy and warmth from MHPs can assist in helping culturally and racially marginalized clients feel comfortable, thus echoing the importance of empathy in nurturing the therapeutic alliance (Elliott et al., 2018). It is therefore incumbent on MHPs to recognize their limitations in their knowledge of different cultural and racial groups and be willing to pursue professional development that addresses these gaps.

Addressing Whiteness in Mental Healthcare

The three broad themes identified in this study included evidence of whiteness within the mental healthcare sector. To understand marginalized clients’ worldviews and preferences, MHPs must first become self-aware of their own assumptions, values, prejudices, perspectives, and social positionality that are informed by their racial and cultural backgrounds and more (Roysircar, 2009). Such self-awareness can help reduce harmful in/actions from occurring that can impede marginalized clients’ mental health outcomes (Roysircar, 2009).

In addition, given clients’ preferences for therapists who have similar lived experiences of marginalization, creating equitable access to MHP tertiary training should be prioritized for marginalized people looking to practice as MHPs. This is especially crucial as people from racially or culturally marginalized groups encounter significant tertiary education access barriers due racism from academic processes (e.g., publication, teaching), spaces (e.g., white-centric curricula), peers, and educators (Buchanan et al., 2021; Cameron & Robinson, 2013; Consoli & Myers, 2022; Constantine et al., 2008; Constantine & Sue, 2007; DeLapp & Williams, 2015; Dudgeon & Walker, 2015; Gillborn et al., 2021; Roberts et al., 2020; Tinsley-Jones, 2001; Wainwright et al., 2012).

Although such reflexive practices and increases in representation can be useful at the micro-transactional or interpersonal levels, it is important to note that they do little for addressing the structural inequities and barriers faced by racially or culturally marginalized clients or MHPs themselves (Truong et al., 2014). Thus, a multifaceted approach that addresses both individual and systemic barriers is needed.

Limitations of this Review

Most of the included studies were conducted in the USA and with adults and thus limits the extent to which the results of this review can be generalized to other countries or age groups. There was also heterogeneity in the types of MHPs of interest and the cultural/racial backgrounds of participants, which limits inter-study comparisons. Moreover, the included studies did not uniformly report the racial or cultural identities of the MHPs that the participants provided their perspectives on. Consequently, it remains unclear in this study whether there are differences in cultural and racial competency between MHPs from different backgrounds – a topic which could be explored in future research. Further, only 20 of the 48 included studies adequately reported the positionality of the researcher(s), which rendered it challenging to determine how this may have affected their interpretations of their results. Finally, due to the lack of consensus regarding the definitions of race, ethnicity, nationality, and culture (Yared et al., 2020), comparisons between studies’ outcomes are limited due to likely differences in how these constructs were operationalized. Notwithstanding these limitations, this review can guide future research focusing on specific subgroups of MHPs and clients from different cultural or racial backgrounds.

Conclusion and Future Directions

Historically, research has tended to focus on MHPs’ perceptions of their own cultural competencies (Benuto et al., 2018; Lee & Khawaja, 2013). Although valuable, such research remains fraught with social desirability bias, self-report bias (i.e., MHPs cannot report what they are unaware of about themselves) and fails to emphasize an emancipatory agenda which places clients’ voices as the central foci (Truong et al., 2014). Thus, this systematic review provided a unique analysis of service users’ experiences of MHPs’ cultural and racial awareness and responsiveness.

The findings of this review have important implications for future practice and research, at the global level. Given the benefits of identity-matching between clients and MHPs, it is imperative that the training and recruitment of marginalized MHPs is increased. Moreover, preservice tertiary courses and MHP registration boards should incorporate mandatory cultural and anti-racism training to help equip MHPs with adequate knowledge to support marginalized clients and help dismantle systemic barriers to equitable care. Specifically, such training should include information about information at the individual level (e.g., cultural customs) and systemic level (e.g., racism, power, whiteness, privilege) to be comprehensive and effective (Curtis et al., 2019; Truong et al., 2014). Physical environment also played an important role for clients’ feeling comfortable, and the established body of research on this topic should be consulted for guidance in creating culturally and racially safe spaces for marginalized clients (Hall et al., 2016; Wexler & Gone, 2012; Zigarelli et al., 2016). Finally, future research would benefit from a continued focus on the perspectives and experiences of marginalized communities to place their voices at the center of finding solutions to meet their idiosyncratic mental healthcare needs.

Footnotes

Acknowledgements

The research team acknowledges and thanks Dr. Katelyn O’Donohue for her time and assistance in the data extraction process.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Considerations

Given the nature of the data collected in this review, this study was exempt from requiring approval from an ethics committee to be conducted.

ORCID iD

A. Sadusky

Appendix

Author Biographies

Andrea Sadusky, MEd&Dev/PhD, Lecturer, Faculty of Education, Monash University, Australia.

Hannah Yared, MEd&Dev/PhD, Teaching Associate, Faculty of Education, Monash University, Australia.

Pamela Patrick, M(Psych)/PhD, Lecturer, Faculty of Education, Monash University, Australia.

Emily Berger, M(Psych)/PhD, Senior Lecturer, Faculty of Education, Monash University, Australia.

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