Impact statement
Mental health and psychosocial support (MHPSS) are increasingly delivered across cultural and national boundaries. In these contexts, clinical supervision often occurs between supervisors and supervisees from different cultural backgrounds. However, there is limited synthesis of how cross-cultural supervision (CCS) is conceptualised and practised in MHPSS services, and whether current approaches are culturally safe. This scoping review provides the first mapping of the CCS literature in MHPSS services. The review highlights gaps in the current evidence by examining how CCS is defined, who produces and frames knowledge in the field, the common practices within CCS and how it is reported to support MHPSS services. The findings show that most of the current literature is produced from Westernised, Educated, Industrialised, Rich and Democratic (WEIRD) contexts that reflect Western paradigms. As global mental health increasingly involves collaboration across countries and cultures, the dominance of WEIRD scholarship and practice raises important questions about how power dynamics within the supervisory relationship affect integration of local knowledge and perspectives in supervision. Using an epistemic injustice framework, this review demonstrates how supervision practices can reinforce or reduce power imbalances between supervisors and supervisees and enable culturally safe CCS. The findings identify key factors that support culturally responsive CCS, including cultural humility, having socio-political and cultural knowledge, and supervisor-led discussions on culture, identity and power. This research contributes to global mental health knowledge by informing culturally safe supervision practices through identifying gaps in representation of non-WEIRD contexts. This review provides practical insights for supervisors, supervisees, educators and organisations working across cultures, identifying priorities for future research needed to enable culturally safe supervision and MHPSS services globally.
Introduction
Clinical supervision in mental health and psychosocial support (MHPSS) services is widely regarded as necessary for attaining clinical competence and ensuring quality client care (Watkins and Milne, Reference Watkins and Milne2014; Falender and Shafranske, Reference Falender and Shafranske2017). It involves senior practitioners facilitating junior supervisees’ professional and clinical competence, through a working alliance that integrates evaluation, support and training to enhance practice and therefore client outcomes (Bernard and Goodyear, Reference Bernard and Goodyear2019; Bordin, Reference Bordin1983; Milne and Watkins, Reference Milne, Watkins, Watkins and Milne2014). Supervision is not only a developmental, evaluative practice, but also a relational process where power is inherently present due to the hierarchical nature of supervision relationships (Cook et al., Reference Cook, McKibben and Wind2018). Supervisors assess clinical work, have more experience, and are respected for their knowledge (Hernández and McDowell, Reference Hernández and McDowell2010; Bernard and Goodyear, Reference Bernard and Goodyear2019). Power within supervision is therefore both hierarchical and epistemic, influencing whose knowledge and clinical judgement are legitimised. These asymmetries intersect with other structural inequalities such as gender and culture, requiring attention and awareness by supervisors and changes to supervision practices to optimise effectiveness (Hernández and McDowell, Reference Hernández and McDowell2010). These dynamics raise important questions about whose knowledge is recognised within supervision, particularly in cross-cultural contexts.
Within the cross-cultural supervision (CCS) relationship, there is increasing recognition of the importance of understanding the role of culture, cultural differences and the need to explore cultural worldviews to understand one’s own and another’s cultural assumptions (Hawkins and McMahon, Reference Hawkins and McMahon2020). This reflexivity is particularly important given the natural tendency to privilege one’s own worldview and values (Hook et al., Reference Hook, Watkins, Davis, Owen, Van Tongeren and Ramos2016). ‘Culture’ is a complex construct encompassing ethnicity, religion, language and worldview that is learned within social environments (Hofstede, Reference Hofstede1994; Holliday et al., Reference Holliday, Hyde and Kullman2021; Vekaria et al., Reference Vekaria, Thomas, Phiri and Ononaiye2023). Those who share meanings and interpret the world similarly are described as belonging to the same culture (Hall, Reference Hall1997). Cultural identity is also not fixed but constructed as a result of differences, rather than independently of them (Hall and du Gay, Reference Hall and du Gay1996), highlighting the inherently relational nature of culture.
Despite increasing attention to culture in supervision, there is little consensus on the meaning of terms used to describe supervisory dynamics that involve cultural difference, with CCS used interchangeably with multicultural supervision (Estrada et al., Reference Estrada, Frame and Williams2004; Eklund et al., Reference Eklund, Aros-O’Malley and Murrieta2014). This scoping review seeks to map the existing literature and clarify the current state of the evidence on CCS. This review adopts a narrow definition of CCS that requires that the supervisee and supervisor relationship is cross-cultural. This distinguishes CCS from supervision where cultural differences arise solely at the level of the client (yet not necessarily between supervisors and supervisees). Therefore, CCS in this review refers to supervision occurring when the supervisor and supervisee are from different cultural or contextual backgrounds (Wong et al., Reference Wong, Nathan, MacDonald and Nicholson Perry2026). ‘Context’ here refers to the broader setting in which supervision occurs – including geographic, sociocultural, socioeconomic, legal and political conditions (Pfadenhauer et al., Reference Pfadenhauer, Gerhardus, Mozygemba, Lysdahl, Booth, Hofmann, Wahlster, Polus, Burns, Brereton and Rehfuess2017), which may differ between supervisor and supervisee independently of cultural background.
What is the relevance of culture in supervision?
Mental health and distress conceptualisation varies across cultural and socio-political contexts (Gopalkrishnan, Reference Gopalkrishnan2018; Lewis-Fernández and Kirmayer, Reference Lewis-Fernández and Kirmayer2019). There is recognition that most clinical supervision literature relates to Westernised, Educated, Industrial, Rich and Democratic (WEIRD) settings and operates predominantly from WEIRD paradigms (Henrich et al., Reference Henrich, Heine and Norenzayan2010; Rothwell et al., Reference Rothwell, Kehoe, Farook and Illing2021; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023). This includes positivist, biomedical and technological paradigms that posit that mental health issues can be understood in the same way as physical medicine and are not context-dependent (Bracken et al., Reference Bracken, Thomas, Timimi, Asen, Behr, Beuster, Bhunnoo, Browne, Chhina, Double, Downer, Evans, Fernando, Garland, Hopkins, Huws, Johnson, Martindale, Middleton, Moldavsky, Moncrieff, Mullins, Nelki, Pizzo, Rodger, Smyth, Summerfield, Wallace and Yeomans2012). Mental health frameworks in WEIRD settings have been developed from biomedical traditions (Mills, Reference Mills2014), while in contrast other cultural contexts may emphasise experiential, moral and spiritual explanations for distress (Kirmayer, Reference Kirmayer1989; Im et al., Reference Im, Ferguson and Hunter2017). These differences may impact how distress is recognised, interpreted and addressed clinically and within supervision. However, research investigating clinical supervision involving cultural differences between supervisor and supervisee is limited.
