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How to Create Cultural Competency in working with Latino Clients
2007: Heather Finkel, Ph.D., Psychology Resident at FOCUS Women’s Resource Center,
Charlottesville, VA, Heather@DoctorFinkel.com, 434-825-3656.
Four important values in Latin-American culture, are: Honor, Respect, Dignity, Warmth.
These values will be the organizing feature of my recommendations today.
My Work History
I worked in San Diego, California as a psychology intern for 3 years working with
Spanish speaking families, individuals, children, adolescents, and groups. I conducted
domestic violence groups in Spanish for Spanish Speaking men who were court ordered
to domestic violence treatment groups. I volunteered as a Mental Health Disaster
Services Worker after Hurricane Katrina working in shelters with Spanish speaking
evacuees. And now, as a psychology resident, currently conduct Spanish Speaking
psychotherapy at FOCUS Women’s Resource Center here in Charlottesville, working
with Women, Men, children, and adolescents.
Client Demographics
FOCUS is a low fee therapy clinic that charges only $10-$65 per session, depending on a
client’s income. The clients I see pay $10-$30 per session; most of my clients report
earning between $8,000 and $20,000 per year. Some have no income and depend on
family members’ support. Almost all of my Spanish Speaking clients are in the United
States illegally. Set fees that are affordable for the clients you hope to see. Aside from
Region 10, the next lowest priced Spanish Speaking psychotherapy is $75 per session,
and then $90 per session, which would likely be cost prohibitive for most of my Spanish
Speaking clients.
Cultural competency begins before you even meet your client.
How can you show your Spanish Speaking and Latino clients honor and respect and treat
them with dignity even before you start to work with them in person?
Bilingual Outreach and Advertisement
I obtained referrals and direct client calls from bilingual fliers posted at every Latino
Grocery store and restaurant (and restaurants the employ many Latino workers), from Emails, from referrals from medical professionals, from a News Paper article about my
services, and from referrals from current clients? It is important to make your services
known to people both in English and Spanish. If the referral source is not Spanish
Speaking, he/she can read the English version of the advertisement and then provide the
Spanish version to the prospective client.
First Call Spanish or English: Receptionist &Voice Mail Greeting &/or Separate #
Even if you do not speak Spanish but will be serving Spanish speaking clients with an
interpreter, you would show respect to your Spanish speaking clients by doing the
following (and the same goes for bilingual fliers):
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When the client calls in, do they speak with an exclusively English-speaking receptionist
or is the receptionist trained in how to say, “Welcome to FOCUS, One moment please. I
will connect you with someone who speaks Spanish.” If you do train someone in, make
sure to test the system out by having Spanish Speaking people that are demographically
similar to the people you expect to be calling in do several practice calls. We did this and
nobody got through to me. They all hung up as soon as they heard the receptionist answer
in English. The voice mail system needs to be bilingual as well, from very early on in the
greeting. You can announce, “welcome to FOCUS” then state, in Spanish “this message
will repeat itself in Spanish” or “If you speak Spanish, please press 2.” Many Spanishspeaking people who don’t speak English will give up or get confused with all the high
phone technology and choices. If possible, have a separate number designated for
Spanish Speaking callers, where the person answering is bilingual and the greeting is
bilingual. I called about 6 different agencies that claim they provide services to Spanish
Speaking individuals (sometimes exclusively to Spanish Speaking individuals) and 5 of
them had English-only greetings.
Schedule (PM hours)
Many of the Spanish Speaking clients I work with have jobs that are very important for
their survival and for the survival of dependant others (both here and in other countries).
They have strong work ethics and do not want risk loosing their jobs over leaving early or
coming late on a weekly basis due to psychotherapy appointments. I have found that it is
very difficult for many of my clients to attend sessions earlier than 4:00, so I recommend
designating one or two (or more) evening hours from 4:00 PM to 9:00 PM (some clients
are even willing to attend a 9:00 PM appointment which ends at 9:50PM).
