Successful therapeutic relationships are built on trust and understanding so that counselors can hardly afford to have words and phrases "lost in translation". The cultural competence of the consultants is also of crucial importance, especially as the clients become more and more linguistically and culturally diverse.
According to the 2019 American Community Survey conducted by the US Census Bureau in 2019, 22% of US households speak a language other than English at home, and 13.5% speak Spanish. And that number will only increase in the years to come. The Instituto Cervantes estimates in its 2019 Yearbook of the Spanish World that by 2060 almost one in three Americans will be of Spanish descent. This makes the United States the second largest Spanish-speaking country in the world after Mexico. The Pew Research Center estimates that 19% of Americans will be born overseas by 2050, up from 12% in 2005. It is estimated that 82% of US population growth will come from immigrants and their descendants.
The counseling profession emphasizes cultural competence, but there is evidence that the overall mental health arena is not keeping pace with the growing demand for bilingual and bicultural services. According to survey results published in 2016 by the American Psychological Association, approximately 10.8% of US psychologists reported being able to provide services in a language other than English, while only 5.5% can provide services in Spanish.
This lack of culturally literate services can affect people's mental health. “If customers can't find a bilingual advisor, they become more isolated. Often they don't talk about their emotional problems because they don't feel like they are being seen or understood on a linguistic or cultural level, ”says Ingrid Ramos, licensed professional advisor (LPC) and director of the Bienestar (wellness) and resilience programs at the women's initiative in Charlottesville, Virginia. "Then you will see a worsening of symptoms."
In order to better meet the needs of bilingual and bicultural clients, psychiatrists themselves have to become more culturally competent. This goes beyond simply speaking another language or recognizing cultural differences. Clinicians need to be prepared to offer bilingual services and to practice cultural humility, which requires better facilities and supervision for bicultural / bilingual training and supervision.
Find the right words
Language is central to counseling as it enables clinicians to build relationships and better understand clients' life experiences, thoughts and behaviors. However, mastering the client's mother tongue is often not enough to make a consultant linguistically competent. Olga Mejía, Associate Professor of Counseling at California State University at Fullerton (CSUF), admits that mental health terminology is not always translated. She often tells her counselors, "There's Spanish and then there's therapeutic Spanish."
Although Spanish is Mejia's first language, she admits that she felt lost during her first clinical position after completing her PhD program. Her clients and colleagues alike assumed that she could easily offer mental health sessions in Spanish, but she made an effort to translate certain technical terms such as confidentiality and the cycle of violence.
That's because the process is not as simple as translating the words and phrases directly, explains Mejía. A direct translation often fails to take into account the cultural context and the nuances between languages. Therefore, she advises her counseling students to translate the idea behind the terms rather than looking for the perfect word. For example, even if there is no word-for-word match for boundaries in the client's language, a counselor can explain that people often set rules or boundaries in relationships.
According to Ye (Agnes) Luo, an assistant professor of counseling at the University of North Texas, it can be difficult to explain what a counselor is and how it differs from a psychologist because some languages like Mandarin use the same word to describe both professions. And certain countries may not differentiate these roles the way the United States does, she adds.
Luo, a member of the American Counseling Association and LPC in Texas who speaks both Mandarin and English, has learned that she cannot simply ask clients if they understand what counseling is because the client's understanding of counseling is may differ from their own. For example, she has worked with clients in Asian countries who expect consultants to prescribe something to "fix" their presentation problems. These clients see her as an authority figure rather than a collaborative process, she notes.
Interpreters also need to be aware of the nuances associated with the way mental health professionals speak. Ramos advises counselors who use interpreters to discuss the therapeutic process with them before going to the session. "Our communication is our tool," says Ramos. "How we say things, how we ask questions, how we think back to the customer – that is the advisory measure." It is therefore important that interpreters understand how to communicate this way when translating for customers, she emphasizes. For example, an interpreter might inadvertently misrepresent a counselor's reflective statement by telling the client, "The counselor is repeating what you just said" instead of translating the reflective statement.