Further to this lack of research, the growth of culturally diverse societies and globalisation of mental health mean that supervisors and supervisees may be increasingly from different contextual and cultural backgrounds. For example, UK-trained supervisors often supervise those who are trained in different geographical and cultural regions such as Africa or the Middle East (Vekaria et al., Reference Vekaria, Thomas, Phiri and Ononaiye2023) and WEIRD supervisors often supervise in low-resource and humanitarian contexts, due to resource constraints and specialist shortages (Dawson et al., Reference Dawson, Bryant, Harper, Tay, Rahman, Schafer and Van Ommeren2015). In these situations, supervisees and supervisors may identify and operate from very different cultural paradigms (Inman, Reference Inman2006), explanatory models of distress (Kohrt et al., Reference Kohrt, Rasmussen, Kaiser, Haroz, Maharjan, Mutamba, De Jong and Hinton2014; Lewis-Fernández and Kirmayer, Reference Lewis-Fernández and Kirmayer2019), communication norms and expectations regarding authority and pedagogy (Wong et al., Reference Wong, Lokot, Perry and Nathanin press).
MHPSS supervisors are often from WEIRD settings (Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023) and reliance on WEIRD paradigms may result in culturally unsafe, epistemically unjust supervision practices when applied outside WEIRD settings or within WEIRD settings where supervisees are from a different contextual and cultural background (Adams et al., Reference Adams, Dobles, Gómez, Kurtiş and Molina2015). When WEIRD paradigms are treated as universally accepted, rather than culturally situated, this risks ethnocentrism – the assumption that one’s own cultural values and knowledge systems are superior (Hammond and Axelrod, Reference Hammond and Axelrod2006). Political power, held largely by WEIRD nations, and cultural power, held by the dominant ethnic group in a society, can also be re-enacted within supervision dynamics (Hawkins and McMahon, Reference Hawkins and McMahon2020). Asymmetries in power and privilege can be manifested through racism, coloniality, white supremacy and dynamics consistent with the foreign gaze (Abimbola et al., Reference Abimbola, Asthana, Montenegro, Guinto, Jumbam, Louskieter, Kabubei, Munshi, Muraya, Okumu, Saha, Saluja and Pai2021) whereby experience and knowledge within local contexts may be interpreted through external, non-local assumptions and frameworks.
Culturally safe CCS through the lens of an epistemic justice framework
The concept of epistemic injustice (Fricker, Reference Fricker2007) provides a framework for understanding how power dynamics can be redressed to ensure diverse forms of knowledge and knowledge production are respected to enable culturally safe care and supervision. Epistemic injustice describes unfairness to someone in their capacity as a knower, in particular how their knowledge, testimony or understanding is discriminatorily and inequitably received and valued (Fricker, Reference Fricker2007). Epistemic injustice occurs when there is hermeneutical and/or testimonial injustice (Fricker, Reference Fricker2007). Hermeneutical injustice occurs when social experiences are not adequately understood due to an absence of means to interpret them, such as language for distress and means to communicate and validate experiences (Fricker, Reference Fricker2007; Edlich and Archer, Reference Edlich and Archer2025). Testimonial injustice occurs with systematic disregard for the credibility of knowledge of certain groups (Fricker, Reference Fricker2007; Bhakuni and Abimbola, Reference Bhakuni and Abimbola2021). Epistemic justice, conversely, is achieved when individuals and communities are afforded credibility as knowers, and have access to shared interpretive resources to make sense of, and communicate, their experiences (Fricker, Reference Fricker2007).
In CCS, privileging WEIRD paradigms over other epistemologies risks epistemic injustice, potentially leading to culturally unsafe supervision. In this review, epistemic justice is used as an analytical lens to identify how cultural responsiveness may contribute to culturally safe CCS. Cultural safety – defined as addressing issues of power that impact quality of care to achieve health equity – explicitly highlights power differentials and the need to reflect on them (Curtis et al., Reference Curtis, Loring, Jones, Tipene-Leach, Walker, S-J and Reid2025). A lack of cultural safety and attention to cultural differences can lead to poorer health outcomes (Papps and Ramsden, Reference Papps and Ramsden1996). When care is culturally unsafe, recipients can feel misunderstood, disrespected and reduce treatment adherence (Laverty et al., Reference Laverty, McDermott and Calma2017). Therefore, culturally safe supervision that respects different experiences, knowledge and ways of knowing is critical.
Cultural safety and epistemic injustice lenses were chosen because of their potential to address issues around power and knowledge that are of heightened relevance in CCS. Despite the increasing practice of CCS and the inherent challenges, there is a limited understanding of CCS processes, such as cultural responsiveness, that are employed in practice and how they may promote culturally safe CCS. This scoping review addresses this research gap by mapping the nature and extent of evidence, clarifying key concepts, identifying common practices, barriers and facilitators and highlighting areas for future research.
Methods
The aim of this scoping review is to examine the literature on cross-cultural supervision in mental health service provision. Specifically, the following questions guided the review:
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1. How, and by whom, is cross-cultural supervision framed in the literature, and what are the key principles and components?
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2. In what settings, situations and contexts has cross-cultural supervision been documented?
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3. What are the barriers and facilitators to effective cross-cultural supervision?
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4. How does cross-cultural supervision assist in the delivery of mental health services in these contexts?
While systematic reviews establish quality of evidence, scoping reviews have a broader remit to identify, explore and map the volume and coverage of literature in a given area (Munn et al., Reference Munn, Peters, Stern, Tufanaru, McArthur and Aromataris2018). The review adopted an integrated approach by Arksey and O’Malley (Reference Arksey and O’Malley2005), Levac et al. (Reference Levac, Colquhoun and O’Brien2010) and Peters et al. (Reference Peters, Marnie, Tricco, Pollock, Munn, Alexander, McInerney, Godfrey and Khalil2020) of systematically identifying, selecting and synthesising the breadth of available evidence through an iterative and transparent review process. The protocol was preregistered and is publicly available on Open Science Framework (Wong et al., Reference Wong, Almeamari, Nathan, Steel, Nicholson Perry and Lokot2024). Also, this review was written in accordance with PRISMA guidelines, reporting on the findings using the PRISMA extension outlined by Tricco et al. (Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley, Weeks, Hempel, Akl, Chang, McGowan, Stewart, Hartling, Aldcroft, Wilson, Garritty, Lewin, Godfrey, Macdonald, Langlois, Soares-Weiser, Moriarty, Clifford, Tunçalp and Straus2018).
Search strategy
Peer-reviewed literature was searched in the following academic databases: Embase, PsycINFO, PubMed, CINAHL, Web of Science, Scopus and Google. Databases were searched from 21 August 2023 to 10 September 2023, with no publication date limits applied. The search strategy for peer-reviewed literature comprised three main terms and their synonyms and subject headings:
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1. Supervision (e.g. supervision, coaching, mentoring, apprenticeship, clinical methods training)
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2. Cross-cultural (e.g. cultural factor, cultural anthropology, multicultural, ethnic group, cultural diversity, sociocultural factors, Intercultural, cross-cultural differences)
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3. Mental Health Services (anxiety, depression, practitioner, therapist, clinician, lay person, problem management plus, task shifting)
Full search terms for the academic database search are in Supplementary Materials 1.