Getting to the office the first time
Honor, respect, dignity and warmth are important cultural values in Latino culture.
The directions to the office can be difficult for people who live far away or are not
familiar with the street names in Charlottesville. One clients, who comes from one and a
half hours away only knew where U.Va. medical center was, so I met her at the piano in
the hospital lobby. We walked to our cars in the parking garage together, and she
followed me to the office. Driving Directions to Focus are not very easy, and it is
difficult to find the correct door on the outside of our building (the IX building). Once
you do find the correct door, it is a long walk down several different hallways before
coming to our waiting room. So, I meet my Spanish speaking clients at the curb side
for their first appointment, near the door, then walk them into the building down long
halls so they learn, on their first visit, how to get there. When the culture, city, and
experience of being in therapy is so foreign to many Spanish Speaking-only people, I
think this act of meeting clients at the curb side for the first visit, creates a sense of
comfort and is a warm act of compassion. It is also a way of treating someone with
dignity, caring, honor, and respect. This can be important in beginning the
therapeutic alliance, especially for the many Latinos who, after coming to the USA
with pride in their country and cultural heritage, find out that they are part of an
oppressed ethnicity and/or culture here in the USA.
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Waiting Room and Office Décor: Colors, Artwork, Magazines
In your waiting room and office, are there colors, artwork, magazines, (maybe even
music) that reflect the culture or cultures of those whom you see for therapy? Is it white
walled and clinical feeling or have you created warmth as well as respect for Latino
culture through the colors, throws, artwork, carpets, and other decor? Are you sitting
with a desk between you and the client/patient creating a feeling of your own superiority
and the sense of distance and an obstacle between the client/patient and therapist?
Forms, Literacy
Are the forms you have them fill out in Spanish or in English? Can they read? If not, be
prepared to take extra time with each client to explain each part of each form and to fill
them out for the client.
Distrust: Vagueness, conflicting information
Make sure confidentiality is thoroughly explained. There may be a sense of distrust in
the system, in you as a therapist, in you as a clinic or agency. Are you going to report
them to the authorities and get them deported, if they are illegally here? Try not to get
bogged down by conflicting testimony, dates, places, or events. Vagueness may be an
attempt to conceal undocumented status or information that could get their correct
identities on a deportation list. It may be difficult for a recent immigrant to understand
their rights and how to interact with authorities such as the police, when in their country
of origin the police and judicial system may have been corrupt left people with the best
option of running away from the police if at all possible (after a car accident or
whenever).
Native/First Language is best for therapy
It is important to conducting therapy in one’s native language, if possible.
It is much easier to talk about socially taboo topics in a foreign language b/c there is no
emotion connected with the words we are using. It’s easier to feel the emotions that are
connected to the words one uses if speaking in one’s native language.
Imagine saying in your first language, “I need my Mommy” and then think of saying it in
a foreign language, “Necesito mi Mama.” When you say it in the language that is not
your native language, it doesn’t feel as gratifying or emotionally powerful.
Summary: Warmth, Honor, Respect, and treating people with Dignity will put you well
on the road to improving your cultural competency. Next I will talk about therapeutic
tools that are helpful and useful in working with the Latino clients I have seen, and then
about illnesses that occur in Latino cultures and not in most other cultures. You can find
a list of Culture Bound illnesses (all cultures have illnesses that are only found in their
culture) on the internet if you Google “index of culture bound syndromes.”
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Trends I’ve noticed
I have noticed 7 Cultural trends in the Spanish Speaking adults I see.
I will now discuss each trend.
Trend 1: (Depression vs. PTSD [post traumatic stress disorder])
Men come in thinking they have depression or a mood disorder, and actually are
suffering from PTSD due to severe physical abuse and trauma in childhood and/or early
adulthood.
Trend 2: (Severe DV [Domestic Violence] History)
Women and Men come in who are in or have been in severely domestically violent
relationships.
