Addressing Acculturative Stress in Psychotherapy: A Case Study of a Latino Man Overcoming Cultural Conflicts and Stress Related to Language Use

1 Theoretical and Research Basis for Treatment

Latinos are the fastest growing racial/ethnic minority in the United Stated. In 2014, Latinos made up 17% of the total U.S. population, and it is estimated to reach 28.6% by the year 2054 (U.S. Census Bureau, 2014). The rapid growth of this population brings attention to the strong probability that there will be a higher number of Latino patients in need of culturally competent mental health care. While Latinos experience similar rates of mental health problems as the general population, only 36% of Latinos seek treatment for depression compared with Whites (Interian & Díaz-Martínez, 2007; Potochnick & Perreira, 2010; Safran et al., 2009). Latinos are also less likely to talk to their primary care provider about mental health concerns or seek services with a mental health specialist (Interian & Díaz-Martínez, 2007). In 2005, a report published by the American Psychological Asociation (APA) showed that only 50% of Latino patients return for a second appointment after the initial visit, compared to 75% of non-Latino clients (Dingfelder, 2005).

Latinos face challenges at various levels that affect their quality of life. Access to mental health care and other services is often difficult due to language fluency, financial barriers, lack of insurance, perceptions of impersonal interactions, distrust of health care providers, and other cultural barriers (Arbona et al., 2010; Gallardo, 2013; Morales, Lara, Kington, Valdez, & Escarce, 2002; Organista, Muñoz, & González, 1994). Although various factors are contributing to the underutilization of mental health services among Latinos, many observers have called attention to the lack of culturally competent care to help understand why Latinos might have difficulties engaging in therapy (Gonzalez-Prendes, Hindo, & Pardo, 2011; Lopez, Shealy, & Rheingold, 2014). It is possible that the lack of a bilingual and bicultural mental health provider creates room for miscommunication and misinterpretation, which is a barrier faced by patients with limited English proficiency (Hunt & Swartz, 2017; Ponterotto, 1987).

For Latinos who surpass the language barrier, another barrier to optimal care could be the result of a therapist’s approach to therapy and understanding of the Latino culture (Gonzalez-Prendes et al., 2011; Organista & Muñoz, 1996). For example, Gonzalez-Prendes and colleagues (2011) pointed out that even when English-speaking Latinos make it to therapy, most therapists are trained in Westernized psychotherapy, which makes it harder to recognize or incorporate specific cultural implications unique for many Latinos. For clinicians working with Latinos, in particular, immigration and family disruptions are important aspects to consider as these might play a role in the client’s current distress and self-rated physical health (Torres & Wallace, 2013).

2 Case Introduction

The case presented here is Mr. Lopez. ¹ Mr. Lopez and his family moved to the United States 3 years ago for a better future. Mr. Lopez was relatively isolated compared with his lifestyle in Colombia. Mr. Lopez had an adverse outlook on the future and his ability to speak and understand English. His negative views interfered with his desire to be involved in his children’s education, pursue career opportunities, and establish social relationships. Mr. Lopez sought opportunities to improve his English and was constantly listening to the news and reading to his children in English. Despite these efforts, Mr. Lopez believed he was not making fast progress in comparison with others that have immigrated before him. Mr. Lopez was aware of his self-criticisms and the pressure he put on himself to be more fluent in English despite only living in the United States for 3 years.

Mr. Lopez self-referred to therapy after he learned about the mental health clinic from a member of his community. Mr. Lopez presented in person and inquired about making an appointment with a Spanish-speaking therapist. At the time of this inquiry, the first author, a Spanish-speaker student therapist, was present and proceeded to inquire about his language preference and general concerns. Mr. Lopez indicated “not feeling comfortable speaking English” and wondering if services were available in Spanish.

3 Presenting Complaints

Mr. Lopez initially reported that he felt ungrateful, despite having a good standard of living. He admitted that even though he had a stable job and his family was together, most of his difficulties and unhappiness were related to his lack of friends, dissatisfaction with his job title, and language proficiency. At work, he opted for communicating via emails instead of phone calls. He was often worried about not being understood on the phone and making a customer upset. His concerns about not being understood carried over to his interpersonal relationships with co-workers and his desire to develop a deeper relationship with them.