The concept of “Cross-Cultural,” represented by terms and subject headings such as “cultural safety” and “cultural humility” captures the literature on power and equity, while ‘decolonisation’, ‘colonialism’ and ‘Indigenous synonyms’ capture literature on whose knowledge systems are represented. Broader terms such as culture, ethnicity and race kept retrieval wide. The concept of “Supervision” and “Mental health” anchored these to the mental health supervision literature. The cultural safety and epistemic justice lenses were then applied at analysis and interpretation (see section “Data extraction and analysis”). Following the process outlined by Piasecki et al. (Reference Piasecki, Waligora and Dranseika2018) we used Google Search to search for grey literature by using Google Chrome browser, using ‘incognito mode’ and clearing cookies. Search results were limited to 100 hits. Search strings for grey literature were:
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1. Cross-Cultural AND Supervision AND Mental Health
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2. Multicultural AND Supervision AND Mental Health
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3. International AND Supervision AND Mental Health
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4. Cross-Cultural AND Supervision AND Psychologist
Inclusion and exclusion criteria
The same criteria were used for the Title/Abstract screening and Full-text review. Please see Table 1 for eligibility criteria:
Inclusions and exclusion criteria
Table 1. Long description
The table is organized into five categories: Participants, Concept, Context, Types of sources, and Language.
* Participants: Included are mental health personnel, supervisors, lay counsellors, paraprofessionals, practitioners, supervisees, and apprenticeships. Excluded are non-mental health staff and activities.
* Concept: Included are definitions of supervision, cross-cultural supervision, and mental health practitioners, as well as studies on race, ethnicity, and interventions like mental health therapies, P M plus, and M H G A P. Excluded are manager-employee relationships, non-clinical casework, and culture defined solely by gender, L B T Q I, or organizational culture.
* Context: All contexts are included; none are excluded.
* Types of sources: Included are peer-reviewed articles and grey literature like reports and blogs. Excluded are dissertations, book chapters, editorials, reviews, newspaper articles, theses, and protocols.
* Language: Included are English-language sources. Excluded are non-English-language sources.
Peer-reviewed references were imported into Endnote and deduplicated using the automated de-duplication function. References were then imported into Covidence software and further duplicates were identified. Grey literature that was identified was reviewed but all were excluded. Title and abstract screening then commenced with two independent screeners starting by concurrently screening the same papers. Weekly discussions were held to discuss any differences in decisions to include or exclude papers. Once this process was refined, reviewing occurred independently, with regular meetings to come to consensus. If two reviewers were unable to come to a resolution, it was decided that subsequent discussions would include a senior team member. Following independent screening and resolution of any differences, the remaining references were divided and screened.
Full-text screening commenced after title/abstract screening was completed, with reasons for exclusions documented. The two independent screeners screened all references and used the same resolution method as the title/abstract stage. There was an iterative process to discuss and refine inclusion/exclusion criteria with the second reviewer to narrow down the literature to the 45 included papers. Refinements to the criteria were agreed during weekly consensus meetings and documented before being applied to subsequent screening. Refinements included changing the inclusion criteria to include non-humanitarian settings after the screeners saw that several papers were being excluded that may have had information of interest, such as US-China collaborations or Aboriginal and Torres Strait Islander supervision papers. This was changed to “None- All contexts eligible” in the exclusion criteria. Other refinements included, excluding papers that discussed cross-cultural academic or PhD supervision, when screeners noticed a large proportion of studies focused on this type of supervision, because this type of supervision was not the focus of the review. This was clarified in the exclusion criteria as “non-mental health activity.” Screeners met with author Michelle Lokot, senior author on the paper, after screening 10% of the papers to discuss the suggested refinements and proposed changes in inclusion/exclusion criteria. Any papers that were tabled for discussion about criteria refinement were tagged in Covidence and re-screened once the final inclusion/exclusion criteria were agreed.
Data extraction and analysis
Key paper characteristics, including type of supervision settings, definitions, key concepts, barriers and facilitators, were extracted using Covidence software (Veritas Health Innovation, 2024). Thematic analysis was conducted to identify and explore themes in the literature relating to cross-cultural supervision in different locations internationally. Given the focus on cultural safety and epistemic justice, the findings are organised to reflect the dominant themes and patterns identified from extraction and analysis. We first examine who is producing CCS research and how they frame it before synthesising how researchers operationalise it in practice, and how it is reported to support mental health service delivery.
A content analysis was conducted on all extracted content for each category of extraction. This was done inductively based on what was extracted from the included documents. A categorisation process occurred, looking at key themes, commonalities and grouping of data into sub-issues, which helped make sense of the key issues that were relevant to the research objectives. A narrative summary was then written, which identified the key issues for research and practice. Author Scarlett Wong conducted all phases. Author Michelle Lokot and Fatema Almeamari participated in the reviewing, defining and reporting themes phases, and authors Sally Nathan and Kathryn Nicholson Perry participated in reporting themes phases. This was consistent with guidance by Pollock et al. (Reference Pollock, Peters, Khalil, McInerney, Alexander, Tricco, Evans, de Moraes, Godfrey, Pieper, Saran, Stern and Munn2023) on the analysis of extracted data in scoping reviews.
Themes were identified inductively from the extracted data. Epistemic injustice and the components of testimonial and hermeneutical injustice were used as a framework to help organise and interpret the themes, shaping how the findings were understood and discussed. While there was a sensitivity to power dynamics and epistemic injustice due to the authors’ positionality, the epistemic injustice framework was only formally adopted for analysis when the themes were developed. For example, when themes around knowledge production and power were formed, they were tested against testimonial and hermeneutical injustice principles.
Author positionality
Our team engaged in reflexive practice to consider how identities and power hierarchies shaped the review process, outlined below.
Scarlett Wong is a second-generation Vietnamese-Chinese refugee who had internalised racism and aspired to Whiteness, having experienced discrimination and racism growing up in Australia. She is a PhD candidate who began her postgraduate training in a positivist tradition. Over the past 7 years, her research in the area of cross-cultural supervision and her supervisory roles working with humanitarian organisations in Palestine, Syria, Türkiye and Bangladesh have changed her perspectives on cultural safety, power and epistemology, and whose knowledge counts in therapy and supervision. Her humanitarian work experience of witnessing epistemic injustice in CCS, as well as conversations with colleagues about how to improve it, sparked her interest in CCS scholarship. She now takes an interpretivist-pragmatic approach to her research and clinical supervision, and values reflection and continual cultural humility and curiosity.
Fatema Almeamari is an Iranian-Bahraini non-binary immigrant living in Turkey. They have a background in clinical psychology and an interest in global and community mental health, participant-centred research approaches, as well as activism- and decolonisation-focused research and practice. They were trained in mixed-methods research during their MA, and did their thesis using qualitative reflexive thematic analysis on the work conditions contributing to burnout among humanitarian psychosocial support workers in Northwest Syria. Their other research experiences focus on stigma (such as racism, sexism, menstruation, queerness) and mental health. Their identity made them want to engage with the data critically and question non-disclosed power dynamics and possible generalisations.
