Closing the gap for Latino patients

By the year 2010, one in five Americans will identify as Hispanic--with cultural ties to Spanish-speaking countries such as Mexico, Cuba and El Salvador. In some areas of the country, such as Texas, Hispanics may outnumber Caucasians by 2035, according to the U.S. Census Bureau. As this population grows, psychologists can expect to see increasing numbers of Latinos in their waiting rooms, classrooms and research labs (see page 68).

But for many Hispanics who seek psychotherapy, their first contact with a mental health professional is also their last--50 percent never return to a psychologist after the first session. Caucasians drop out at a rate of about 30 percent, in comparison. Several factors play into this access disparity--including the cost of health care for a disproportionately low-income population (see page 62)--though many Latinos quit therapy simply because they do not feel understood, says Elizabeth Fraga, PhD, a Latino-focused practitioner and full-time lecturer at Columbia University's Teachers College.

"Some Hispanics are not completely comfortable [speaking] in English," says Fraga. "And sometimes the values of psychotherapy--or the therapist--are antithetical to those of the Hispanic client."

For example, says Fraga, Latino cultures tend to value a family's health more than that of its individual family members and may view a psychologist's suggestions for self-care--such as taking a short vacation alone--as selfish.

Psychologists can avoid such pitfalls by learning about the cultural framework that Hispanic clients may bring to therapy, notes John Gomez, PhD, a psychology professor at Our Lady of the Lake University in Texas and the evaluation director of the university's Communicative and Cultural Competency for Mental Health Providers program. Learning to speak Spanish also helps, he says.

"Unfortunately, there are not many Latino psychologists," Gomez says--only about 1 percent of all U.S. psychologist practitioners identify themselves as Latino. "But you don't have to be Latino to be helpful."

Indeed, researchers are beginning to discover ways practitioners can better serve their Hispanic clients. As yet, the field lacks a volume of research that compares psychological interventions tailored to Latino clients with therapy as usual, Gomez says. However, encouragingly, qualitative research and some preliminary findings suggest that the strategic use of Spanish--even with English-fluent Latino clients--and couching interventions in Latino values may improve therapy, and could put a dent in that 50 percent dropout rate.

Speaking the mother tongue

While most Latinos who live in the United States know both English and Spanish, many recent immigrants and older adults feel more comfortable speaking their native language, according to the 2000 census. Even Latinos fluent in English may find it easier to recount episodes from their early childhoods or talk about emotions in their mother tongues, research suggests.

In one early study, published in the Journal of Psycholinguistic Research (Vol. 22, No. 3), researchers found that adult bilingual participants who spoke Spanish as children provided more detail in Spanish than in English when talking about their childhoods--potentially providing more insights to practitioners. For example, in Spanish one participant recalled walking in a forest, thinking, "Wow...you just see all the different colors and the different types of barks on the trees...and you just listen to all the crisp [sounds] of the leaves as you walk through." When telling this same story in English, the participant used less colorful language: "I took a long walk through the woods...and I was just gazing upon the beauty of what nature has."

"The reason for that is you spend parts of your life organizing and talking about living an experience in one language, and that language becomes connected with that experience," says one of the study's authors, Rafael A. Javier, PhD, a psychology professor at St. John's University in New York.

A more recent study, published in the October 2003 International Journal of Bilingualism (Vol. 7, No. 3), found that individual words in bilingual people's first language may have richer meanings for them. In this study, 63 bilingual college students read a list of 315 words in English and the same 315 words translated into Spanish. The list included emotion words, such as "love," abstract words like "liberty," and concrete words such as "table." After reading each word, the participants attempted to summon an image relating to the word and ranked their ability to do so on a seven-point scale. The researchers then compared these scores with those from an earlier study in which participants rated those same words in English.

After reading an emotion word in Spanish, the participants found it easier to visualize a related scene than when the emotion word was in English. Concrete and abstract words lent themselves equally to association, whether they were in English or Spanish.

The finding suggests that Latino clients may more easily tap into their emotions when they talk about them in their first language, says study author Jeanette Altarriba, PhD, a psychology professor and associate dean for academic affairs for the College of Arts and Sciences at the University at Albany of the State University of New York. Conversely, when bilingual clients switch into English while in a session, they may be trying to distance themselves from their emotions, she says.

Given these findings, a practitioner may want to encourage Latino clients to switch between languages, says Altarriba. Even if the psychologist is not bilingual, he or she can glean the emotional content of a story, notes Altarriba, and allowing patients to speak passionately in Spanish can serve as an emotional release.

"I would not want to convey that a monolingual therapist cannot help bilingual people," says Altarriba. "But [monolingual therapists] should know that language switching has a logic to it."

Values in action

While speaking Spanish may not be necessary for working with bilingual Hispanic clients, understanding common Latino values can be crucial, says Fraga.

In an as-yet-unpublished study, Fraga surveyed 107 Latino students receiving therapy from a university counseling center. With a written survey, she asked them how ethnically and culturally similar their therapists were to them and how satisfied they were with their first sessions. Fraga found that satisfaction with a therapist hinged on how well the Hispanic client felt the therapist understood Latino culture, but not on the therapist's ethnicity.

With so few practicing psychologists identifying as Latino, "this is great news because it's difficult to give clients an ethnic match," she says.

Training practitioners to be conversant in Hispanic values could prove easier than finding Latino therapists, Fraga notes. Some of these values include family-centeredness, or "familism," and the tendency to aim for harmony in personal relationships, or "simpatia" (see box, page 59), according to researchers such as Patricia Arredondo, EdD, a psychology professor at Arizona State University, and Israel Cuellar, PhD, a psychology professor at Michigan State University.

Familiarity with such values can help therapists understand their Latino clients, notes Altarriba.

"If you come from a society that highly values individualism, you may not think as a therapist to include the family, to ask questions about the family or to interview family members," Altarriba says.

When practitioners appreciate the importance of a client's family, they can suggest interventions in league with clients' values, she says. For example, instead of suggesting an overworked mother take time out for herself, a practitioner may want to emphasize that by resting, the client will have more energy for her family.

Practitioners may also want to avoid asking Latino clients to directly confront people with whom they have personal relationships. Some Latinos prefer to express their feelings more subtly, perhaps though indirect language, and practitioners can help their clients find ways to communicate that do not chafe their deeply held beliefs about the centrality of interpersonal harmony, says Gomez.

However, cautions Altarriba, Hispanic individuals vary widely in their values and beliefs--understanding a client's cultural background serves only as a starting point. And having this knowledge will become increasingly important as the U.S. Latino population continues to grow, she notes.

"If you don't have therapists who have some familiarity with Latino culture and language--or an interest in becoming familiar with it--it is going to be difficult for Latinos to find people who can aid them," says Altarriba.