Mr. Lopez made numerous attempts to learn English, and while he spoke it at times, he believed that others would not understand him and laugh at his accent. He reported that he was better at understanding it than speaking it. However, Mr. Lopez also admitted to feeling embarrassed about asking others to provide clarification when he did not understand them. Although he never experienced negative encounters to support his belief that others make fun of his speaking abilities, it was apparent that he felt stressed out about his language barrier. Mr. Lopez made significant efforts to improve his language proficiency. He enrolled in an online language learning program and watched movies in English every night.

Mr. Lopez was also worried that his language limitations might interfere with his ability to communicate with his children’s teachers and limit his involvement. He felt conflicted about the education system in the United States and how different it was from his home country. Some of the differences he pointed out included the amount of homework his children were required to do and how helpful/available his teachers were to them. These worries about his involvement and language barriers led Mr. Lopez to question his motives for immigrating to the United States and worry about the future of his family.

4 History

Mr. Lopez grew up without a father and was close to his mother, who lives in Colombia. He has an older brother to whom he has always admired. He always compared himself with him and felt less accomplished than him throughout his whole life. Growing up, Mr. Lopez had difficulties keeping friends and making decisions on his own. Mr. Lopez noted that his mother and brother were always critical of him; however, he asserted that it was constructive. That is, Mr. Lopez described these criticisms as motivating and influential on his decisions to do better. He expressed feeling doubtful about his abilities throughout his life but never experiencing a significant failure or hardship, as he had been able to overcome most obstacles. To some extent, he believed that his successes have been out of luck.

Mr. Lopez reported a history of anxiety and depression on his maternal side. He indicated that his mother had been in therapy for many years, which also helped him understand the benefits of therapy from her. Mr. Lopez stated that his relationship with his mother was close, despite her living in Colombia. He contacted her multiple times a week and inquired her input before seeking therapeutic help. Mr. Lopez and his brother worked in the same industry and lived close to each other. Despite this proximity, Mr. Lopez indicated that their relationship had grown apart over the years.

Mr. Lopez was married for 20 years and had two children under the age of 10. He denied marital problems but admitted to feeling inferior to his wife because she spoke better English than he did. Mr. Lopez and his family arrived in the United States 3 years earlier. Although they entered the United States with a temporary workers’ visa, Mr. Lopez, and his family, applied for permanent residency and were awaiting the decision while Mr. Lopez was in therapy. He described this process as stressful and worrying about whether he had to make the decision to stay illegally or return to Colombia.

Mr. Lopez had a degree in engineering and used to travel internationally for prestigious work-related events. In the Unites States, he was working in a different industry, one that did not provide the same pay or fulfillment like he did in Colombia. Most of his job requirements involved administrative tasks. He expressed a desire to practice in the same industry of his degree and obtain a job with higher pay and status, however; he was worried about the costs and how old he would be if he pursued that option. Mr. Lopez was reportedly exceptional at his job and provided suggestions to improve various aspects of the company. His contributions had been welcomed and led to compliments from his boss. Although his current job provided an adequate income, Mr. Lopez believed he deserved a promotion and referred to his limited English proficiency as a significant barrier.

5 Assessment

Mr. Lopez received an evaluation through a semi-structured clinical interview with the first author, a Latina female doctoral student in clinical psychology. The initial visit focused on gathering information about personal history, perceived cultural differences and factors influencing adjustment to the United States, family response to the move, and immigration status. Mr. Lopez continued treatment with this therapist in Spanish and eventually transitioned to having sessions in English.

Over the course of therapy, the therapist conducted a verbal assessment of depressive and anxiety symptoms. Mr. Lopez reported feelings of pessimism, inappropriate guilt, self-deprecation, hopelessness, and catastrophic thinking. Most of his negative thoughts surrounded his views and difficulties adapting to a new life in a new country. “I am the only one having this hard of time . . . If I don’t succeed, I am a failure,” were some of the negative thoughts driving his negative self-view.

