Abstract
This article aimed to address the following question: In what specific ways, can couple therapists improve their work with immigrant couples via telebehavioral health (TBH)? This article offers perspectives from experience working with immigrant couples via telehealth, which include key barriers to using in-person therapy for immigrant couples, the effectiveness of TBH for immigrant couples, and consideration for couple therapists as they venture into TBH with immigrant couples. With a focus on the expansion of services, one way to improve health equity for immigrant couples and bridge the gap between the traditional health care system and couples in undeserved communities is by developing TBH systems, which may lead to increase access to care for clients as well as expand provider options and resources.
Case Example
The case is composites or altered significantly to protect privacy.
Theme: The theme of the presented case example is the interface of couple therapy, culture, romantic relationships, and telebehavioral health (TBH) in the United States.
Case representation: Azra, a 32-year-old, English-speaking female of Turkish descent, accompanied by her 36-year-old, Turkish-speaking female partner Ceren presented to a private practice in the East coast of the United States with the chief complaint about the challenges in their sexual relationship. While Azra was fluent in the English language, Ceren had more conversational language barriers and struggled to express her emotions in the English language. Their therapist, a licensed Asian American couple therapist, was a culturally informed therapist with great interest in global mental health and strived for cultural competence and humility. However, despite the therapist’s attunement to providing culturally informed couple therapy, she continued to struggle due to the presented language barriers, and conversely, the couple reported not feeling connected or able to express themselves fully in a language that is not their native tongue. The couple was able to find a therapist who lived in another city in their state of residence, who was fluent in the Turkish language and provided telehealth therapeutic services during the COVID-19 pandemic.
TBH consultation: Conversations about couples’ cultures, partner expectations, stigma about therapy and same-sex relationships, and intersectionality were discussed. Azra and Ceren reported feeling at ease within this first session since language and related cultural experiences were no longer a constraint and thus continued to utilize the flexibility and convenience of TBH for their therapeutic needs.
Conclusion: TBH may offer a wide range of services depending on immigrant couples’ needs and increase access to care with a therapist best fit for diverse therapeutic needs.
There are an estimated 89.4 million immigrants in the United States (Esfandiari, 2016). The reasons for migration to the United States vary based on sociocultural, sociopolitical, and economic factors, commonly known as push–pull factors (Preston, 2014; Tsapenko, 2015). The decision to migrate is often influenced by a variety of complex push–pull factors including social, cultural, seeking religious freedoms, financial security, and better job prospects (Mobasher, 2006). The challenges associated with migrating such as loss of social network, oppression based on religion and/or ethnicity, and sociopolitical affiliations are considered to be some of the most significant influences that contribute to the way in which these push–pull factors are experienced by immigrants. Previous research has suggested that constraints associated with adjustment to the new environment for immigrants may be associated with a number of related complex outcomes, seen as both emotional and physical challenges (Perez Foster, 2001). However, there remains a gap in the current literature that focuses on the experiences of immigrant couples’ lives in the United States. More specifically, emphasis on immigrant couples’ mental health experiences from a multisystemic approach remains a gap in the literature to support evidence-based solutions to provide tailored couples’ treatment needs to this population (Kazemi et al., 2018).
The immigrant population is growing faster than any other population across the United States (Peterie, 2018). Therefore, health care providers, researchers, and policy makers are presented with a tremendous opportunity to positively impact generations to come by revising current practices and considering effective changes that will ultimately impact the interrelated integrative systemic nature related to human experience (Pinsof, 2018). With a focus on the expansion of services, one way to improve health equity for immigrant couples and bridge the gap between the traditional health care system and couples in underserved communities is by developing TBH systems (Hilty et al., 2004). TBH includes the use of technology and the internet to provide mental health services and behavioral health assessment and treatment with the flexibility of proximal distance in order to increase access to care for clients as well as expand provider options and resources (Hilty et al., 2004).
This article aimed to address the following question: In what specific ways, can couple therapists improve their work with immigrant couples via TBH? This article offers perspectives from experience working with immigrant couples via telehealth, which includes key barriers to using in-person therapy for immigrant couples, the effectiveness of TBH for immigrant couples, and considerations for couple therapists as they venture into TBH with immigrant couples.
Key Barriers to Using In-Person Therapy for Immigrant Couples
At the core of the immigrant couples and using therapy stories are a number of issues that highlight the importance of using TBH and how it can improve psychosocial–spiritual care for immigrant couples. The barriers are explained here and the benefits are discussed in more detail in the next section.