Medical interpretation can feel more transactional, but because counseling involves emotional disclosure and vulnerability, it requires a certain tone and range of communication skills, continues Ramos, who serves on the board of Creciendo Juntos, an organization that provides support and resources serves Latinx families and Latinx organizations in the cities of Charlottesville and Albemarle Counties. Because of this, the Virginia Department of Behavioral Health and Developmental Services distinguishes between medical and mental health interpreting, she says. For example, the agency emphasizes the importance of meeting mental health counselors and interpreters before a session, while recognizing that this is not always necessary in medical settings.
Consultants also need to be able to talk to clients about their bilingual language skills, advises Luo, a consultant at C2 Counseling in Corpus Christi, Texas. While looking for her personal advisor, she found a clinician who applied to be bilingual in Mandarin and English. But in their first session together, counselor Luo asked if it was okay for her to speak in English, not Mandarin, because she had never used Mandarin in a clinical setting. Luo gave in, but it wasn't the experience she wanted or expected.
Cultural competence and humility
Consultants must take into account the client's country of origin, not just the client's language. "Language matters," notes Mejía, a bilingual and bicultural licensed psychologist. "But [clinicians] must have the language with cultural competence or cultural sensitivity along with cultural humility." For example, in Spanish, knowing when and how to use tu and usted (both words for you) changes based on age, gender, seniority, and familiarity. If counselors do not have the cultural understanding of this distinction, it could affect their relationship with the client and the client will not be 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 literacy can also have serious implications, including possible misdiagnosis. Some of Hanks' Native American clients have told her that other mental health professionals have previously mistakenly diagnosed her as schizophrenia or depression with psychotic traits because they mentioned seeing ghosts or being guided by ancestors during a traditional ceremony. Counselors need to listen to the client and learn about their culture in order to determine exactly what is culture related and what is clinically meaningful, she emphasizes.
"A big part of [cultural humility] is understanding the story of where you are and what that means," says Hanks, an ACA member who wrote the article, "One Collective Voice: Resilience of Indigenous Peoples and One Appeal to the Legal Profession "Co-Authorized," Published on CT Online in February 2020. She advises counselors to learn the history of the places where they live and work first, as that history, when combined with current guidelines, will affect clients.
Since Ramos, originally from the Dominican Republic, often works with clients from Mexico and Central America, she brings a sense of cultural humility and curiosity to her session. 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 this phrase mean in your country?" If she still does not fully understand what the client is trying to convey, she will dig deeper and ask what the term means in her community or family.
"As a bicultural counselor, it's important to remember that each culture has its own way of talking about symptoms, illness and treatment," says Ramos. To gain a better understanding of the problem at hand, she asks customers how they understand or see the problem and how their culture sees their symptoms or behaviors. She also asks how people in her culture usually deal with these symptoms or behaviors.
Since Native American wellness approaches are often about finding balance, Hanks, Anishinaabeg, who is enrolled in the White Earth Nation in Minnesota, sometimes uses 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 about the universe. It consists of a circle divided by a horizontal and vertical line of four colors (black, white, yellow and red). Each tribe interprets the medicine wheel differently.
In Hanks' traditional teachings of their Ojibwe tribe, the medicine wheel serves the indigenous peoples to understand the world and their roles in it. "I've used it much like a wellness wheel to help clients figure out where they need balance in their lives or find ways to reconnect counseling concepts in a cultural setting," she says. She also uses it to initiate conversations about grief and the life cycles.
Although the medicine wheel is widely recognized among the Native American people, its use varies from tribe to tribe, says Hanks. For this reason, she cautions counselors to practice cultural humility and get trained before incorporating the medicine wheel into their clinical practice. The same goes for using interventions that may be more responsive to a client's culture, but with which the counselor is largely unfamiliar.
