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Running head: LANGUAGE & CULTURAL BARRIERS FOR CLINICAL PSYCHOLOGISTS

The Negative Effects of Language Barriers, and a Lack of Cultural Competency for Clinical

Psychologists Working with the Spanish-Speaking Community in the United States

Haleigh Bries

Loras College
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LANGUAGE & CULTURAL BARRIERS FOR CLINICAL PSYCHOLOGISTS

INTRODUCTION
It has previously been established that mental health plays a major role in behavior, and

impacts many other aspects of daily life. Therefore, being able to discuss mental health matters

with a trained professional has proven to be very beneficial for many individuals. Additionally, it

is also universally understood (and has been backed up by previous research) that

communication is key in any human relationship, but this is especially relevant in the

relationships between clinical psychologists and their patients. It is through clear communication

that clinicians can build trust and rapport with their patients, and how both parties can work

together to find the best solutions for an individual’s needs. The concern however, is what

happens when an individual needs therapeutic services in order to address a mental health issue,

but they do not have access to a clinical psychologist who speaks the same language as them.

Unfortunately, this is the reality for many Spanish-speaking Latinos in the United States,

as they are traditionally among those who do not receive equal opportunities for quality mental

health services in comparison to other English-speaking individuals (Verdinelli et. al, 2009, p.

230). As a result, the outcomes and quality of mental health services for Spanish-speaking

Latinos in the United States is often compromised due to the inability of clinical psychologists to

properly communicate with them during therapy (Verdinelli et. al, 2009, p. 230). Even though

culturally and linguistically appropriate services (CLAS) were established to ensure the equal

treatment of everyone in clinical settings, we still see disproportionate care for linguistically and

culturally diverse groups (Barksdale et. al, 2014, p. 370). Universally, culturally and

linguistically appropriate services are recognized as services which are in accordance with a

client’s culture, beliefs, native or preferred language, communication, and overall needs

(Barksdale et. al, 2014, p. 370). While there have been advancements in therapeutic services
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for Spanish speaking individuals in the United States, there are still many deficiencies in

cultural competencies and the presence of language barriers that inhibit this demographic

from receiving quality therapeutic care. The point of this paper is designed to address this

concern by looking at the negative implications of a lack of communication between patients and

clinical psychologists due to language barriers, as well as how language barriers and insufficient

cultural competency trainings play a role in the lack of quality care available to specifically the

primarily Spanish speaking population in the United States.

“Hispanics currently constitute 16% of the total US population, and census projections

estimate that by the year 2050 that number will rise to 30%” (Aponte-Rivera et. al, 2014, p. 259).

In order to sufficiently address this barrier between English speaking clinical psychologists and

Spanish speaking patients in the United States (which will continue to be of relevance), this

paper will first identify language-concordant care, and explore why it is necessary in patient and

therapist relationships. It will also address various aspects of communication itself in order to

better map out why the exchange of information through verbal language use in language-

concordant care is prevalent in a therapist and patient relationship (especially when considering

that bilingual therapists often conduct therapy session differently based on the primary language

of the patient they are serving (Verdinelli et. al, 2009, p. 230)). Secondly, it is important to

understand what has already been done to address the issue of language barriers and the lack of

cultural competency training for clinical psychologists. For this reason, this paper includes a

review of various studies that have already been conducted that have played a role in the

advancement of understanding the importance of language in association to clinical therapy, and

addressing certain mental health disorders. Additionally, in light of the need for improvement,

this paper will address steps that have been proposed be taken in order to combat these language
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barriers and lack of training in order to offer more quality care to the Spanish speaking

population in need of therapy in the United States. Finally, this paper will unpack how a lack of

cultural competency and sensitivity training and a lack of Spanish speaking clinical

psychologists in the United States is a diversity and social issue, and how it needs to be

addressed in order for psychologists to better abide by Title VI of the Civil Rights Act of 1964,

as well as The American Psychological Association's Ethical Principles of Psychologists and

Code of Conduct.

