In 2021, the world saw the highest number of displaced people since World War II—a staggering 89.3 million, with 27.1 million of them refugees (UNHCR, 2022). This number has only increased due to the war in Ukraine, adding to the growing global displacement crisis (United Nations, 2022). Refugees face extreme adversity, leading to a higher prevalence of mental health disorders, yet most lack access to culturally appropriate mental health services. To help address this gap, we co-designed a toolkit aimed at supporting ethical clinical practice in complex, cross-cultural contexts. This toolkit is designed to empower clinicians to overcome cultural barriers and deliver more effective mental health care (https://www.ethical-action.ed.ac.uk/clinical-practice).
The toolkit introduces a model of ethical reflection throughout the clinical process, or what we call the “clinical journey,” which spans 10 key stages. These stages include organisational culture, the referral process, initial evaluations, interventions, collaborations with other professionals, and even the legacy left after the completion of care. Clinical practice in intercultural contexts is inherently complex—what may seem obvious in one culture can create significant ethical dilemmas in another (Calia et al., 2022). That’s why our toolkit encourages continuous reflection at each stage, using a structured framework known as the “Four P’s”:
Place: Examining the physical, political, cultural, and historical context of the care setting and how it shapes the ethical challenges encountered.
People: Considering all stakeholders involved in the ethical dilemma, including clients, clinicians, colleagues, local communities, and referring organisations.
Principles: Reviewing relevant ethical and legal frameworks that guide clinical practice and help identify or resolve ethical risks.
Precedents: Looking at how similar ethical challenges were addressed in the past to inform current decision-making.
These four considerations—Place, People, Principles, and Precedents—intersect at every stage of clinical practice, providing a comprehensive approach to ethical reflection. By focusing on the 4P’s, clinicians can uncover ethical complexities and navigate them toward thoughtful, culturally responsive solutions.
This clinical toolkit builds on our earlier work, which resulted in a toolkit for ethical research created in collaboration with 400 global researchers from 30 countries. Like our clinical toolkit, the research toolkit encourages cross-cultural ethical reflection in complex global health and social challenges (Reid et al., 2019). Ultimately, both initiatives aim to contribute to the broader global movement for decolonised, equitable mental healthcare. Our goal is to provide resources that support culturally secure clinical practices, both within national health systems and across NGOs, to ensure all individuals have access to the mental healthcare they deserve.
Dr Clara Calia is currently working as a Senior Lecturer in Clinical Psychology on the Clinical Doctorate in psychology at the University of Edinburgh (UK) and as a member of the anti-racism group in the Clinical Doctorate in the UK. She also worked as the Ethics & Integrity Lead role in Clinical Psychology and, between 2019 and 2022, as Deputy Director of Research (Research Ethics and Research Integrity) at the School of Health in Social Science at the University of Edinburgh. Clara is a member of the BPS Human Rights Advisory Group. Clara’s main research interests are in the areas of Cross- cultural Neuropsychology, Global mental health and Ethics in clinical and global research (https://www.ethical-global-research.ed.ac.uk/). Social justice is the main drive of her research and clinical work, by promoting principles of equity, ethics, participation, dialogue with culturally diverse populations, and those at risk of social injustice.
Dr Cristobal Guerra is a Clinical Psychologist, with a Master in Psychology, Doctor in Psychotherapy, and Diploma on Research Ethics. His clinical experience includes supporting child and adolescent victims of interpersonal trauma in Chile between 2001 and 2018. Cristobal is a member of the Center for Studies in Childhood, Adolescence and Family of the NGO Paicabi and of the Center for research on work, family and citizenship "Cielo" of the Universidad Santo Tomas. Cristóbal is a Professor of the School of Psychology at the Universidad Santo Tomás, Chile and member of the ethics committee. Research priorities include trauma, CBT and resilience.
Professor Liz Grant is Assistant Principal Global Health and Director of the Global Health Academy. The Academy supports the creation, curation and implementation of global health knowledge, working alongside a diverse global community including practitioners, trainers, researchers, policy makers, business, local community and international agencies. Liz leads the Planetary Health Futures strand in the Edinburgh Futures Institute (EFI), and directs the Certificate in Global Health Challenges, co-directs the Masters of Family Medicine and the MSc in Planetary Health. She is a co-Director of the Global Compassion Initiative and the Compassion Lab in EFI. Liz is a Fellow of the Royal Society of Edinburgh, the Royal College of Physicians of Edinburgh and the Royal Society of Arts. She is the Deputy Dean International for the Royal College of Physicians.
Professor Corinne Reid is a Clinical and Counselling Psychologist and global researcher. Her deep interest in ethics developed through research collaborations with Indigenous communities in Australia, as part of an international team investigating youth mental health need in Malawi and in her work as a clinical psychologist with marginalised communities. Her priority is to support researchers and clinicians to tackle complex global challenges through developing ethical multidisciplinary teams and strong community partnerships. Corinne is also co-founder of the FLOURISH research team partnering with researchers in LMICs to address mental health needs in culturally safe ways; and the ETHOS initiative, supporting universities to embrace planetary health. In her former role as Provost and Deputy Vice-Chancellor for Research at Victoria University, Corinne led a whole-of-university commitment to planetary health. Corinne is Honorary Professor at the Academy of Sport, The University of Edinburgh.
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