Literature suggests that immigrant couples and families experience varying degrees of challenges with the process of acculturation (Ballard et al., 2016; Raffaelli & Wiley, 2013; Weine, 2011). An identified constraint in the lives of immigrant couples is the disruption in their network of support as they leave their countries of origin which may lead to a sense of disconnection from the intimate partner relationship to their communities. Furthermore, it may impact layers of loss including distance from one’s culture and values, connection through the use of the native language and self-expression, shifts in socioeconomic status, minority status and intersectionality, as well as familiarity with interaction with and obtaining of resources (e.g., using the health care system and going to therapy; Kamya & Mirkin, 2019). Given the multifactorial needs and the depth of losses, as well as the constraints around the access to therapeutic services that will meet the diverse needs of immigrant couples, the utilization of the TBH platform may provide great relief from the multisystemic factors that impact their lives.
Moreover, the zeitgeist within the United States, which has heavily politicized immigrant couples and families in the recent 2 decades, has demonstrated a consistent and dominant discourse about immigrants as a threat. This in turn may highly impact the psychological and emotional well-being of immigrant couples as well as their access to resources and psychotherapeutic services (Zayas et al., 2015). More specifically, the anti-immigrant sentiment is an extension of racism and related racist rhetoric in the current cultural climate of the United States (Silva, 2015). Most therapists do not receive training for working with immigrant couples, let alone working with immigrant couples via TBH (Pickens et al., 2019). Furthermore, immigrant couples may experience some challenges such as changes in traditional gender roles, figuring out family identification, and acculturation-based challenges (American Psychological Association, 2013).
Efficacy of TBH for Immigrant Couples Seeking Therapy
The nature of health communication in the past few decades has changed by developing internet communication (Goodman-Deane et al., 2016). While the use of internet technology by health professionals has been widely established (Bacigalupe et al., 2014; Cabieses et al., 2013), mental health services continue to lag behind in the utilization of teletherapeutic services. Mental health professionals hesitate to adopt digital communication tools in their work compared with their colleagues in other fields (Sprenger et al., 2017). Thus, some of the benefits of TBH for immigrant couples include attention to the development of leaders and couple therapists in couple therapy and a focus on a multisystemic consideration and practices via TBH.
The Importance of the Primary Language
Studies highlight the significant role of language between clients and providers via TBH (Hilty et al., 2015) and in-person (Hilty et al., 2017). Researchers reported that the rate of importance for therapists’ ability to converse in their clients’ primary language (or using an interpreter) is 5.4 on a scale from 1 to 7 (Hilty et al., 2015). Those surveyed clients reported that more interpreters and therapists who speak the primary language of clients were needed. TBH provides more flexibility and options for immigrant couples to have a therapist who speaks their native language and/or has an interpreter.
The Improvement of Access
TBH could provide a more flexible platform to overcome some of the barriers related to accessibility to couples and family therapeutic services while increasing the capacity among couple therapists who practice in rural areas, as well as agencies in such areas that are challenged with recruitment and retainment of their therapists with specific specializations. TBH may also allow couple therapists to offer care in various settings (e.g., traditional, integrated behavioral health care [IBHC]) while expanding their scope of practice and providing greater opportunities for remote consultation and supervision.
Reducing Health Disparities
Some of the most recent literature has linked health care disparities with compromised health outcomes (Butel & Braun, 2019). Various sources across health systems including bias, stereotyping, prejudice, and clinical uncertainty have been noted to contribute to such disparities (Griggs et al., 2017). A number of studies suggest that racial and ethnic minority clients, including immigrant couples, are more likely to refuse treatment due to their adverse experience with discrimination within the current U.S. health care system (Butel & Braun, 2019; Griggs et al., 2017). Thus, utilization of TBH has the potential to minimize the impact of compromised workforce and accessibility barriers while reducing the risk of the identified health disparities for immigrant couples who are seeking therapeutic services.
Turning Down Immigrant Couples’ Costs
Cost is also identified as a common barrier for immigrant couples seeking therapy (Mehrotra et al., 2017). For those with limited incomes, it is not always feasible to consider the cost of transportation, childcare, and lost work time in addition to the given cost of psychotherapeutic services. Offering TBH could further reduce immigrant couples’ costs associated with lost work time, transportation, and childcare needs (Mehrotra et al., 2017) and thus positively impact attrition prior to meeting the couple’s therapeutic treatment goals.
Services in a Timely Manner
By improving accessibility and flexibility, TBH may provide timely care and assist in reducing costly emergency room visits. Intervening in a timely manner allows mental health services to reduce health costs and release the limited resources available (Basto-Pereira & Maia, 2019). Studies indicate that clients including couples use medical services 90% less frequently after using appropriate mental health care and services (U.S. Department of Health, 2020).