BODY

Screenings and Clinical Trials

Even though in the year 1993 the National Institute of Health developed a set of

guidelines which mandate the equal inclusion of minority populations throughout clinical

research, the Spanish-speaking population is still underrepresented in the vast majority of clinical

research being conducted (Aponte-Rivera et. al, 2014, p. 259). This is important when discussing

the implications of language and cultural competencies on the quality of therapeutic care

available because the inclusion of minorities and Spanish-speaking individuals means that

psychologists are (or are not) able to gain a better understanding of how Spanish-speaking

individuals may be affected by various mental health problems. The inclusion of Spanish-

speaking individuals in mental health screenings and clinical trials means that clinical

psychologists can then reflect upon this when working with their own Spanish-speaking patients

in therapy settings. For example, when developing a depression research site aimed specifically

at addressing the inclusion of Spanish-speaking individuals in the United States, researchers

found that patients who self-identified as Hispanic often experienced less effective therapy and

treatment outcomes in comparison to their non-Hispanic white counterparts when it came to

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treating major depressive disorder (Aponte-Rivera et. al, 2014, p. 259). Clinical psychologists,

can take this information and work to develop more linguistically and culturally appropriate

methods for encountering patients who identify as Hispanic. Knowing that Hispanic patients

tended to have higher depression scores, as well as a higher percentage of previous attempts of

suicide (yet still were less likely overall to attend therapy) (Aponte-Rivera et. al, 2014, p. 261), is

an indication to clinical psychologists that making strides toward inclusion for the Hispanic

community in order for them to receive quality clinical and mental health services is essential. In

addition, it is also implied that some aspects of therapy may need to change or accommodations

may need to be made in order to promote equality, and encourage linguistically and culturally

diverse demographics to seek out mental health services.

When looking at some of the additional research that has been done to address the needs

of the Latinx/Spanish-speaking community here in the United States it is important to address

how our understanding of mental health in general, and the inclusion of this demographic in

various screenings and clinical trials, has enhanced our understanding of how to address certain

mental health issues in clinical and therapy settings. This is due to the fact that in order to know

how to engage in conversations and prescribe effective treatments for individuals in the

Latinx/Spanish-speaking community, we must first understand how they may be affected by

certain mental health disorders. In direct response to this need for more inclusion of minorities

(but Spanish-speaking individuals in particular), a team of researchers focused on depression in

screenings and clinical trials in order to better understand various aspects of mental health related

topics that this demographic may experience (Gonzàles et. al, 1997, p. 94). Working to have a

better understanding of how to identify if a Spanish-speaking individual has depression so that

they may then be able to seek proper treatment is essential (Gonzàles et. al, 1997, p. 94). While it
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is important to remember not to generalize the whole population of Spanish-speakers in the

United States, it is still worthy of noting that the researchers found that Spanish-speaking

participants with self-proclaimed lower acculturation levels identified both an automated voice-

interactive computer-telephone depression assessment method and a face-to-face depression

assessment method to be equally as effective in accessing levels of depression (Gonzàles et. al,

1997, p. 106). What this reveals is that while the method of assessment in this case may not

weigh heavily on the effectiveness of detecting certain mental health related disorders, the

language in which the assessment is conducted may play a role in the quality and accuracy of

detection and treatment.

Language-Concordant Care

The first thing that is important to identify in order to understand the relationship between

language and treatment is language-concordant care. Language-concordance (in the context of

the topic for this paper) is defined as an encounter between a clinical psychologist and a patient

in a therapy setting, in which the therapist and the patient both have to ability to speak the same

language (Molina et. al, 2019, p. 1). In order for accurate communication to occur between a

psychologist and a patient, they need to have a basic understanding of the language that the other

is speaking. Research has shown that the availability of clinical health care providers in the

United States is increasingly disproportionate to the growing population of individuals in needs

of mental health services in the United States who are predominantly Spanish-speaking

(Villalobos et. al, 2016, p. 49). Additionally, Spanish-speaking patients typically do not have the

same access to “linguistically and culturally compatible mental health services” (Gonzàles et. al,

1997, p. 94) as their English-speaking counterparts, even though according to the American

Psychological Association therapy is seemingly twice as effective if it is conducted in the native

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language of the patient. This means that in order to provide higher quality care to a growing

number of patients, clinical psychologists working with Spanish-speaking individuals should be

conducting their therapy sessions in Spanish when necessary, or at least have special

accommodations available. However, this often times is not the reality considering the majority

of clinical psychologists in the United States are not bilingual or multilingual, and they only

speak English.

Depending on the demographic location within the United States, different areas are in

greater need for Spanish-speaking psychologists due to their higher populations of Spanish-

speaking individuals (Jacobs et. al, 2006, p. 3). It is often found that there are larger populations

of Spanish-speaking individuals in various communities throughout the United states, however,

the presence of Spanish-speaking individuals is certainly not limited to distinct areas. Therefore,

as we have seen an increase in recent years of Spanish-speaking individuals and their families

entering into the United States, there is also a heightened need for more Spanish-speaking

clinical psychologists. As described in the literature, data from the U.S. Census in the year 2000,

states that, “… more than 46 million people in the United States do not speak English as their

primary language…” (Jacobs et. al, 2006, p. 2). In addition, this data also shows that while

individuals may have some ability to understand and speak English, this does not constitute these

individuals as being fluent English-speakers (Jacobs et. al, 2006, p. 2).