Sally Nathan is a White, able-bodied, heterosexual, cisgender woman, born in Australia with British and Spanish ancestors. Her professional role as an academic has been largely shaped by Western health and well-being paradigms. However, her research over the past 20 years has included working with other cultural groups and First Nations peoples, communities and organisations. These experiences have challenged assumptions and broadened perspectives on what factors and experiences in health and well-being are contextually and culturally mediated. She recognises the professional and institutional privileges of her professional role and the privileges in her personal life and is focused on how these may reinforce inequities in health and social systems that much of her research seeks to illuminate and address.
Kathryn Nicholson Perry is a White, settler-Australian who grew up in the UK. Her work as a clinical psychologist, academic and researcher has been shaped by Western psychological and academic institutions, influencing how she interprets and participates in knowledge production. Having held senior leadership roles, she recognises the professional and institutional privileges she occupies and reflects on how these may reinforce or challenge inequities in health and social systems.
Michelle Lokot is a woman of Sri Lankan ethnicity and Australian nationality, who now resides in the UK Her multi-disciplinary training in law, international and community development and gender studies has shaped her understanding of power. Her work as a humanitarian practitioner has caused her to reflect on her own role in reinforcing colonial power hierarchies in her roles managing and providing technical advice on programmes. This privilege and power have taken various forms in the humanitarian sector, academia and consultancy work, and are complicated by her ethnicity and gender.
Findings
The findings are presented in three main sections. In section “Introduction” we report on who is producing CCS research to position the perspectives and definitions of CCS. This provides context for section “Methods”, how CCS is operationalised across settings and section “Findings”, how CCS is reported to contribute to mental health service delivery.
Final sample
An initial 24,848 papers were identified from our search strategy and imported into Endnote, with 6,831 duplicates removed using Endnote’s automated deduplication function. The remaining 18,017 were imported into Covidence. A further 61 duplicates were removed by Covidence. The eight grey literature sources identified from Google Search were all deemed irrelevant. There were 17,956 papers eligible for title and abstract screening. Of those screened, 213 met criteria for full-text review, with 168 subsequently excluded due to: 1. Not being empirical; 2. Involving academic supervisees; 3. Not studying the supervisory relationship; 4. The supervisor and supervisee being from the same context/culture; and 5. The full text being unavailable. The final sample consisted of 45 papers. Figure 1 outlines the review process using a PRISMA diagram.
PRISMA diagram. Source: Page et al. (Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann, Mulrow, Shamseer, Tetzlaff, Akl, Brennan, Chou, Glanville, Grimshaw, Hróbjartsson, Lalu, Li, Loder, Mayo-Wilson, McDonald, McGuinness, Stewart, Thomas, Tricco, Welch, Whiting and Moher2021). https://doi.org/10.1136/bmj.n71.
Figure 1. Long description
The flowchart is organized into three vertical phases: Identification, Screening, and Included.
1. Identification Phase:
- Left side: Identification of studies via databases and registers. Records identified from databases (n = 24,848) include PsycINFO (n = 5379), Scopus (n = 1329), Embase (n = 5888), PubMed (n = 2845), Web of Science (n = 8255), and CINAHL (n = 1152). An arrow points right to ‘Records removed before screening: (6,892)’.
- Right side: Identification of studies via other methods. Records identified using Google (n = 8). An arrow points right to ‘Records excluded (n = 8)’.
2. Screening Phase:
- An arrow from the database identification box leads to ‘Records screened (n = 17,956)’. An arrow from the Google identification box also merges into this screening step.
- From ‘Records screened’, an arrow points right to ‘Records excluded (n = 17,741)’.
- A downward arrow leads to ‘Reports assessed for eligibility (n = 213)’.
- From ‘Reports assessed’, an arrow points right to a list of ‘Reports excluded: (n = 168)’. Reasons include: Not empirical (n = 86), Academic supervisees (n = 33), Not focused on supervisory relationship (n = 28), From the same culture/context (n = 13), and Full-text not available (n = 8).
3. Included Phase:
- A final downward arrow leads to the bottom box: ‘Studies included in review (n = 45)’.
The detailed characteristics of the 45 papers included in this study are in Supplementary Materials 2. Despite the broad search approach, all included papers were academic papers, with no grey literature included. Most, 69% (n = 31) were conducted in the US, followed by 8% (n = 4) in Australia, 6% (n = 3) in China, 4% (n = 2) in Israel, 4% in multisite (Syria/Bangladesh/Türkiye/Sub-Sahara Africa), 2% (n = 1) in India, 2% in Nepal, 2% in South Africa, 2% Ukraine, 2% Cambodia and 2% unspecified. There were 23 papers that used qualitative methods, 18 that used quantitative methods, and 4 that used mixed methods. Almost half the papers (n = 22) used surveys/questionnaires to understand attitudes and experiences. Few studies (n = 5) were evaluations of specific cross-cultural supervision programme. Two-thirds of papers were published since 2015, showing a growth of CCS literature in the past decade. The majority of study participants were from psychology or counselling (n = 36), followed by social work (n = 12) and family and marriage therapy (n = 11). A small number of papers explored paraprofessionals (n = 3). Twenty-six papers represented supervisee perspectives only, 10 represented supervisors only, 7 represented both and 1 represented researchers and programme directors.
Who is framing CCS and how are they framing it
Most papers were produced in WEIRD contexts (n = 39), drawing on supervision models from a Western paradigm. In contrast, few studies (n = 6) were in non-WEIRD contexts (China, Israel, Ukraine, Syria, Türkiye, India and Cambodia) (Bain and Baradon, Reference Bain and Baradon2018; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Haj-Yahia and Roer-Strier, Reference Haj-Yahia and Roer-Strier1999; Mo and Tsui, Reference Mo and Tsui2016; Saunders, Reference Saunders2022; Seponski and Jordan, Reference Seponski and Jordan2018) or were WEIRD combined with non-WEIRD cross-national studies (n = 4) (Falender et al., Reference Falender, Goodyear, Qian, Jia and Jiang2019; Baraka et al., Reference Baraka, Zaporozhets, Sells and Goodyear2021; Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023). However, these studies were adapted primarily from WEIRD supervision models. One Australian paper was developed by Aboriginal professionals and was the only paper that explored a non-WEIRD supervision model (Harris and O’Donoghue, Reference Harris and O’Donoghue2020).
Only one study (Garrison et al., Reference Garrison, Yeung, Ho, Hong, Son, Lin and Bermingham2022) included a positionality statement for authors. Also, several WEIRD papers did not explicitly state the location of the study; however, the US location was inferred through other study information (n = 14). One paper, based in the US, grouped all people of colour into one grouping (African-American, Latino, Middle Eastern), compared to White people who were in a separate grouping (Bhat and Davis, Reference Bhat and Davis2007).