Mr. Lopez’s presented with symptoms of anxiety, obsessive worrying, and some depressed mood. Language barriers limited Mr. Lopez to engage in social activities and communicate with others. While Mr. Lopez reported feeling isolated, he did not report severe distress, sadness, or other symptoms that are consistent with depressive disorders. Although he described himself as pessimistic and a worrier, he indicated that these worries have gotten worse since he applied for legal residency, 2 months before starting therapy. Based on the information gathered through the assessment, a diagnostic impression of generalized anxiety disorder (GAD) was considered; however, follow-up questioning during treatment revealed that the primary source of these worries was due to his difficulties adjusting to a new culture. As a result, Mr. Lopez’s problems adapting appeared to be affecting his current social environment, consistent with Acculturation Difficulty (V62.4) as defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). The duration of his symptoms and stress-related disturbance due to multiple stressors such as relocation, cultural changes, language barrier, and worries about his future immigration status are also consistent with Chronic Adjustment Disorder, with anxiety (F43.22).

6 Case Conceptualization

With all clients, a working relationship between the therapist and the clients is critical. For Latinos, interpersonal warmth is crucial and perceived distance, or “unfriendly” interactions might decrease the likelihood of a Latino client returning to therapy (Gonzalez-Prendes et al., 2011). Gallardo (2013) noted that personal disclosures might help Latino clients feel more connected to their therapist and perceive them as “caring and real.” To help cultivate a positive relationship and improve Mr. Lopez’s engagement in treatment, the therapist made many self-disclosures to illustrate shared experiences due of immigration and acculturation.

During the intake, it was apparent that Mr. Lopez’s ways of thinking and assumptions were contributing to worries about himself and the future. Mr. Lopez was highly motivated for treatment to improve his thinking style and become a better father and husband. Because family relationships are important in the Latino culture (Benson-Florez et al., 2016; Gonzalez-Prendes et al., 2011; Interian & Díaz-Martínez, 2007; Organista & Muñoz, 1996), it was critical for Mr. Lopez to feel comfortable about discussing family problems in the therapy session. As noted, it is particularly necessary for therapists working with Latinos to integrate cultural values such as familismo and personalismo to improve client’s understanding and engagement in treatment (Benson-Florez et al., 2016; Gallardo, 2013).

Cognitive behavioral therapy (CBT) was used to target Mr. Lopez’s maladaptive thinking patterns and improve his self-views. Most of the therapy focused on working with Mr. Lopez to overcome self-criticisms about speaking English and increase his self-confidence. Despite only living in the United States for 3 years, Mr. Lopez had a proficient level of understanding that satisfied his work requirements. Although not formally assessed, Mr. Lopez perceived his speaking abilities lower than his comprehension level. Despite his limitations, Mr. Lopez was able to speak and engage in English conversations if needed, but often avoided them. As a result, it was important to provide Mr. Lopez with the confidence to communicate in English.

In addition to focusing on building confidence about language use, therapy also focused on discussing and processing perceived sociocultural differences and barriers faced from relocating to the United States. As part of the acculturation process, it was evident that Mr. Lopez was unfamiliar with the education system and how to get involved in his community. His worries about not being involved in his children’s education and not being “a good father” could have been caused by his limited knowledge, language barrier, perceived distance, and detached relationship with his children’s teachers. It was hypothesized that Mr. Lopez would benefit from a combined treatment approach that would address his cognitions through CBT while incorporating psychodynamic therapy to process cultural similarities and differences that are often experienced in the acculturation process.

7 Course of Treatment and Assessment Progress

Therapy was conducted in an outpatient training psychology clinic in a southern state. Treatment consisted of 22 individual sessions each lasting 50 min. The first 15 sessions were weekly and conducted in Spanish. The remaining seven sessions were held in English. The final two sessions occurred at 1-month intervals. At each visit, Mr. Lopez completed the Spanish version of MyOutcomes, a tool that measures client progress and experience of the therapeutic alliance (Miller, Duncan, Brown, Sparks, & Claud, 2003). The ratings obtained at each session helped evaluate the Mr. Lopez’s experience with the topic discussed, approach to therapy, and satisfaction with the therapeutic alliance. Real-time results provided an opportunity to discuss changes, help identify areas of improvements, and evaluate progress over time (Miller et al., 2003; Overington & Ionita, 2012).

