Successful therapeutic relationships are built on trust and understanding, so counselors can ill afford to have words and phrases become “lost in translation.” Cultural competency on the part of counselors is also crucial, especially as clients are becoming more linguistically and culturally diverse.
According to the 2019 American Community Survey conducted by the U.S. Census Bureau, 22% of U.S. households speak a language other than English at home, with 13.5% speaking Spanish. And this number will only increase in the years ahead. The Instituto Cervantes, in its Yearbook of Spanish in the World 2019, estimates that nearly 1 in every 3 Americans will be Hispanic by 2060, making the United States the second-largest Spanish-speaking country in the world after Mexico. The Pew Research Center projects that 19% of Americans will be foreign born by 2050, up from 12% in 2005. It also estimates that 82% of U.S. population growth will come from immigrants and their descendants.
The counseling profession emphasizes cultural competency, but evidence suggests that the mental health field as a whole isn’t keeping up with the rising demand for bilingual and bicultural services. According to survey results released by the American Psychological Association in 2016, approximately 10.8% of U.S. psychologists reported being able to provide services in a language other than English, with only 5.5% able to provide services in Spanish.
This lack of culturally competent services can take a toll on people’s mental health. “When clients can’t find a bilingual counselor, they become more isolated. Often, they don’t talk about their emotional issues because they don’t feel that they can be seen or understood on a linguistic or cultural level,” says Ingrid Ramos, a licensed professional counselor (LPC) and the director of the Bienestar (wellness) and Resilience programs at The Women’s Initiative in Charlottesville, Virginia. “Then, you see a worsening of symptoms.”
To better meet the needs of bilingual and bicultural clients, mental health professionals must become more culturally competent themselves. That goes beyond simply speaking another language or being aware of cultural difference. Clinicians need to be prepared to offer bilingual services and practice cultural humility, which requires better bicultural/bilingual training opportunities and supervision.
Finding the right words
Language is central to counseling because it allows clinicians to build rapport and better understand clients’ life experiences, thoughts and behaviors. But fluency in the client’s native language is often not enough to make a counselor linguistically competent in session. Olga Mejía, an associate professor of counseling at California State University, Fullerton (CSUF), acknowledges that mental health terminology doesn’t always translate. She often tells her counseling students, “There’s Spanish, and then there’s therapeutic Spanish.”
Although Spanish is Mejía’s first language, she admits she felt lost during her first clinical position after completing her doctoral program. Her clients and colleagues alike assumed that she could easily offer mental health sessions in Spanish, but she struggled to translate certain technical terms commonly used in the field such as confidentiality and the cycle of violence.
That’s because the process isn’t as straightforward as translating the words and phrases directly, Mejía explains. A direct translation often doesn’t take into account the cultural context and nuance between languages. Therefore, she advises her counseling students to translate the idea behind the terms rather than searching for the perfect word. For example, even if there isn’t a word-for-word match for boundaries in the client’s language, a counselor can explain that people often set rules or limits in relationships.
According to Ye (Agnes) Luo, an assistant professor of counseling at the University of North Texas, even explaining what a counselor is and how that differs from a psychologist can be challenging because some languages, such as Mandarin, use the same word to describe both professions. And certain countries may not distinguish between these roles the way that the United States does, she adds.
Luo, an American Counseling Association member and LPC in Texas who speaks both Mandarin and English, has learned that she can’t simply ask clients if they understand what counseling is because the client’s understanding of counseling may differ from her own. For example, she has worked with clients from Asian countries who expect counselors to prescribe something to “fix” their presenting issues. These clients viewed her as an authority figure rather than perceiving therapy as a collaborative process, she notes.
Interpreters must also be aware of the nuances involved in the way mental health professionals speak. Ramos advises counselors who use interpreters to discuss the therapeutic process with them before going into session. “Our communication is our tool,” Ramos says. “How we say things, how we ask questions, how we reflect back to the client — that’s the counseling intervention.” Therefore, it is important that interpreters also understand how to communicate in this way when translating for clients, she points out. For example, an interpreter could accidentally misrepresent a counselor’s reflective statement by telling the client, “The counselor is repeating what you just said,” rather than translating the reflective statement.