Trend 3: (“Bad Character”)
Women and men who come in reporting they have a “bad character.” The first time I
heard a client state that she had a “bad character,” I thought she must be referring to a
personality disorder. However, within a couple of minutes of inquiry, I realized that this
meant she experiences “anger management difficulties,” and no personality disorder was
observed. Many of my Spanish Speaking clients report one of the primary two goals of
therapy is to work on anger management.
Trend 4: (Externalization vs. internalization of blame – AM [anger management])
In the context of Anger Management, I have found more willingness among Latino
clients to take responsibility for one’s anger management difficulties rather than to blame
external sources or people. My Latino clients appear to be more invested in working on
themselves to heal, learn new tools and skills, and to get better. My English-speaking
clients with A.M. issues definitely externalize blame quite a lot.
Trend 5: (Leaving children behind)
I also see the trend of women who have left children behind (with extended family or the
children’s grandmother) in Mexico or El Salvador and are distraught over missing their
children, but want to stay for another year or two to save up $7,000 to go back an build a
house so they will have something and not live a life of having nothing and working for
$4 per day at a factory while struggling to pay for an apartment.
Story 1:
One of the Spanish Speaking children I see was left for a year with extended family in
her native country, while parents came to the USA. Although she denies having negative
feelings about this, she exhibits a generalized experience of injury, and tests her parents,
teachers, school system, and peers to see if they care enough about her to help her out
when she has a complaint or is suffering emotionally. She has a hard time being away
from her parents at a pre-adolescent developmental stage in which pushing away and
beginning to create one’s own individuated identity is common.
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Story 2 and Trend 6: (caught between two cultures)
One adolescent Spanish-Speaking client reports feeling caught between two cultures, her
mother’s traditional culture and the US culture. She wants more freedom, but Mom’s
culture values being with family and being protective of daughters. There is traditionally
a high value on preserving a girl’s virginity as well. Given the context of the US culture
in which she is being raised, this client feels incarcerated by her mother’s overprotection.
This experience of feeling caught between two cultures is the 6th trend I have noticed.
Trend 7: (Isolation)
Some of my clients report feeling lonely and isolated. They report very few friends and
nobody to talk to about their problems. This is true of some of my English-speaking
clients also. However, it seems that the loneliness expressed by the Latino clients is more
of an expression of isolation due to language and cultural barriers, and is less often a
social skills or depression issue (which it seems to be more often in the English speaking
clients).
The Need for Low Fee, Evening Hour, Spanish Speaking Psychotherapy
Despite the fact that going to a psychotherapist is culturally not a very accepted thing to
do in Mexico and Central America, there is a great need for affordable Spanish speaking
therapy here in Charlottesville and throughout the United States. With other Spanish
Speaking therapy clinics charging $75 to $90 per session, it is cost prohibitive for many
Latino Immigrants to attend therapy, unless they can find a low fee clinic that offers
Spanish speaking therapy.
9-5 clinic hours make weekly psychotherapy schedule prohibitive for many Spanish
Speaking immigrants.
Helpful Therapeutic Tools and Approaches
Things I find helpful in session with clients is using CBT and DBT lessons and Anger
Management lessons in Spanish, written down on paper for the client to take home and
review for homework, or copied from a Spanish Language psychotherapy workbook,
when the lesson seems relevant. For anger management “Sin Golpes” by Christauria
Welland and David Wexler is very good...they have a book and workbook, which you
can buy on Amazon.com. The book was based on Christauria Welland’s Doctoral
Dissertation in the field of clinical psychology, studying Domestic Violence treatment of
Spanish Speaking men in San Diego, CA. It contains a relaxation CD in the back of
the book and stories from ancient times, traditional Aztec and Mayan stories of
journeys and heroism and battles and healing. The book also has a lot of quotes and
sayings from men who have been through the training. Dichos (aphorisms, sayings,
or proverbs) are found in all cultures and express universal truths in just a few works that
are easily remembered. The use of Dichos and stories from the client’s culture of origin
strengthens ties to a client’s culture by reminding them of their roots and where they
came from. Stories and sayings “Dichos” have been shown in research to be effective
therapeutic tools in working with Latino Clients. Sayings possess wisdom because they
have traveled through the whispering of the years. One example of a Dicho or saying is,
“You reap what you sow” or, its Spanish equivalent, “El que la hace, la paga. Quien mal
anda, mal acaba” A dicho stating that a life lived badly will end badly.