Progress was assessed through improvements in MyOutcomes ratings; Mr. Lopez’s score on the first visit fell in the “at risk” range (score = 22.2), while his ratings during the last session fell in “on track” range (score = 38.6). Clinical judgment and the transition from communicating in Spanish to English with the therapist was also another indication of progress. Mr. Lopez’s therapist was a Latina female from Peru. Although the therapist was also a first generation immigrant and bilingual in Spanish and English, the therapist informed Mr. Lopez that her training was in English and that attempts would be made to provide culturally appropriate psychotherapy. Mr. Lopez’s therapist received weekly supervision and sought resources to improve her understanding and familiarity with technical terms, psychoeducational materials in Spanish and English, and culturally adapted treatments.

8 Complicating Factors

Some complicating factors were present in this case study. While ethnic similarity and shared experiences played a significant role in this case study, it is also important to recognize that ethnocultural empathy could lead to an over focus on similarities and possible transference in the therapeutic relationship (Comas-Diaz & Jacobsen, 1991). To overcome this barrier, the therapist worked closely with a supervisor on a weekly basis to process any problematic countertransference, and understand how it could be impacting the therapeutic relationship and the client’s progress. An additional complicating factor was unfamiliarity with immigration law as the therapist was uncertain about Mr. Lopez’s classification and whether the law required her to report him. However, after further consultation, the therapist learned that his “temporary work visa” qualified as a temporary protected status and was subjected to a different set of laws than those that apply to undocumented immigrants.

The importance placed on the family may facilitate or be an obstacle to treatment for Latino clients. In Mr. Lopez’s case, most of his maladaptive thoughts were about his family and his role. The therapy would have failed if the therapist ignored family values and the therapy focused on changing his views to prioritize his happiness over that of his family’s. The integration of family values into treatment allowed Mr. Lopez to discuss family problems and use family as a motivation to change instead of focusing on self-interest. Another cultural factor that is fundamental for fostering rapport with Latino clients is personalismo (Gallardo, 2013; Gonzalez-Prendes et al., 2011). In this case, the cooperative interactions and personal connection led Mr. Lopez to ask the therapist to attend his birthday celebration and meet his family.

Providing therapy in a different language with limited formal training was a complicating factor for this case study. To address this barrier, the therapist provided psychoeducational handouts written in Spanish that included technical terminology for cognitive distortions and a detailed explanation of how CBT works. The therapist also gave examples in Spanish and encouraged Mr. Lopez to complete thought records in session and to go over them together. It is important to note that these materials were created to facilitate Mr. Lopez’s understanding and that there is no research to support the language validation of these materials. The translation of technical terms and treatment components was difficult, and it required the therapist to consult with the client for meaning interpretation. While these efforts show some of the considerations made to provide linguistic and culturally appropriate services, it also highlights the need for culturally adapted evidence-based interventions.

Another limitation of this case study is that no psychological screeners were administered to help determine the severity and frequency of symptoms specific to anxiety or depression. In part, this was due to the limited research that has been done to validate these measures on Spanish-speaking patients, as well as the utility of these measures beyond the research setting (Sanchez & Shallcross, 2012). For this case, session ratings (MyOutcomes), self-reported improvement, and clinical judgment helped evaluate Mr. Lopez’s general functioning and level of interference across the course of therapy.

9 Access and Barrier to Care

Although socioeconomic status is often a barrier to mental health services among Latinos (Morales et al., 2002), Mr. Lopez did not experience financial or transportation problems while seeking treatment. Reluctance to seek psychotherapy among Latinos is often due to cultural stigma and possible cultural dissonance between the client and the therapist (Gonzalez-Prendes et al., 2011; Organista & Muñoz, 1996; Santiago-Rivera & Altarriba, 2002). A common barrier to care that could have resulted if Mr. Lopez was not able to find a Spanish-speaking therapist. Unavaibility of a bilingual therapist could have delayed his care and potentially worsen his symptoms. As illustrated in this case study, the availability of a bilingual/bicultural therapist was a factor that might have contributed to Mr. Lopez’s engagement and positive outcomes.

10 Follow-Up

Mr. Lopez’s therapist was required to continue her training at a different site. Given Mr. Lopez’s interest to continue therapy and address various problems, he was transferred to continue with a male student therapist. While the new therapist did not speak Spanish, Mr. Lopez felt confident and agreed to continue therapy with the new therapist. For him, the decision to continue treatment in English was a great indication of his progress and confidence gained about his English abilities. Due to confidentiality demands, the therapist did not know whether Mr. Lopez has continued working with the new therapist or if his progress continues.