The implications of language-concordance in therapeutic care are far reaching. Being

able to communicate accurately and confidently is what builds a relationship between the patient

and the therapist. Language-concordant care leads to higher quality experiences for the patient

because speaking a common language helps to build trust between a patient and their therapist

(Molina et. al, 2019, p. 1). This is due to the fact that having a common language increases
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accuracy when clinical psychologists are making a diagnosis based on listening to the patient

(Molina et. al, 2019, p. 1). If the therapist is unable to understand the patient then they are less

likely to be able to understand the situation correctly. This also leads directly into the impact of

language-concordance of treatment options. If there is a language barrier between the patient and

the therapist, then the proper diagnosis may not be made, which leads to ineffective treatment

options (Molina et. al, 2019, p. 1). All of this play into the trust between the clinical psychologist

and the patient. However, for many English-speaking clinical psychologists and Spanish-

speaking patients this relationship cannot be built due to this language barrier. It is for this reason

that language-concordant care in patient and therapist relationships is so essential in order to

provide quality care to individuals.

The reality of quality care as established by The American Psychological Association,

and as pointed out by Valencia-Garcia and researchers, influences not only how language-

concordant care in therapy is conducted, but also in gaining consent before even starting therapy

with clients. According to the APA standards of ethics, clinical psychologists are required to

verify that all patients have given informed consent when receiving any form of therapy or

mental health assessment (Valencia-Garcia et. al, 2018, p. 144). This can present an issue for

clinicians if they are unable to fully and adequately present and explain documents and

procedures related to informed consent with their patients in the necessary language (Valencia-

Garcia et. al, 2018, pp. 144-145). Informed consent with the use of a qualified translator may

provide a valid alternative, however as pointed out in this study, it is imperative that the

interpreter can fully and adequately present and explain all documents and procedures related to

informed consent on behalf of the clinician in order to abide by the ethical standards (Valencia-

Garcia et. al, 2018, p. 145). 

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Biculturalism

Another term that was identified through language and culture barrier psychology

research was what was referred to as biculturalism. Biculturalism is important to understand

when identifying and analyzing the effects of language and cultural barriers in clinical

psychology because it plays a crucial role in the strength of the relationship between clinicians

and their patients. One study in particular that was conducted in 2014 noted that there has been

previous research done which analyzes the Mexican American Bilingualism Scale (MABS), but

took this research even further by analyzing the effects of biculturalism specifically for Mexican

American individuals who speak English or Spanish (Basilio et. al, 2014, p. 541). It addressed

specifically their beliefs and feelings regarding their “bicultural comfort”, “bicultural facility”,

and “bicultural advantages” in speaking their preferred language (Basilio et. al, 2014, p. 543). Of

particular interest for the purposes of this paper are bicultural comfort and bicultural facility.

Bicultural comfort was defined as the individual’s level of comfort when speaking English or

Spanish while bicultural facility was defined as their perceived level of difficulty when speaking

one language over another, or when switching back and forth between both languages (Basilio et.

al, 2014, p. 543). What they found was that high levels of bicultural comfort as well as higher

levels of bicultural facility often lead to higher use of English when speaking, which in turn

revealed that they often also had fewer experiences of discrimination (Basilio et. al, 2014, p.

547). This is important to note when discussing language barriers between clinicians and their

patients because it reveals that patients may feel the need to speak in English (even if it is not

their primary of preferred language) in order to avoid feelings of discomfort and acts of potential

discrimination. However, individuals who seek mental health services but do not have the option
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to speak English may not be afforded the same levels of bicultural comfort of bicultural facility.

This can be very detrimental to their experience and the outcomes in counseling or therapy.

Another way that language-concordance and cultural competency play a role in clinician

and patient relationships is through the ability of clinicians to build a therapeutic alliance with

their patients. In cross-cultural psychotherapy settings, it has been found that within a two-year

time span, most therapists will report numerous encounters working with a plethora of clients

who exhibit culturally and potentially even linguistically different backgrounds (Maxie et. al,

2006, p. 89). Biculturalism and the ability for patients to feel comfortable in therapy through the

facilitation of conversation builds rapport between both parties, and allows for a strong sense of

therapeutic alliance. This has been shown to also increase the outcomes of therapy and

treatments. However, when analyzing other possible options if language-concordance is not

possible directly between a clinician and a patient, research has also been interested in learning

more about the role of interpreters, and if the presence of an interpreter can still illicit this same

therapeutic alliance.