The dominant type of setting and supervisory configuration was intra-national supervision (local supervisors with local supervisees) in WEIRD settings n = 29. The types of settings and supervisory configurations are shown in Table 2 below.
Number of studies according to study setting and type of supervisory configuration
Table 2. Long description
The table consists of four columns representing supervisory configurations and two rows representing study settings.
Column headers from left to right:
1. Non-local supervisor with local supervisee.
2. Local supervisor with non-local supervisee.
3. Local supervisor with local supervisee.
4. Non-local supervisor with non-local supervisee.
Row 1: Non-W E I R D settings.
- Non-local supervisor with local supervisee: 8 studies including Seponski and Jordan (2018) Cambodia, Baraka et al. (2021) Ukraine, Lekkeh et al. (2023) Syria/Türkiye/Bangladesh, Falender et al. (2019) China, Kemp et al. (2019) Sub-Saharan Africa, Goodyear et al. (2023) US/China, Mo and Tsui (2016) Hong Kong/China, and Saunders (2022) Nepal.
- Local supervisor with non-local supervisee: 1 study by Devassy et al. (2022) involving an Indian supervisor and W E I R D supervisees.
- Local supervisor with local supervisee: 2 studies in Israel by Haj-Yahia and Roer-Strier (1999) and Toukhy and Gershfeld-Litvin (2021).
- Non-local supervisor with non-local supervisee: 0 studies.
Row 2: W E I R D settings.
- Non-local supervisor with local supervisee: 0 studies.
- Local supervisor with non-local supervisee: 10 studies including Akkurt et al. (2018), Garrison et al. (2022), Guvensel et al. (2015), Jain and Aggarwal (2020), Killian (2008), Lee et al. (2022), Li et al. (2020), Mori et al. (2009), Nilsson and Anderson (2004), and Ross et al. (2019).
- Local supervisor with local supervisee: 24 studies primarily in the U S and Australia, including authors such as Bain and Baradon (2018), Bhat and Davis (2007), Calamia et al. (2022), Cook et al. (2020), Harris and O’Donoghue (2020), and Wiley et al. (2021).
- Non-local supervisor with non-local supervisee: 0 studies.
* Participants were from a mix of WEIRD and non-WEIRD settings.
The majority of papers lacked a definition of CCS (n = 39). Only six papers gave definitions for CCS. Two of these papers provided their own definitions for CCS (Dressel et al., Reference Dressel, Consoli, Kim and Atkinson2007; Baraka et al., Reference Baraka, Zaporozhets, Sells and Goodyear2021) while four referred to other literature for their definitions (Kissil et al., Reference Kissil, Davey and Davey2013, Reference Kissil, Davey and Davey2015; Mo and Tsui, Reference Mo and Tsui2016; Toukhy and Gershfeld-Litvin, Reference Toukhy and Gershfeld-Litvin2021). Across the six papers that defined CCS, half defined it in terms of differences between supervisor and supervisee based on cultural background or ethnicity (Dressel et al., Reference Dressel, Consoli, Kim and Atkinson2007), nationality (Baraka et al., Reference Baraka, Zaporozhets, Sells and Goodyear2021) or other demographic variables (Toukhy and Gershfeld-Litvin, Reference Toukhy and Gershfeld-Litvin2021). Kissil et al. (Reference Kissil, Davey and Davey2013, Reference Kissil, Davey and Davey2015) extended this further, defining CCS as involving both culturally different supervision dyads as well as general discussions about cultural differences within supervision. Meanwhile, Mo and Tsui (Reference Mo and Tsui2016) adopted a broader definition, describing CCS as conducting “supervision with different cultural models or patterns” (p. 63). There was little conceptual distinction between “cross-cultural” and “multicultural”, with the terms referring to essentially the same supervisory process. Race was also used to describe cultural difference in several papers (n = 17); however, in these studies race was rarely defined, except in White-Davis who described it as ‘a uniquely pervasive social construct built around skin colour’ (2016, p. 348).
How does cross-cultural supervision occur in practice across contexts
Four key themes were identified describing experiences of CCS in practice. These were: using relational processes, experiencing challenges in communication and language; adopting cultural responsiveness through cultural humility, multicultural discussions and applying cultural/contextual knowledge; and addressing power and discrimination.
Using relational processes
Relational aspects were consistently reported as central to CCS, including supervisor and supervisee qualities, working alliances and peer support. Supervisors who were supportive, committed, genuine, empathic and non-judgemental enabled positive experiences that were reported to increase confidence, supervisee voice and clinical instincts (Dressel et al., Reference Dressel, Consoli, Kim and Atkinson2007; Baraka et al., Reference Baraka, Zaporozhets, Sells and Goodyear2021; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022). Sharing resources, attentiveness to supervisee cultural struggles and tailoring supervision styles, such as using a didactic approach for less competent supervisees, were also enablers (Lawless et al., Reference Lawless, Gale and Bacigalupe2001; Li et al., Reference Li, Chou, Yang, Chang and Kim2020; Baraka et al., Reference Baraka, Zaporozhets, Sells and Goodyear2021; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021; Saunders, Reference Saunders2022; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023). Supervisees proactively seeking supervisor support, developing self-awareness of cultural identity and cultural strengths, were also reported to enable positive CCS (Guvensel et al., Reference Guvensel, Dixon, Parker, McDonald and O’Hara2015; Drinane et al., Reference Drinane, Wilcox, Cabrera and Black2021; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022). A positive working alliance developed through supervisors who framed cultural diversity as an asset (Bhat and Davis, Reference Bhat and Davis2007; Cook et al., Reference Cook, Jones and Welfare2020; Jain and Aggarwal, Reference Jain and Aggarwal2020) and an attitude of mutual learning, trust and respect between supervisors and supervisees (Killian, Reference Killian2001; Bain and Baradon, Reference Bain and Baradon2018; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023). Access to peer support with supervisees of similar cultural background was also valuable (Verdinelli and Biever, Reference Verdinelli and Biever2009; Ho and O’Donovan, Reference Ho and O’Donovan2018; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022).
Experiencing challenges in communication and language
Communication and language differences were a common barrier. Supervision in English was common (the supervisor’s language) and led to verbal and non-verbal communication challenges for non-English-speaking supervisees (Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023; Ho and O’Donovan, Reference Ho and O’Donovan2018; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023; Mori et al., Reference Mori, Inman and Caskie2009; Ross et al., Reference Ross, Ta and Grieve2019; Seponski and Jordan, Reference Seponski and Jordan2018). Reported cultural differences in communication norms included shame in response to being publicly corrected (Nilsson and Anderson, Reference Nilsson and Anderson2004; Li et al., Reference Li, Chou, Yang, Chang and Kim2020), a preference for didactic versus reflective approaches (Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023; Mo and Tsui, Reference Mo and Tsui2016; Seponski and Jordan, Reference Seponski and Jordan2018) and differing comfort with self-disclosure (Nilsson, Reference Nilsson2007; Nilsson and Duan, Reference Nilsson and Duan2007). CCS was described as requiring consistent supervisor commitment and at least one face-to-face meeting (Baraka et al., Reference Baraka, Zaporozhets, Sells and Goodyear2021; Seponski and Jordan, Reference Seponski and Jordan2018) and challenging when conducted online due to internet issues, time zone differences and limited privacy (Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023).