Medical interpretation can feel more transactional, but because counseling involves emotional disclosure and vulnerability, it requires a certain tone and set of communication skills, continues Ramos, who serves on the board of Creciendo Juntos, an organization that provides support and resources for Latinx families and Latinx-serving organizations in the city of Charlottesville and Albemarle County. For this reason, the Virginia Department of Behavioral Health and Developmental Services distinguishes between medical and mental health interpreting, she says. For example, the agency underscores the importance of mental health counselors and interpreters meeting before a session, while acknowledging this is not always necessary in medical settings.
Counselors also have to be upfront with clients about their bilingual language proficiency, advises Luo, a counselor at C2 Counseling in Corpus Christi, Texas. When searching for her own personal counselor, she found a clinician who advertised herself as bilingual in Mandarin and English. But in their first session together, the counselor asked Luo if it was OK if she spoke in English, not Mandarin, because she had never used Mandarin in a clinical setting. Luo acquiesced, but it was not the experience she had desired or expected.
Cultural competency and humility
Counselors must consider the client’s country of origin, not just the client’s language. “Language is essential,” notes Mejía, a bilingual and bicultural licensed psychologist. “But [clinicians] have to have the language with the cultural competency or cultural sensitivity, along with the cultural humility.” For example, in Spanish, knowing when and how to use tu and usted (both words for you) changes depending on age, gender, seniority and familiarity. If counselors don’t have the cultural understanding of that distinction, then they could hurt their relationship with the client, and the client will not feel seen or heard, she says.
As Alaina Hanks, a licensed professional counselor-in-training at the Gerald L. Ignace Indian Health Center in Milwaukee, points out, a lack of cultural competency can also have serious repercussions, including potential misdiagnoses. Some of Hanks’ Native American clients have told her that other mental health professionals previously misdiagnosed them as having schizophrenia or depression with psychotic features because they mentioned seeing spirits or receiving guidance from ancestors during a traditional ceremony. Counselors must listen to the client and learn about their culture to accurately determine what is connected to culture and what is clinically significant, she stresses.
“A huge part of [cultural humility] is understanding the history of where you are and what that means,” says Hanks, an ACA member who helped co-author the article “A collective voice: Indigenous resilience and a call for advocacy,” published on CT Online in February 2020. She advises counselors to start by learning the histories of the places where they live and work because these histories, in combination with current policies, affect clients.
Because Ramos, who is from the Dominican Republic, often works with clients from Mexico and Central America, she brings a sense of cultural humility and curiosity into session with her. Sometimes, her clients assume that she understands everything they say just because she speaks Spanish. She knows not to make that assumption. Instead, she routinely asks, “What does that phrase mean in your country?” If she still doesn’t fully grasp what the client is trying to convey, she will dig deeper and ask what the phrase means in their community or family.
“As a bicultural counselor, it’s important to remember that every culture has its own way of speaking about symptoms, illness and treatment,” Ramos says. To gain a better understanding of the presenting issue, she asks clients how they understand or see the problem and how their culture views their symptoms or behaviors. She also asks how people in their culture typically cope with these symptoms or behaviors.
Because Native American approaches to wellness are often about gaining balance, Hanks, who is Anishinaabeg and enrolled in the White Earth Nation in Minnesota, sometimes incorporates the medicine wheel when working with Native American clients. The medicine wheel is a sacred symbol used by many Indigenous tribes to represent all knowledge of the universe. It consists of a circle, divided by a horizontal and vertical line, with four colors (black, white, yellow and red). Each tribe interprets the medicine wheel differently.
In Hanks’ traditional teachings from her Ojibwe tribe, the medicine wheel operates as a way for Indigenous people to understand the world and their roles within it. “I have used it similar to a wellness wheel in helping clients identify where they need balance in their lives or finding ways to reconnect counseling concepts in a cultural framework,” she says. She also uses it to initiate conversations about grief and the cycles of life.