In a study regarding this notion of therapeutic alliance in counseling and clinical

psychology, researchers looked at patients with limited English proficiency, and how their

relationship with a bilingual therapist or their relationship with an English-speaking therapist

through the use of a qualified translator may be similar or different in terms of building a

therapeutic alliance (Villalobos et. al, 2016, p. 56). The researchers involved wanted to identify

if language-concordance between a patient and an interpreter would still yield a strong sense of

therapeutic alliance in comparison to when Spanish-speaking patients had direct access to a

Spanish-speaking mental health care provider (Villalobos et. al, 2016, p. 56). The research

findings noted that there was no significant difference between speaking with a bilingual
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behavioral health consultant directly in comparison to speaking with a nonbilingual health care

consultant through a qualified interpreter (Villalobos et. al, 2016, p. 53) These findings aligned

with that of Molina and researchers who found that “patients’ health outcomes depend on their

belief that they share valued goals with their physicians. An inability to articulate valued goals or

a breach in trust because of a language barrier hence becomes an obstacle to developing a

therapeutic alliance and improving health outcomes” (Molina et. al, 2019, p. 2).

Patient-Centered Communication and Cultural Congruence

While it has been established through various psychology literature that patient-centered

communication is essential to a clinician’s ability to provide quality care to their patients, there

has been limited research done concerning the role of understanding language-concordance in

terms of understanding emotional cues in patient-centered communication (Mujica et. al, 2020,

p. 423). Various cultural beliefs regarding the expression of emotion are relevant in cross-

cultural psychotherapy in its connection to developing a clear understanding of what a patient is

trying to communicate with the clinician (Maxie et. al, 2006, p. 89). For this reason, a team of

researchers focused on emotion-based patient-centered communication, and how this may impact

the relationship between the clinician and their client (Mujica et. al, 2020, p. 423). While they

believed, based on previous research that had been done, that clinicians and patients who self-

identified as the same ethnicity would experience fewer and less obstructive cultural barriers in

respect to their communication of emotions in a therapy setting, they ended up finding that this

hypothesis was not supported by their research findings (Mujica et. al, 2020, p. 425).

Furthermore, the researchers went on to explain that due to a clinician’s awareness of their own

lack of cultural concordance with certain patients, that they may utilize additional forms of

patient-centered communication (such as analyzing tone and body language) in order to make up
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for their potential innate differences in expressing emotion (Mujica et. al, 2020, p. 430). This

sense of self-awareness and patient-awareness on behalf of the clinician may also account for a

stronger sense of therapeutic alliance between the clinician and their patient (due to an

intentional building of trust and understanding on the part of the clinician), which could

potentially be a contributing factor to these results (Mujica et. al, 2020, p. 431). These findings

support the need for more cultural competency trainings for clinical psychologists so that they

have more tools and skills when working with minority and Spanish-speaking patients who may

express their thoughts, feelings, and emotions in ways that are culturally different than that of the

clinician in order to promote a stronger therapeutic alliance in therapy settings. Specific cultural

competency training options include the tradition classroom setting, however, researchers and

experienced educators would argue that structured immersion experiences would result in more

in higher cultural competency outcomes (Domínguez et. al, 2020, p. 2).

It is through patient-centered communication that clinical psychologists are able to

establish cultural congruence in order to meet the needs of their patients. This style of

communication will allow agencies to better reflect upon and analyze the limitations of their

organization in terms of addressing the needs of various minority and linguistically diverse

populations. For example, in a Cultural Congruence Index which focuses specifically on the

English and Spanish languages, patients attending therapy, as well as their clinical therapists, are

encouraged to identify their own personal inclusion of English and Spanish in therapy sessions

(Costantino et. al, 2009, p. 944). Some of the questions involved in this particular index were

directed at the patients, while others were directed at the clinicians. Questions for the patients

were concerning the importance for patients that their clinician speak their native language, or

the importance for them to understand their cultural background (Costantino et. al, 2009, p. 944).
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In comparison, the questions directed at the agencies prioritized the hiring status of linguistically

diverse individuals as members of their staff, if they provide qualified interpreters when

linguistically diverse staff is not available, and the level of encouragement for their staff to attend

cultural competency training (Costantino et. al, 2009, p. 944). Diverse staff and the continued

encouragement of cultural competency training is essential in order to address the continually

growing needs of the Spanish-speaking community and other minority populations.