11 Treatment Implications of the Case

This case illustrates the successful application of CBT to address acculturative stress and improve the English-speaking confidence of a Latino man. In this case, the therapist worked with a Latino male from Colombia who immigrated to the United States 3 years prior. It is not known if a similar approach would be effective with individuals who are more acculturated or have been living in the United States for longer. Therapists must acknowledge that time spent in the United States does have a linear relationship with acculturation level (Cervantes et al., 2013; Dillon et al., 2013), as individuals differ on how they adapt, and what they assimilate or reject from the mainstream culture over time. Despite the positive outcomes of this case study, it is important to recognize that it is not known with certainty which of the linguistic and cultural considerations are necessary to help Spanish-speaking patient address acculturative stress. Although Mr. Lopez seemed to benefit from this treatment approach, there is no follow-up data to examine if these improvements have maintained beyond the culmination of therapy with the bilingual therapist.

The heterogeneity of the Hispanic population is important to recognize to deliver culturally appropriate services. Although Spanish was a common bond, different nationalities have distinct cultural saying or idioms, as well as variation in word choices to express the same idea that could create misunderstandings (Santiago-Rivera & Altarriba, 2002). As seen in this case, the limited familiarity with terms and expressions unique to the Colombian culture made it difficult for the therapist to understand emotion-driven phrases. Therefore, bilingual therapists are encouraged to pay attention and discuss the meaning of various idioms and word meanings that a client might voice in-session.

Studies have shown the importance of engaging Latino clients early on to improve engagement and strengthen therapeutic relationship (Fierros & Smith, 2006; Santiago-Rivera & Altarriba, 2002; Zigarelli, Jones, Palomino, & Kawamura, 2016). In this case, it was important to delay the focus on the initial challenge of maladaptive thoughts until an atmosphere of personalismo was established. Implementing cultural values early on allowed Mr. Lopez to address acculturation problems and feel comfortable to discuss how it impacted his family and English-speaking abilities. Interian and Díaz-Martínez (2007) also recommended integrating familismo early on to help foster motivation, as Latino clients might be likely to change and improve for the betterment of their families and fulfillment concerning their family roles. Although therapists might work with clients from various background, it is important to note that some studies have found that Latinos share common cultural values (Gonzalez-Prendes et al., 2011; Morales et al., 2002), such as those described in this case study.

12 Recommendations for Clinicians and Students

As the Latino population continues to grow (U.S. Census Bureau, 2014), there will also be more Latinos in need of mental health services. This case study supports the importance of cultural awareness and integration of cultural values throughout the course of treatment. Anyone working with Latino clients must understand that overcoming language barriers is only one of the many factors contributing to culturally informed care (Gallardo, 2013; Interian & Díaz-Martínez, 2007). Delivering therapy to Spanish-speaking Latinos with low acculturation might present barriers that might be hard to overcome by a therapist who only focuses on translating and conducting therapy in the client’s preferred language and does not pay attention to meaning interpretation. It is recommended that clinicians check in with clients about their understanding of the content discussed in session as well as written materials provided by the clinician.

It is also recommended that clinicians interested in working with Latinos seek out training opportunities and familiarize themselves with evidenced-based and culturally adapted treatments available for Latinos, such as CBT for Latinos with depression (Aguilera, Garza, & Muñoz, 2010; Organista & Muñoz, 1996). Given the heterogeneity among Latino, clinicians are encouraged to evaluate the appropriateness of the treatment to ensure that a linguistic and culturally validated intervention is appropriate to fit for client’s needs. When possible, clinicians are encouraged to employ validated measures to help monitor client’s progress and changes in the therapeutic alliance, such as the one included in this case study. Such tools can help therapists identify when clients are not improving and initiate discussion about barriers to progress (Miller et al., 2003).

Finally, clinicians working with immigrant clients are encouraged to acknowledge the impact of acculturation on the client’s presenting complaints. While a Latino client might be fluent in English and has years living in the United States, taking the time to discuss stressors related to the adaptation to a new sociocultural environment provides a better understating of the client’s worldview and source of distress (Dillon et al., 2013; Torres & Wallace, 2013). In fact, Díaz-Martínez (2003) recommended conducting an ethnocultural assessment as part of the intake interview to understand difficulties with acculturation, background, and living situation, and the impact immigration could have caused to the client’s familial relationships.