Although the medicine wheel is widely recognized among Native American populations, its use varies from tribe to tribe, Hanks says. For that reason, she cautions counselors to practice cultural humility and get training before incorporating the medicine wheel in their clinical practice. The same can be said about the use of any intervention that might speak more fully to a client’s culture but with which the counselor is largely unfamiliar.
Mejía urges counselors to be curious and culturally humble to ensure that they don’t fall prey to assumptions or black-and-white thinking about a culture. For example, in working with a teenage Latinx client, counselors shouldn’t automatically assume that the client is going to leave home to attend college. Instead, Mejía advises clinicians to slow down and consider: Why wouldn’t the client go away to college? What cultural factors might encourage the client to choose a college closer to home? What would it be like if the client did attend school away from home?
Striving to cultivate cross-cultural relationships
Ramos often uses narrative therapy to incorporate a client’s culture, family context and worldview — including their sense of spirituality — into treatment. She frequently uses Latinx cultural references, such as dichos y refranes (i.e., Spanish proverbs and sayings), to engage clients and make their culture and stories central to the session. For example, in a group format, Ramos may ask clients to share popular sayings used in their family, community or culture that relate to the dynamic the group is discussing. In the past, clients have mentioned dichos such as “El tiempo lo cura todo” (which is similar to “Time heals all wounds”) and “Dios aprieta, pero no ahorca” (which is similar to “When God shuts a door, he always opens a window”). This technique can help clients reconsider how they view themselves and their personal journeys, Ramos says.
Ramos doesn’t believe that counselors have to be proficient in Spanish to incorporate Spanish sayings into their practice. “The main point is always to use invitational language in the counseling setting to elicit the dichos and reflections from the client as a way to honor the cultural meaning the dichos might have for them,” she explains.
Ramos also focuses on cultivating the relationship from the second the client enters her office. In the United States, people have grown accustomed to filling out forms as soon as they enter a health facility, but that isn’t true for all cultures. Ramos points out that many Latinx cultures value personalism (i.e., person-to-person contact). So, she first gets to know her clients and discusses the forms with them rather than simply handing them the forms without any explanation.
Ramos has noticed that if she clearly explains the intake process to her clients who are immigrants or refugees, they are more willing to engage with the steps needed to get services. On the other hand, if she just hands these clients a form, they may hesitate to answer questions because they don’t fully know or trust her yet. Simply saying, “Welcome to the office. How did you find us?” or “How can we serve you today?” can be a nonthreatening way to start the conversation, Ramos suggests. “It doesn’t have to be a 30-minute intervention. It can be five to 10 minutes of explaining why they are here and what the process is,” she adds.
Counselors also need to be sensitive to literacy levels. Asking clients to fill out forms may cause anxiety or shame if they don’t know how to read or write in their native language, Ramos points out. Cultivating that relationship for the first 10 minutes before having them fill out forms can help put clients at ease. Ramos then asks clients whether they feel comfortable filling out the forms themselves or might prefer her support in doing that. This is a simple way to dismantle the shame around any literacy issues so that focus can be put on clients’ needs, she explains.
Recognizing the need for bilingual/bicultural training
Given the increased demand for counselors who are bilingual/bicultural, there is a corresponding need for counselor education to include more programs aimed at preparing counselors to be linguistically and culturally competent. Unfortunately, says Mejía, an ACA member whose research focuses on immigration and the training of bilingual/bicultural therapists, there are not many programs like this currently in the United States, and for the ones that do exist, there are no standards for this type of training.
Mejía noticed that many of the bilingual counseling students at CSUF lacked the support they needed during their practicum training. They rarely had bilingual/bicultural supervisors, and they often had to translate documents, forms and counseling terms on their own without any guidance, she recalls. “They’ve been learning all the [counseling] skills in English, and all of a sudden, they are expected to do it in a different language,” which was intimidating and challenging, she says.