Putting Language and Cultural Congruence into Practice

One study in particular that was designed to analyze multicultural competence

differences between psychology graduate students and multicultural psychologists who have

professional experience working in the field. In addition, the researchers also wanted to examine

the “Should” vs. “Would” (Sehgal et. al, 2011, p. 4) mentality, and if one group was more likely

to utilize the multicultural practices that they supposedly endorsed (Sehgal et. al, 2011, p. 5).

They found that higher levels of education, and an increase in professional experiences predicted

greater use of demonstrated multicultural counseling competencies (Sehgal et. al, 2011, p. 5).

They also found that certified psychologists who had multicultural experiences working in their

field had significantly higher scores related to the idea that multicultural strategies “Should” be

used, and also demonstrated significantly higher scores that these practices “Would” be used in

comparison to the graduate students (Sehgal et. al, 2011, p. 5). Some of the important practices

that were established during this study that relate to the topic of this paper were the need for

clinical and counseling psychologists to address the realities of language barriers that might be

presented during therapy, as well as the need for clinical and counseling psychologists to address

the realities of immigration history for minority groups here in the United States (Sehgal et. al,

2011, p. 4). Otherwise, they argued that the field of clinical and counseling psychology would
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continue to see poor or ineffective treatment outcomes for patients who identify as part of a

minority population, as well as an increase in the high “dropout” rate of these individuals from

therapy (Sehgal et. al, 2011, p. 1).

However, simply being a bilingual or multilingual psychologist does not automatically

guarantee that they will be able to provide quality care in various languages. The notion of

“professional language” (Costa et. al, 2014, p. 33), is an interesting concept in which

multilingual therapists may still face language-discordance due to the fact that the vast majority

of their graduate and clinical training was conducted in English (Costa et. al, 2014, p. 33). This

affected how they encountered clients in therapy. This is not to say that multilingual

psychologists are unable to communicate with patients in therapy. However, it does imply that

the manner in which graduate students learn clinical skills will influence how they perform and

how they conduct themselves in real world situations. This is simply because in their graduate

programs they may not have specifically learned the psychological/clinical vocabulary and

terminology necessary to conduct quality sessions in other languages (Costa et. al, 2014, p. 33).

These findings would explain why in the study conduct by Verdinelli and Biever, they found that

only seventeen out of a total of 137 “Spanish-speaking professionals” (Verdinelli et. al, 2009, p.

231), actually met the necessary criteria (which included a high enough level of Spanish

proficiency, long enough experience working in mental health services specifically for Spanish-

speaking individuals, and had few to no concerns about their actual ability to conduct therapy in

Spanish (Verdinelli et. al, 2009, p. 231).

CONCLUSION
While there have been advancements in therapeutic services for Spanish speaking

individuals in the United States, there are still many deficiencies in cultural competencies
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and the presence of language barriers that inhibit this demographic from receiving quality

therapeutic care. Overall, this research urges psychology graduate programs to implement more

cultural sensitivity training in their programs, and highlight the need for more Spanish speaking

clinical psychologists in the United States in order to address this diversity and social issue in

which all people have a right to have access to quality mental health care. Based on the

supporting research, I believe that psychology graduate programs need to focus more of their

efforts on “professionalizing language competency,” (Molina et. al, 2019, p. 4). This means

making language-concordance and language competencies a priority in graduate programs where

students will go out and be working with larger members of the Spanish-speaking community.

This will help build stronger relationships between English-speaking clinicians and Spanish-

speaking individuals in need of therapeutic services, which in turn will encourage more Spanish-

speaking individuals to seek mental health services when needed.

Overall, this increase in language-concordant care, and improved communication will

increase accuracy of diagnoses, as well as more effective treatments (Molina et. al, 2019, p. 4).

While there have been strides of improvement, I would argue that measures need to be taken

even further in terms of implementing cultural sensitivity training, and that increasing the

number of Spanish-speaking clinical psychologists in the United States need to increase in order

for psychologists to address this diversity and social issue. Additionally, these steps are required

in order to better abide by Title VI of the Civil Rights Act of 1964, which states that no one

residing in the United States shall be denied services, or be subjected to discrimination due to

their national origin and cultural backgrounds, and ensures that the mental health resources and

services available to the Spanish-speaking population in the United States is no longer

disproportionate to the actual number of people in the US who need them. Overall, this will
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significantly impact the quality of care they have access to in comparison to other groups, and

will ensure that clinical psychologists and mental health service facilities are abiding by The

American Psychological Association's Ethical Principles of Psychologists and Code of Conduct

when working with culturally and linguistically diverse populations.

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