Adopting cultural responsiveness
Cultural responsiveness was described as occurring through cultural humility, multicultural discussions and contextual knowledge. Culturally responsive supervision was described as actively adapting supervision to ensure cultural relevance and appropriateness, and positively correlated with clinician self-efficacy in two key studies (Kissil et al., Reference Kissil, Davey and Davey2013, Reference Kissil, Davey and Davey2015). Three main strategies for cultural responsiveness were commonly described in the studies: practising cultural humility, conducting multicultural discussions and applying or gaining cultural/contextual knowledge.
Cultural humility, which is the critical reflection of one’s limitations and assumptions, openness to learning different perspectives and a broadening of what is considered a ‘legitimate’ worldview, was found to enable more open disclosure and broaching of cultural differences (Cook et al., Reference Cook, Jones and Welfare2020; Drinane et al., Reference Drinane, Wilcox, Cabrera and Black2021; Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023; Killian, Reference Killian2001; Lawless et al., Reference Lawless, Gale and Bacigalupe2001; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023; Lusk et al., Reference Lusk, Terrazas and Salcido2017; Seponski and Jordan, Reference Seponski and Jordan2018; Vandament et al., Reference Vandament, Duan and Li2022; Verdinelli and Biever, Reference Verdinelli and Biever2009). While most studies focused on supervisor cultural humility, one study of Western supervisees with Indian supervisors in India noted the importance of supervisees having cultural humility and reflecting on Eurocentric views (Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022).
Multicultural discussions were described as explicit discussions about culture, discrimination, identities and internalised oppression between the supervisor and supervisee (Toukhy and Gershfeld-Litvin, Reference Toukhy and Gershfeld-Litvin2021; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021) and were identified as important for culturally responsive supervision in a number of studies (n = 14). These discussions commonly addressed power dynamics, promoted cultural humility, reduced concealment of cultural identity and enhanced supervisee self-efficacy (Akkurt et al., Reference Akkurt, Ng and Kolbert2018; Drinane et al., Reference Drinane, Wilcox, Cabrera and Black2021; Nilsson and Anderson, Reference Nilsson and Anderson2004). Initiation and early introduction of multicultural discussions by the supervisor in a natural and non-directive manner was found to enable culturally responsive CCS (Lawless et al., Reference Lawless, Gale and Bacigalupe2001; Taylor et al., Reference Taylor, Hernandez, Deri, Rankin and Siegel2007; Ho and O’Donovan, Reference Ho and O’Donovan2018; Vandament et al., Reference Vandament, Duan and Li2022). Conversely, an absence of multicultural discussions was associated with identity concealment and lower self-awareness and cultural competence (Akkurt et al., Reference Akkurt, Ng and Kolbert2018; Bhat and Davis, Reference Bhat and Davis2007; Drinane et al., Reference Drinane, Wilcox, Cabrera and Black2021; Killian, Reference Killian2001; Lawless et al., Reference Lawless, Gale and Bacigalupe2001; White-Davis et al., Reference White-Davis, Stein and Karasz2016).
Supervisee and supervisor knowledge of cultural, legal and political contexts strengthened supervisee confidence and sense of ownership (Verdinelli and Biever, Reference Verdinelli and Biever2009; Nelson et al., Reference Nelson, Bennett-Levy, Wilson, Ryan, Rotumah, Budden, Beale and Stirling2015; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Saunders, Reference Saunders2022). Conversely, limited supervisor multicultural training (Hernandez et al., Reference Hernandez, Taylor and McDowell2009) and knowledge of cultural strengths-based supervision (Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021) reduced cultural safety (Killian, Reference Killian2001; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022).
Addressing power and discrimination
Power was explored in the included literature in two main ways. Firstly, it described how supervisor authority was privileged while supervisee voice was concealed (Killian, Reference Killian2001; Lawless et al., Reference Lawless, Gale and Bacigalupe2001; Hernandez et al., Reference Hernandez, Taylor and McDowell2009; Kissil et al., Reference Kissil, Davey and Davey2013; Seponski and Jordan, Reference Seponski and Jordan2018; Drinane et al., Reference Drinane, Wilcox, Cabrera and Black2021; Saunders, Reference Saunders2022). A supervisor’s perceived power of “foreign expertise,” combined with racial marginalisation and power differences reflected in the socio-political context, amplified supervisor authority (Killian, Reference Killian2001; Bain and Baradon, Reference Bain and Baradon2018; Seponski and Jordan, Reference Seponski and Jordan2018; Falender et al., Reference Falender, Goodyear, Qian, Jia and Jiang2019). Secondly, power was mentioned in terms of describing how to balance power through reciprocity, mutual respect, cultural humility and transparency (Killian, Reference Killian2001; Jain and Aggarwal, Reference Jain and Aggarwal2020; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023). Supervisors who balanced power saw interactions as an opportunity for self-development and growth, creating a positive learning environment (Wieling and Marshall, Reference Wieling and Marshall1999; Dressel et al., Reference Dressel, Consoli, Kim and Atkinson2007; Ross et al., Reference Ross, Ta and Grieve2019; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021). Culturally responsive supervisors explicitly recognised power and privilege, engaged in reflective practice on their power and blind spots and empowered supervisees through contextualising supervision programmes for local contexts (Killian, Reference Killian2001; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021; Saunders, Reference Saunders2022).
How cross-cultural supervision assists the delivery of mental health services
Included papers provided multiple examples of how CCS assists in the delivery of mental health services. There were four main mechanisms through which CCS, using the kinds of strategies in the previous section, was reported to improve client care in the reviewed studies:
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1. Improved supervisee skills: Culturally responsive CCS helped increase supervisee competence, confidence and effectiveness when working with clients and reduced supervisee burnout and secondary trauma (Kissil et al., Reference Kissil, Davey and Davey2013; Seponski and Jordan, Reference Seponski and Jordan2018; Saunders, Reference Saunders2022; Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023)
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2. Adaptation of WEIRD models: Non-Western supervisees were supported to adapt WEIRD models to cultural/socio-political dynamics of the client context (Guvensel et al., Reference Guvensel, Dixon, Parker, McDonald and O’Hara2015; Toukhy and Gershfeld-Litvin, Reference Toukhy and Gershfeld-Litvin2021)
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3. Enhanced cultural humility: Supervisees improved understanding of discrimination, reduced Eurocentric bias and ethnocentrism, incorporating multiple cultural perspectives into interventions (Killian, Reference Killian2001; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022)
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4. Reduced concealment: Multicultural discussions enabled open and honest case discussions (Cook et al., Reference Cook, Jones and Welfare2020; Toukhy and Gershfeld-Litvin, Reference Toukhy and Gershfeld-Litvin2021; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022)
At a macro-structural level, CCS was described as strengthening organisational cultural competence (Ramirez, Reference Ramirez2003). In contexts lacking a formal MH regulatory or ethical body (e.g. Cambodia, China), CCS was reported to support non-WEIRD supervisees to navigate complex ethical and client safety issues through ethical discussions with supervisors (Ramirez, Reference Ramirez2003; Taylor et al., Reference Taylor, Hernandez, Deri, Rankin and Siegel2007; Mo and Tsui, Reference Mo and Tsui2016; Saunders, Reference Saunders2022).