In response, Mejía started and serves as the director of the Ánimo Latinx Counseling Emphasis program at CSUF. The program consists of five master’s-level courses focused on helping students become self-aware as bilingual and bicultural counselors, knowledgeable of Latinx cultures and therapeutic Spanish, and familiar with interventions appropriate to Latinx and Spanish-speaking clients. It also teaches counseling students about social justice advocacy for issues relevant to the Latinx community and allows students, depending on their proficiency, to practice speaking Spanish in a clinical setting.
Ánimo, which loosely translates to encouragement or spirit, is in its third year, and Mejía can already see the positive impact the program is having on the counseling students at CSUF. She frequently gets inquiries from students about the program, which speaks to the need for such training. But behind the program’s success is a harsh reality: It took 10 years of determination and dedication on the part of Mejía and her colleagues to receive the institutional support needed to bring the program to fruition.
Bilingual/bicultural training programs such as Ánimo also allow counseling students to support and learn from each other. The students in the program recently decided that they want to establish an Ánimo student group to build a supportive community for bilingual/bicultural counselors, which Mejía thinks is a wonderful idea.
Challenges faced by bilingual/bicultural counselors
Often, there is a cultural “tax” associated with being a bilingual or bicultural counselor. Mejía started the Ánimo program to help counseling students, but she doesn’t get consistent faculty release time (i.e., reduced teaching responsibilities to work on other projects) to fulfill duties related to the program, including training faculty, promoting the program, interviewing prospective students, attending meetings, and conducting exit interviews with graduating students. In addition, prospective and current students often seek her out — as director of the program — for advising and mentoring. Still, she finds a way to balance it all because as a first-generation college graduate herself, she knows how important these connections are and how valuable the program is to other bilingual/bicultural counselors.
Sometimes, colleagues and agencies may expect bilingual counselors to take on additional roles — including ones that might be outside their scope of knowledge or training. When Ramos was an in-home counselor, she would support clients by attending school or social services meetings with them. Those agencies didn’t always schedule an interpreter because they assumed she would operate as both the client’s interpreter and therapist. “That put me in a situation where my mind that I wanted to use for the emotional support of this family now had to be used for interpreting,” Ramos recalls. Interpreting itself can be taxing, she adds, so she had to set boundaries and assert that she needed an interpreter in certain situations so that she could successfully perform her true job as a counselor.
Luo says some of her bicultural counseling students find it difficult to establish boundaries in session. If a counselor feels personally connected to a client because they share a language or similar culture, a danger exists that the counselor could overidentify and self-disclose too much, she cautions.
Isolation can also be an issue for counselors who find themselves in a region or clinical practice in which they are the only ones who are bicultural or bilingual. All counselors can benefit from participating in support groups with other helping professionals, but bilingual/bicultural counselors have unique challenges that may require them to find support groups with clinicians who also share these struggles, Ramos says. For example, a bicultural counselor may have high caseloads of people whose immigration or socioeconomic status affects their ability to access the resources they need, which in turn may affect their well-being.
Of course, it may not be easy to find this support if counselors live in an area without much diversity. Ramos offers the following suggestions for connecting with other bilingual/bicultural professionals:
- Reach out to agencies within the community that provide mental health services to see if they have bilingual counselors on staff.
- Find organizations that provide services to immigrants and refugees and that focus on education and advocacy. Although these organizations may not concentrate solely on mental health, they do work to identify the needs and gaps in services for these populations, Ramos says. And counselors could collaborate with these organizations to build a resource network.
- Check with the counseling or social work departments at local universities and colleges to find alliances of refugees, immigrants or other minority groups.
- Attend online webinars and trainings, which are more widely available now because of the COVID-19 pandemic. These events will help counselors connect with other bilingual and bicultural providers.
Improving supervision for bilingual/bicultural trainees
One of Mejía’s motivations for starting the Ánimo program was the lack of available supervisors who are culturally and linguistically competent. A supervisor’s lack of cultural competency is a barrier for counselors-in-training, Mejía asserts. Students often tell her they feel unheard or overlooked when their supervisor doesn’t understand an issue they have as a bicultural counselor or as a counselor working with a client from a different culture.