Mejía urges counselors to be curious and culturally humble to make sure they don't fall victim to assumptions or black and white thinking about a culture. For example, when working with a teenage Latinx client, advisors shouldn't automatically assume the client is leaving to go to college. Instead, Mejía advises clinicians to slow down and think: Why shouldn't the client go to college? What cultural factors might encourage the customer to choose a college close to home? How about if the client didn't go to school at home?
Striving to maintain intercultural relationships
Ramos often uses narrative therapy to incorporate a client's culture, family context and worldview – including their sense of spirituality – into treatment. She often uses Latinx culture references like Dichos y Refranes (i.e. Spanish Proverbs and Sayings) to engage clients and put their culture and stories at the center of the session. For example, in a group format, Ramos can ask clients to share popular sayings that are used in their family, community, or culture that relate to the dynamic the group is talking about. In the past, customers have mentioned dichos like “El tiempo lo cura todo” (similar to “Time heals all wounds”) and “Dios aprieta, pero no ahorca” (similar to “When God closes a door”). it always opens a window ”). This technique can help customers rethink their point of view and personal journeys, says Ramos.
Ramos does not believe that counselors need to be proficient in Spanish in order to use Spanish sayings in their practice. “The main point is always to use the invitation language in the counseling environment to evoke the client's dichos and reflections, to appreciate the cultural significance the dichos might have for them,” she explains.
Ramos also focuses on nurturing the relationship from the moment the client walks into her office. In the US, people have gotten used to filling out forms as soon as they enter a healthcare facility. However, this does not apply to all cultures. Ramos points out that many Latinx cultures value personalism (i.e., person-to-person contact). So she gets to know her customers first and discusses the forms with them instead of just giving them the forms without explanation.
Ramos has found that when they clearly explain the reception process to their customers, who are immigrants or refugees, they are more willing to engage in the steps necessary to receive services. However, if she just hands out a form to these customers, they may be reluctant to answer questions because they don't yet fully know or trust her. To put it simply: “Welcome to the office. How did you find us? ”Or“ How can we serve you today? ”Can be a non-threatening way to start the conversation, suggests Ramos.“ It doesn't have to be a 30 minute intervention. It can take five to ten minutes to explain why you're here and how the process works, ”she adds.
Counselors must also be sensitive to the level of literacy. Asking customers to fill out forms can cause fear or shame if they cannot read or write in their native language, emphasizes Ramos. Maintaining this relationship for the first 10 minutes before filling out forms can help reassure customers. Ramos then asks the customers whether they would like to fill out the forms themselves or whether they would prefer their support. This is an easy way to reduce the shame of literacy problems so that the focus can be on customer needs, she explains.
Recognition of the need for bilingual / bicultural training
Given the increased demand for bilingual / bicultural counselors, there is a corresponding need for counselor training to include more programs that aim to prepare counselors for linguistic and cultural competence. Unfortunately, says Mejía, an ACA member whose research focuses on immigration and bilingual / bicultural therapist training, there aren't many programs of this type currently in the U.S., and for those that do, there are no standards for them Type of training.
Mejía noted that many bilingual counseling students at CSUF lacked the support they needed during their internship training. They rarely had bilingual / bicultural supervisors and often had to translate documents, forms and advice terms themselves without guidance, she recalls. "They all learned [counseling] skills in English and suddenly they are expected to do it in another language," which was intimidating and challenging, she says.
In response, Mejía started and directed the Ánimo Latinx Counseling Emphasis program at the CSUF. The program consists of five master's courses designed to help students become self-confident as bilingual and bicultural counselors who are familiar with Latinx cultures and therapeutic Spanish, and who are familiar with interventions appropriate for Latinx and Spanish speaking clients. It also provides advice to students on advocating for social justice on issues relevant to the Latinx community and allows students to practice speaking Spanish in a clinical setting depending on their level of proficiency.