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Therapy: Journey you are on together
I like to present therapy as a journey that the therapist and client are on together
helps create a feeling of joining together on the journey. This aligns well with the
Latino cultural value of collectivism, inclusiveness, community and togetherness. It’s
not just the client who can benefit from the tools learned in therapy and from the process
of psychotherapy, but the therapist as well. Everyone can benefit from reviewing and
acquiring more anger management skills and tools from time to time.
God and Spirituality
Many Latino clients have a strong sense of spirituality and God. Incorporating into the
therapeutic process and/or encouraging spirituality, prayer, and development of a church
community (e.g. via attending church of the incarnation or another church with Spanish
Speaking services), can help with psychological/emotional healing as well as aide in
developing a community for those who feel isolated and lonely.
Folk Beliefs and illness that are “culturally bound”
Some (but not all) Latinos believe in and are scared of Brujeria and Santeria or
Witchcraft. Some believe that a bruja (or witch) can but the evil eye on you and cause a
“Mal Puesto” or illness. Here is a story that illustrates this: there was a Latino man
who presented to the ER with severe tightness in his chest and heart pain. After an EEG
it was determined that he was not having a heart attack and that it was a likely a panic
attack. The man was so distraught and continued to clutch his chest in great pain. A
nurse went to a bible and ripped out a picture of Jesus, showed it to the man, and pressed
the picture to his chest. The man held it firm to his chest and very soon the chest pain
stopped entirely. The man reported that he had been cursed buy a bruja (witch) in his
country of origin after an ex-girlfriend paid a witch to curse him and make him die a
painful death of a heart attack. This story demonstrates the strong power of spirituality
and belief in God as well as the impact of brujeria and the evil eye.
Other culturally-bound illnesses in Latin America are:
Ataque de nervios: An illness of distress. Symptoms include uncontrollable shouting,
attacks of crying, trembling, heat in the chest rising to the head, and verbal or physical
aggression. Ataques de nervios frequently occur as a result of a stressful family event,
especially the death of a relative, but also a divorce or fight with a family member. One
research study concluded that a significantly larger number of people with anxiety or
affective disorder PLUS ataque de nervios reported a history of physical abuse, sexual
abuse and/or a substance-abuse caretaker than those with Anxiety or affective disorder
without attaque de nervios in their past.
Nervios: (Latin America) An illness of distress, refers to a general state of vulnerability
to stressful life experiences and to a syndrome brought on by such stresses. Symptoms
may be very broad, but commonly include emotional distress, headaches, irritability,
stomach disturbances, sleep disturbances, nervousness, easy tearfulness, inability to
concentrate, tingling sensations, and dizziness.
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Susto: an idiom of distress principally reported among Latinos in the U.S. and Latin
America. Susto is an illness attributed to a frightening event that causes the soul to leave
the body, leading to symptoms of unhappiness and sickness. Symptoms are extremely
variable and may occur months or years after the supposedly precipitating event.
Alterante names include espanto, pasmo, tripa ida, perdida del alma, and chibih.
Bilis and Colera: part of a general Latin American idiom of distress and explanation of
physical or mental illness as a result of extreme emotion, which upsets the humors
(described in terms of hot and cold.) Bilis and colera specifically implicate anger in the
cause of illness.
With honor, respect, dignity, and warmth you will go a long way in your cultural
competency in working with Latino clients.