Discussion
This review contributes to the emerging literature on cultural safety in supervision and is the first review to map the cross-cultural (CCS) literature in MHPSS services. It highlights the lack of consensus in CCS in terms of how it is defined, the broad range of what it comprises and how it contributes to MHPSS service delivery. The type of CCS also varied substantially across the studies, demonstrating inconsistent operationalisation of the concept. Rather than fixed categories, we interpret the findings as suggesting that CCS may be conceptualised as occurring across a spectrum of configurations to better reflect the nuances of cultural differences and to challenge White normativity. These configurations range from supervisors and supervisees working in the same context but differing in cultural background (e.g. US White Supervisors with US Black supervisees), to working in the same context with more pronounced cultural differences (e.g. South African White supervisors from a professional background with Black South African paraprofessional supervisees), to other cultural differences such as supervisors and supervisees from different countries of origin (e.g. WEIRD supervisees in India working with local Indian supervisors) with different socio-political systems. CCS may therefore be conceptualised as a spectrum whereby supervisory relationships differ in the extent of contextual, socio-political and cultural differences between participants.
The literature is dominated by WEIRD scholarship. Therefore, the findings presented should be understood and critically reviewed within the context of the included predominantly WEIRD literature rather than as a comprehensive representation of CCS literature. The themes, concepts and processes identified in included papers in this review are likely to reflect Western framing and understanding of supervision and may exclude other models, definitions, framing, functions, practices and processes from non-Western contexts. The few studies with humanitarian settings and non-WEIRD contexts acted as sites of application, rather than knowledge production, with limited locally generated insights to inform future policy and practice. Our finding of the WEIRD-centricity of CCS knowledge with limited representation from non-WEIRD contexts is novel, with implications for epistemic justice. When concepts are primarily generated from WEIRD contexts, hermeneutical injustice (e.g. lacking language for one’s experience) may occur, narrowly framing lived experience based on WEIRD paradigms. WEIRD normativity in the literature, evidenced by lack of positionality statements and location of study, risks reinforcing WEIRD models of supervision as universal. This dynamic also reflects ‘elite capture’, the process whereby priorities of advantaged groups can dominate and shape institutions to represent their own cultural norms, including professional standards, processes and agendas (Táíwò, Reference Táíwò2022). This concept could be applied in further development of the proposed framework and in future research. This ethnocentrism may be perpetuated by WEIRD supervisors and scholars. Similarly, the use of the concept of acculturation – the process of cultural and psychological change resulting from contact with other cultures (Mehmet Nurullah Akkurt et al., Reference Akkurt, Ng and Kolbert2018) reflects White normativity because it is only applied to non-local supervisees in WEIRD contexts. This implies that adaptation is only unidirectional, with only cultural adjustment expected of supervisees (Killian, Reference Killian2001; White-Davis et al., Reference White-Davis, Stein and Karasz2016; Ross et al., Reference Ross, Ta and Grieve2019; Garrison et al., Reference Garrison, Yeung, Ho, Hong, Son, Lin and Bermingham2022). Similarly, the term ‘diverse’ is at times used as a descriptor for people of colour, with White people therefore non-diverse, as the reference point and norm (Cook and Helms, Reference Cook and Helms1988). Indeed, critics suggest that diversity language perpetuates existing power hierarchies (Ahmed, Reference Ahmed2012), reflecting the broader dynamics of epistemic injustice within CCS literature. Overall, given the lack of non-WEIRD CCS knowledge that is being developed and disseminated, both testimonial and hermeneutical injustice may occur in CCS, limiting the development of culturally safe CCS models.
The frequent use of the term CCS in the literature reviewed without a clear definition makes the concept ambiguous, limiting transferability and comparability of CCS literature. In the absence of definitional clarity, authors fail to declare their epistemological assumptions underpinning CCS, risking representation of ‘cross-cultural’ as neutral, self-evident and limiting the possibility of challenging underlying assumptions. Ensuring accurate conceptual definitions can support epistemic justice. For example, definitional clarity regarding the word ‘race’ is important for CCS where cultural differences are interpreted through racialised categories that can have contested, socio-political meanings (Omi and Winant, Reference Omi and Winant2015). While race is widely accepted as a social construction representing worldviews and culture, historically it has been used to classify human biological attributes such as skin colour and genes, and sometimes used controversially as a metonym for ‘species’ (Smedley and Smedley, Reference Smedley and Smedley2005; Omi and Winant, Reference Omi and Winant2015). Across included studies, authors were unclear if they were referring to race as a biological descriptor or as a social construct. If race is treated as an index for biological difference, socially produced inequalities may be taken as natural differences (Smedley and Smedley, Reference Smedley and Smedley2005). In CCS, this risks contributing to epistemic injustice through perpetuation of knowledge hierarchies based on biology. This has implications for CCS as it may legitimise the idea that knowledge of people from certain backgrounds is inferior, leading to discriminatory and culturally unsafe supervision.
Power was structurally embedded in the CCS relationship described in included studies through perceived authority of foreign expertise and socio-political/economic differences (Falender et al., Reference Falender, Goodyear, Qian, Jia and Jiang2019). This compounding effect of heightened epistemic authority of supervisors based on their socio-political authority risks supervisee concealment of their perspectives. Therefore, testimonial injustice can occur, leading to culturally unsafe supervision. However, if power asymmetries are explicitly recognised and discussed with supervisees collaboratively through multicultural discussions (Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021), these risks may potentially be mitigated.
The findings have practical implications for supervision in non-WEIRD settings. They suggest that focusing on relational processes within supervision, positioning local supervisees as experts and adapting supervision to local contexts may be appropriate, culturally responsive approaches to incorporate into CCS.
Recommendations
Based on the findings, the following are recommendations for supervisors, supervisees, researchers and policymakers to consider:
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1. Acknowledge WEIRD paradigm dominance, ethnocentrism and White normativity: Consider limitations when transferring learnings from WEIRD and non-humanitarian settings, where the MH paradigms are often rooted in Western epistemology. Recognise the influence of the authors’ culture through positionality statements in scholarly literature. Include research and conduct supervision in languages other than English.
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2. Clearly define concepts of CCS: Use clear definitions of terminology in policy, practice and research including cross-cultural supervision, race and ethnicity
These recommendations are suggested primarily for researchers and policy makers:
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3. Prioritise research in non-WEIRD contexts, including humanitarian settings: Support local supervisees in non-WEIRD and humanitarian settings to lead supervision research projects, highlighting local priorities. Support non-WEIRD MH education that develops local supervision expertise in the local context.