Ánimo, loosely translated into encouragement or spirit, is in his third year and Mejía can already see the positive impact the program is having on the counseling students at CSUF. She frequently receives inquiries from students about the program, indicating the need for such training. However, behind the success of the program lies a harsh reality: it took 10 years of determination and dedication from Mejía and her colleagues to obtain the institutional support needed to make the program a reality.
Bilingual / bicultural training programs like Ánimo also enable counseling students to support and learn from one another. The students on the program recently decided to create an Ánimo student group to build a supportive community for bilingual / bicultural counselors, which Mejía thinks is a wonderful idea.
Challenges for bilingual / bicultural counselors
There is often a cultural “tax” associated with being a bilingual or bicultural counselor. Mejía started the Ánimo program to help advise students, but she is not given a consistent release time for the faculty (i.e., reduced teaching responsibility for working on other projects) to complete the duties associated with the program, including training Faculty, promoting the program and interviewing prospective students, attending meetings and conducting exit interviews with graduates. In addition, prospective and current students often visit her as a program director for advice and support. Still, she finds a way to balance it all because, as a first generation college graduate, she knows how important these connections are and how valuable the program is to other bilingual / bicultural counselors.
Sometimes colleagues and agencies expect bilingual consultants to take on additional roles – even those that are outside their area of knowledge or training. When Ramos was a counselor at home, she supported clients by attending school or social gatherings with them. These agencies did not always include an interpreter as they assumed she would act as both interpreter and therapist for the client. "That put me in a situation where my mind, which I wanted to use for the emotional support of this family, now had to be used for interpreting," recalls Ramos. Interpreting itself can be exhausting, she adds, so she had to set boundaries and claim that in certain situations she needed an interpreter in order to successfully carry out her true job as a consultant.
According to Luo, some of her bicultural counseling students find it difficult to set boundaries in the session. If a counselor feels personally connected to a client because they share a language or similar culture, there is a risk that the counselor will identify too much and reveal himself, she warns.
Isolation can also be a problem for counselors who are in a region or clinical practice where 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 face unique challenges that may require finding support groups with clinicians who share those struggles as well, says Ramos. For example, a bicultural counselor may have a large number of people whose immigration or socio-economic status affects their ability to access the resources they need, which in turn can affect their wellbeing.
Of course, it may not be easy to find this support when counselors live in an area without great diversity. Ramos offers the following suggestions for contacting other bilingual / bicultural professionals:
Check with agencies within the community that provide mental health services to see if there are bilingual counselors on the staff.
Find organizations that provide services to immigrants and refugees that focus on education and advocacy. While these organizations may not just focus on mental health, they are working to identify the needs and gaps in services for these populations, says Ramos. And consultants could work with these organizations to build a resource network.
Contact the counseling or social work departments of local universities and colleges to find alliances of refugees, immigrants, or other minority groups.
Take part in online webinars and training courses that are now more available due to the COVID-19 pandemic. These events will help counselors connect with other bilingual and bicultural providers.
Improvement of supervision for bilingual / bicultural trainees
One of Mejía's motives for starting the Ánimo program was the lack of available supervisors who are culturally and linguistically competent. A manager's lack of cultural competence is an obstacle to training counselors, claims Mejía. Students often tell her that they feel unheard or overlooked if their supervisor does not understand a problem they have as a bicultural counselor or a counselor working with a client from another culture.
Mejía is also frustrated when supervisors ask their trainees to translate another colleague's meeting or the clinic's forms or to answer the phones because they are bilingual. Trainees are not compensated for this work, and these tasks do not count towards their clinical hours, she points out. Mejía often asks superiors: "Would an English-speaking trainee be obliged to do this?"
Ramos found that bilingual / bicultural counselors in training tend to reject their own feelings and challenges unless they have a manager who is culturally competent. They may think that they are the only ones dealing with a problem and they may be reluctant to raise their concerns to their manager. "A manager who is culturally related to the population you serve can fill the void needed to assist the counselor," she says.