Mejía also gets frustrated when supervisors ask their trainees to translate another colleague’s session or the clinic’s forms or to answer the phones because they are bilingual. Trainees are not compensated for this work, and these tasks don’t count toward their clinical hours, she points out. Mejía often asks supervisors, “Would an English-speaking trainee be required to do this?”
Ramos has noticed that bilingual/bicultural counselors-in-training tend to dismiss their own feelings and challenges when they don’t have a supervisor who is culturally competent. They may think that they are the only ones dealing with an issue and hesitate to bring up their concerns with their supervisor. “Having a supervisor who can relate culturally with the population you are serving can fill the gap needed in support for the counselor,” she says.
As Hanks observes, it can be challenging for supervisors and counseling professionals who have been in the field for a long time to admit that they don’t know something. But taking a reflective and humble approach to supervision helps bicultural counselors to feel seen and heard, she says.
Hanks recalls a positive experience she had with a supervisor who was curious and didn’t make assumptions. While working in a youth shelter, Hanks was approached by a Native American child because she assumed that Hanks, who is also Native American, would better understand her. Hanks’ supervisor didn’t address the situation by telling her to set better boundaries. Instead, the supervisor said, “I noticed this one child is really close to you. Tell me more about it. Tell me what you think is going on. What do you think about it clinically?” Those questions led to a productive conversation about Hanks’ therapeutic relationship with the client.
Luo has always had supervisors who were culturally different from her, and none of them asked about how their cultural difference affected the dynamics of supervision. Luo encourages supervisors to be the ones to initiate these conversations rather than waiting for trainees to bring up the topic. Now as a supervisor herself, Luo makes a point to always address culture with her supervisees. For example, she might say, “As you have probably noticed, we come from different cultural backgrounds. Do you want to talk about how these cultural factors affect our relationship?”
Bridging cultural differences
In Milwaukee, Mark Denning of the Oneida Nation created the program Unity Fire to address challenges related to the COVID-19 pandemic and social justice struggles. The program is open to the public and uses Native American customs to help unite communities during a time when many people feel isolated, unheard and unsafe.
Hanks attended a unity fire held during the protest over the killing of George Floyd and remembers it being heavy with emotion. The firekeepers taught those attending how to offer a prayer into the fire using traditional sacred medicines. “There’s space at these fires for [cross-cultural] connection,” Hanks says. “That’s why they call it the ‘unity fire.’ It’s all about people uniting again.”
Ramos’ agency — The Women’s Initiative — aims to create community partnerships. Its Bienestar program provides counseling in Spanish to Latinas and connects Latinx children and men with bilingual providers in the community. It also offers workshops and presentations centered on Latinx cultural values and resiliency, mental health issues, and cultural barriers that this population often faces.
Staff members at The Women’s Initiative also offer support groups for immigrant and refugee women. For example, Ramos led a basket weaving group, which for many clients was a way to connect a culturally significant craft with emotionally relevant concepts such as change, disappointment and resilience.
The Women’s Initiative also partnered with the International Rescue Committee and Hyojin Im, an associate professor in the School of Social Work at Virginia Commonwealth University and an expert on mental health services and refugee communities, to host trauma-informed cross-cultural psychoeducation (TICCP) leadership training for immigrant and refugee communities in Charlottesville. The TICCP program offers a series of workshops that teach bilingual leaders in these communities about the mental health impact of refugee and immigrant trauma and cultural adjustments to a new country.
TICCP has been a way to bring immigrant and refugee communities together and to create leaders within those communities from which others can learn about mental health, Ramos notes. These leaders “can help to make referrals and to deal with the stigma around mental health,” she adds.
Ramos loves connecting bilingual/bicultural therapists with immigrant and refugee communities and empowering these communities to be active participants in their own mental health. “Whenever I can bridge that gap [between cultures], I like to do it,” she says, “because I know it means a client or family will receive a better service.”
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.