Consideration for Couple Therapists as They Venture Into TBH for Immigrant Couples
Couple therapists can use TBH to provide the following behavioral and mental health services for immigrant couples: (1) evaluation and diagnosis: couple therapists can use TBH to observe immigrant couples, conduct relationship scales, systemically assess, and determine the therapeutic needs for the couple; (2) case consultation and conjoint psychotherapy: some TBH programs enable couple therapists to consult via direct video communication, telephone consults, with other providers such as psychiatrists for medication management and clinical psychologists for diagnostic evaluations. Similarly, the accessibility of TBH allows such integrative systems of care to conduct conjoint psychotherapy when necessary for the clients; (3) treatment: TBH typically provides psychotherapy and psychoeducation as well as specialized therapeutic services that are often sought out for immigrant couples within therapeutic services; (4) continuing care: TBH programs may provide case management services through the telehealth platform as a means to improve immigrant couples’ health and relationship outcomes. For example, couple therapists may coordinate with the couples’ direct and indirect systems to meet the identified needs of the couple. This flexibility with TBH services may provide greater comfort and coordination on the part of the clients and in turn reduce the degree of related stress and integration of the systemic nature of the noted concerns; (5) provider education: couple therapists can receive continuing education about TBH through distance learning as well as related educational webinars as it is related to continuing education growth and expansion of their scope of practice (Chong & Moreno, 2012). The five discussed services are some of the critical aspects that couple therapists may need to consider in utilizing the TBH platform to expand systemic therapeutic services in working with immigrant couples.
The Couple Therapists’ Position
While conducting TBH service to immigrant families, the therapist has two positions (Singhal, 2016). First, the couple therapist must explore and reflect on their own position about the utilization of technology within their practice. Second, couple therapist must acknowledge their own understanding of the unique needs of immigrant couples’ uprooted experiences as well as cultural and/or linguistic competence about immigrant families and their culture of origin including the intersectionality within it. The attention given to the couple therapists’ noted positions is a critical piece of the treatment frame that may not be overlooked while working with individuals from diverse ethnic and cultural backgrounds (Singhal, 2016). While the notion of therapist positionality often revolves around the notion of therapist neutrality, to adopt a position of neutrality with the assumption that it is the most respectful way to interact with immigrant clients and clients from diverse backgrounds is a myth. There are some very good reasons why a therapist needs to adopt a position toward one’s behavior. This does not mean that we create a coalition with one partner against the other; it means that we support one while supporting the other. One aspect of the therapeutic process where a therapist’s positioning may manifest is in the balance between silence and attention in the therapy room and to whom that effort is directed (Lehmann, 2014). In the case of a therapist’s positioning around technology, older therapists may be more skeptical of the information and methods provided by technology.
Cultural Humility
Cultural humility is a lifelong journey characterized by constant self-reflection (Tervalon & Murray-Garcia, 1998). Regarding immigrant couples’ culture, as couple therapists in both traditional and IBHC settings, we should try to be humble, flexible, and have a client-oriented approach (Hook et al., 2013). In addition, recognizing and addressing power imbalances in working with immigrant couples is another aspect of cultural humility (Rajaei & Jensen, 2020). The notable identified dyadic role imbalances and concerns about injustice may occur as a result of the intersectional differences that exist between the couple therapist and the couple’s social location or cultural and contextual factors as well as the dominant culture. Therefore, couple therapists are encouraged to be attentive to their own social location factors, implicit biases, the position of privilege, and the intersectionality of the parts of the identities that intersect with the immigrant couples’ social locations. The framework that is suggested for the couple therapists to utilize in their clinical practice with immigrant couples is proposed by McDowell et al. (2018), which proposes the adaptation of socioculturally attuned family therapy as a guideline for best practice clinical care. Figure 1 offers a visual illustration of the framework.
Conceptual framework for socioculturally attuned family therapy.
McDowell et al. (2018) proposed movement in the direction of third-order change. This change involves families’ understanding of how social forces shape and shift their life narratives and impact intimate partner relationships as well as material realities. Drawing on the insight proposed by McDowell et al. (2018) and the process of change, couple therapists are encouraged to explore how dominant discourses are tied to vehicles of marginalization, systemic oppression, and interactions with privilege for immigrant couples. Couple therapists are also encouraged to invite immigrant couples to explore the way in which sociocultural dynamics intersect with their presenting problems as constraints. Couple therapists join in the effort by listening attentively and deeply in search for the couple’s experiences, shared values, and meanings while navigating the immigrant couples’ attempt to cocreate their preferred narratives (McDowell et al., 2018; Rajaei & Hodgson, 2019). Thus, the attention on third-order change increases the likelihood of raising the couple’s awareness. Couple therapists can help immigrant couples view dominant narratives from a multisystemic lens, which includes a sociopolitical framework and facilitates the deconstruction of power-embedded relational injustices and empower resistance (McDowell et al., 2018).