As Hanks notes, it can be a challenge for long-time supervisors and consultants to admit they don't know. A reflective and humble approach to oversight helps bicultural counselors feel seen and heard, she says.
Hanks remembers a positive experience with a manager who was curious and made no assumptions. While working in a youth home, Hanks was approached by a Native American child because she believed that Hanks, who is also Native American, would understand her better. Hanks' supervisor did not address the situation by telling her to set better boundaries. Instead, the manager said, “I noticed that this one child is very close to you. Tell me more about it. Tell me what you think is going on What do you think about it clinically? “These questions led to a productive conversation about Hanks' therapeutic relationship with the client.
Luo always had supervisors who were culturally different from her, and none of them asked how their cultural difference affected the dynamics of supervision. Luo encourages supervisors to initiate these conversations instead of waiting for trainees to bring up the topic. Now as a supervisor, Luo attaches great importance to always addressing the culture with her supervisees. For example, she might say, “As you have probably noticed, we have different cultural backgrounds. Would you like to talk about how these cultural factors affect our relationship? "
Bridging cultural differences
In Milwaukee, Oneida Nation's Mark Denning launched the Unity Fire program to address the challenges posed by the COVID-19 pandemic and the struggles for social justice. The program is public and uses Native American customs to unite communities at a time when many people feel isolated, unheard, and insecure.
Hanks participated in a unit fire held during the protest against the assassination of George Floyd and recalls that it was full of emotion. The firefighters taught attendees how to use traditional sacred medicines to bring a prayer into the fire. "There is room for a connection in these fires [cross-cultural]," says Hanks. "That's why they call it the 'fire of unity'. It's just about people reuniting."
Ramos & # 39; Agency – The Women's Initiative – aims to build community partnerships. The Bienestar program provides Latinas counseling in Spanish and connects Latinx children and men with bilingual providers in the community. It also offers workshops and presentations that explore Latinx's cultural values and resilience, mental health issues, and cultural barriers that this population often faces.
Employees of the women's initiative also offer self-help groups for migrant and refugee women. For example, Ramos headed a basket weaving group that offered many customers an opportunity to combine a culturally significant craft with emotionally relevant concepts such as change, disappointment and resilience.
The Women's Initiative also worked with the International Rescue Committee and Hyojin Im, an associate professor at the Virginia Commonwealth University School of Social Work and an expert on mental health services and refugee communities, to host a trauma-informed cross-leadership training for Cultural Psychoeducation (TICCP) for immigrant and refugee communities in Charlottesville. Das TICCP-Programm bietet eine Reihe von Workshops an, in denen zweisprachige Führungskräfte in diesen Gemeinden über die psychischen Auswirkungen von Traumata von Flüchtlingen und Einwanderern sowie über kulturelle Anpassungen in einem neuen Land unterrichtet werden.
TICCP war ein Weg, um Einwanderer- und Flüchtlingsgemeinschaften zusammenzubringen und Führungskräfte in diesen Gemeinschaften zu schaffen, von denen andere etwas über psychische Gesundheit lernen können, bemerkt Ramos. Diese Führer "können helfen, Empfehlungen abzugeben und mit dem Stigma der psychischen Gesundheit umzugehen", fügt sie hinzu.
Ramos liebt es, zweisprachige / bikulturelle Therapeuten mit Einwanderer- und Flüchtlingsgemeinschaften zu verbinden und diese Gemeinschaften zu befähigen, aktiv an ihrer eigenen psychischen Gesundheit teilzunehmen. "Wann immer ich diese Lücke schließen kann [between cultures]mache ich es gerne", sagt sie, "weil ich weiß, dass ein Kunde oder eine Familie einen besseren Service erhalten wird."
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Lindsey Phillips ist Autorin von Counseling Today und UX-Content-Strategin. Kontaktieren Sie sie unter [email protected] oder über ihre Website unter lindseynphillips.com.
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