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4. Develop new models of CCS processes and configurations: New models are needed that distinguish the spectrum of cross-cultural supervisory configurations and types to support further understanding in this field. Qualitative studies that evaluate CCS programmes to understand processes and impacts of CCS could help inform new CCS models.
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5. Expand search strategy: Include non-indexed, practice-based sources from low- and middle-income countries, other language sources and other grey literature in future reviews.
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6. Identify core components and transferability: Further research involving supervisors and supervisees across WEIRD and non-WEIRD settings may be needed to identify the core components of CCS, determine which processes are transferable across settings and evaluate their impact on supervision and service delivery.
The following recommendations are practical suggestions for supervisors and supervisees:
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7. Engage in multicultural discussions: Ensure supervisor-led multicultural discussions occur early (Lawless et al., Reference Lawless, Gale and Bacigalupe2001; Taylor et al., Reference Taylor, Hernandez, Deri, Rankin and Siegel2007; Vandament et al., Reference Vandament, Duan and Li2022). Adopt a strengths-based approach to discussing cultural identity (Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021). Explicitly recognise power dynamics in the supervisory relationship, and in the socio-political context (Killian, Reference Killian2001; Wiley et al., Reference Wiley, Phillips and Palladino Schultheiss2021).
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8. Practise cultural humility: Be open and curious, engaging in continual self-awareness of one’s own and others’ culture (Goodyear et al., Reference Goodyear, Duan, Falender, Lin, Jia, Jiang and Qian2023; Lekkeh et al., Reference Lekkeh, Faruk, Jahan, Beetar, Kurt, Wells and Wong2023). Understand the context and culture of the supervisee, supervisor and/or client (Verdinelli and Biever, Reference Verdinelli and Biever2009; Nelson et al., Reference Nelson, Bennett-Levy, Wilson, Ryan, Rotumah, Budden, Beale and Stirling2015; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Saunders, Reference Saunders2022).
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9. Seek support: Seek peer supervision from others in the same culture and proactively ask for the supervisor’s help on issues when needed (Verdinelli and Biever, Reference Verdinelli and Biever2009; Ho and O’Donovan, Reference Ho and O’Donovan2018; Devassy et al., Reference Devassy, Thampi, Harrison, Scaria, Metzger and Joubert2022; Lee et al., Reference Lee, Knutson, Koch, Brown and Keyes2022).
Limitations
This review has several limitations. There was a limited representation from non-WEIRD contexts, which means the findings about CCS processes have been empirically grounded largely in WEIRD contexts, with their relevance to non-WEIRD, humanitarian and low-resource settings inferred theoretically and requiring local verification. Also, applying a cultural safety and epistemic justice lens to a predominantly WEIRD evidence base is limiting, with the absence of non-WEIRD perspectives constraining the ability to see alternative themes and processes. The restriction to English-language sources may have also excluded relevant literature from non-WEIRD contexts. Further, the limited grey literature search strategy and inclusion criteria may have unintentionally excluded sources such as non-English-language sources and unpublished sources. Also, while our search strategy included programme reports, the search strategy may not have captured these effectively. Future search strategies should consider including other search terms to increase the likelihood of capturing this type of literature. Finally, the current review only encompasses literature up to September 2023 and future reviews should update the evidence base.
Conclusion
This review addresses a gap in the literature on CCS supervision in mental health service provision, by exploring how, and by whom CCS is framed, what settings it is documented, the barriers and facilitators and how CCS may assist in the delivery of mental health services. Our findings indicate that there is little consensus on definitions and terminology, reflecting fragmentation in the field. Further, the main voices and contexts in CCS are WEIRD. While cultural safety and epistemic justice were reported to be enabled by open discussions about power and culture, power asymmetries and communication challenges were the main barriers. Through these processes, CCS was reported to assist MHPSS service delivery by improving supervisee skills and cultural humility, supporting adaptation of WEIRD models to local contexts and enabling more open case discussions. However, the limited scholarship from non-WEIRD settings exposes the asymmetries in knowledge production, including whose perspectives shape CCS theory. As CCS expands globally, this imbalance is concerning. Continued privileging of WEIRD frameworks risks both testimonial injustice (through underrepresentation) and hermeneutical injustice (through privileging WEIRD frameworks), with practical implications for supervision models that may be insufficiently contextualised. Greater inclusion of non-WEIRD scholarship and research is essential to support the development of epistemically just and culturally safe CCS models.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10297.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2026.10297.
Author contributions
The design of this scoping review and its parameters were developed by Scarlett Wong, Sally Nathan and Michelle Lokot. The literature search was conducted by Scarlett Wong. Studies were reviewed and data were extracted by Scarlett Wong and Fatema Almeamari. Data analysis was conducted by Scarlett Wong. The review process was guided by Sally Nathan and Michelle Lokot. The article was drafted by Scarlett Wong and critically revised by Sally Nathan and Michelle Lokot. All authors (Scarlett Wong, Fatema Almeamari, Sally Nathan, Kathryn Nicholson Perry and Michelle Lokot) contributed to editorial support and final manuscript approval.
Competing interests
The authors declare none.
Data availability statement
The data that support the findings of this review are available in the supplementary materials and within the article.
Funding statement
This research is funded by ELRHA’s Research for Health in Humanitarian Crises (R2HC) Programme (Grant Number: RG203720), which aims to improve health outcomes by strengthening the evidence base for public health interventions in humanitarian crises. R2HC is funded by the UK Foreign, Commonwealth and Development Office (FCDO), Wellcome and the Department of Health and Social Care (DHSC) through the National Institute for Health Research (NIHR). The funding body had no role in the conceptualisation, writing of the report, or the decision to submit the report for publication.
Open access
Comments
Dear Editors,
We thank you in advance for considering our manuscript titled “Cross-Cultural Mental Health Supervision: A Scoping Review through the lens of Cultural Safety and Epistemic Injustice” for publication in Global Mental Health.
This review is the first paper to synthesise and map the literature on cross-cultural mental health globally. The aim of the review is to understand understand who is framing the evidence, how they frame it, what are common processes and dynamics discussed, and how it supports mental health service delivery. We identify themes and gaps in the evidence, and discuss the implications for researchers, policy makers and practitioners.
The scoping review was conducted according to recommended methodological guidelines and reported in accordance with PRISMA-ScR. The protocol was registered on Open Science Framework in advance, and screening was conducted using Covidence software.
In the context of the increasing practice of cross-cultural supervision globally, with limited understanding for culturally safe practices, we believe this manuscript will be particularly useful for cross-cultural supervisors and supervisees. Additionally, the gaps and implications identified, such as a lack of research involving non-Western contexts, will be of interest to global mental health researchers.
This is an original, not previously published manuscript that has not been submitted for publication elsewhere. All authors have reviewed and approved the manuscript submitted. There are no conflicts of interest identified.
We look forward to your response and thank you for your time to consider our work.
Kind regards,
Scarlett Wong