Supervision and Consultation
Couple therapists should stay committed to their association’s codes of ethics, federal laws (e.g., Health Insurance Portability and Accountability Act), and the mental health laws of the state they are living in about providing TBH services. In addition, couple therapists make every attempt to consider how decisions and actions might impact immigrants, their families, the health care system, themselves, and society. As such, couple therapists or supervisors should talk about professional ethics in their supervision and consultation meetings regularly. Furthermore, couple therapists or supervisors should talk about ethical decision making and hypothetical case scenario in their supervision (King et al., 2015). Couple therapists or supervisors and supervisees in IBHC settings need to be mindful of potential ethical issues and collaborate with immigrant couples and team members (Hodgson et al., 2013), given that they may encounter ethical dilemmas such as limits of confidentiality and multiple relationships.
Couple therapists or supervisors should talk to supervisees to further empower immigrant couples in therapy as some of them have already lost their voices in the United States. Taking a broader view, supervisees should understand that intersectionality (i.e., simultaneously considers the coexistence of various social location aspects, privilege, and oppression; Crenshaw, 1989) can play an essential role in immigrant couples’ experiences. Therefore, supervisees should remain culturally humble, openly discussing topics such as race, age, gender, ability, nationality, spirituality, sexual orientation, and other social locations via TBH while remaining vigilant about issues of similarities and differences in supervisory relationships and explore potentials for multiple “hot spots” and “blind spots” (Todd & Rastogi, 2014). Thus, this means the greater comfort the supervisors have in similarities with their supervisees, the more likely that there will be an increased probability of having blind spots outside of awareness (Todd & Rastogi, 2014).
Particularly when working with immigrant couples, supervisors should be attuned to the following points and discuss them with supervisees (Rajaei et al., 2020): (1) focus on the relational processes within cultures, (2) consider and discuss power, (3) be aware of societal context, (4) maintain awareness of intersectionality, (5) practice cultural humility (Hernandez-Wolfe et al., 2015).
Moreover, couple therapists or supervisors may benefit from integrating the Heightening Multicultural Awareness (HMA) model (Luxton et al., 2016) to challenge and support the supervisees in the exploration. Specifically, HMA provides a guideline as to how to encourage awareness of attitudes by introducing the reality of cultural differences and similarities into supervision and increasing awareness of how cultural issues affect work with clients (i.e., culture as the identified patient). This effort to promote self-awareness enhances the supervisees’ ability, through personal exploration, to understand their own multicultural identifies and biases associated with their personal socialization. Furthermore, utilizing a model such as HMA (Cambell, 2000) assists the couple therapist or supervisor in helping their supervisees expand their knowledge through reading and experiences while beginning to recognize the impact of behavior on clients through the means of cultural genograms. The general knowledge provided to supervisees about multicultural issues is to be derived from various theoretical, empirical, and clinical sources relevant to different cultural groups (Ladany et al., 2005). The self-awareness on the part of the supervisees, in combination with their general knowledge, is believed to expand and heighten the supervisees’ cultural awareness and leads to formulating a new identity as a couple therapist (Cambell, 2000) as a result of this awareness and guidelines as to how to take appropriate action to promote social change and cultural pluralism on how to address and understand the unique variables related to immigrant families (Landay et al., 2005). Specific cultural issues may include cultural group membership, personality traits, values, willingness to self-disclose, and the motivation to change. Couple therapists or supervisors are also encouraged to attune to their supervisees’ multicultural psychotherapy self-efficacy as well as the effectiveness of their supervisees’ working alliance, which includes their ability to develop an emotional bond with clients and engage in multiculturally sensitive discussions when negotiating the goals (i.e., multicultural identity change) and the task of therapy (i.e., the extent to which multicultural issues will be discussed).
Conclusion
The utilization of the TBH platform is an effective way to improve accessibility, quality, and efficiency for immigrant couples seeking therapeutic services with a specialty in care. Couple therapists need a better system workflow integration with shifts in multisystemic values and beliefs regarding the expansion of access to care including utilization of TBH platforms. Thus, with the current shifts in needs for services, it is an important period in history to call for the development of leaders and couple therapists who practice couple therapy to focus on a genuine systemic thought and practice in providing the best standard of care through the use of TBH platforms. Working with immigrant couples challenges couple therapists to move beyond the cultural and organizational norms (e.g., in-person therapy) and requirements. This may lead to the strength, resilience, and richness of immigrant couples of other cultures. Couple therapists are encouraged to understand the immigrant experiences in their broadest context within the United States, and this consideration involves exploring the dyadic experiences of emotional pain and improves accessibility, quality, and efficiency in care. It is a privilege to accompany immigrant couples in the United States along that road.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
