Psychotherapy, Spanish, and Hispanic Patients With Limited English Proficiency

The therapeutic relationship between a physician and Hispanic patient with limited English proficiency (LEP) presents unique opportunities and challenges. Generally, the demand for bilingual physicians far outpaces the supply. Among all medical specialties, this discrepancy is perhaps most consequential in psychiatry. Within psychiatry, the matter of language concordance is most significant in psychotherapy, given its emotionally charged nature, the important subtleties of communication, and the need for cultural humility.

Jerome and Julia Frank (1) understood psychotherapy, at its core, to focus on persuasion and healing, emphasizing the central importance of the therapeutic relationship between healer and patient. Among the most attractive aspects of psychotherapy to medical students is its cultivation of a vision of the patient as a whole person amid reductionist tendencies within medicine. Psychiatrists are the only physicians trained in both medicine and psychology, with a focus on neurobiology. Although other professionals offer excellent psychotherapy, this article is limited to psychotherapy offered by psychiatrists. As a bilingual son of two Colombian immigrants who hopes to offer psychotherapy in Spanish to Hispanics with LEP, I am drawn to these topics.

Population

It is important to remember that “Hispanic” refers to an ethnic group composed of people from various races and with origins spanning 20 countries. Although other terms are often used interchangeably to describe this population, Hispanic is used to emphasize the shared Spanish language. This article does not speak for all 60 million Hispanics in the United States. Rather, it focuses on Hispanics with LEP. Specifically, it focuses on a population that is largely composed of individuals who immigrated to the United States and whose first language is Spanish. Forty percent of Hispanics in the United States are immigrants. Of those who are foreign born, 60% claim to speak Spanish primarily. Approximately 34.8 million Hispanics ages 5 and older speak Spanish at home (2).

Demand

Compared with non-Hispanic Whites, Hispanics are almost twice as likely to prefer nonpharmacological interventions over medications for the treatment of depression (3). Perhaps the most significant demand among this population concerns language concordance. When language concordance is present between patient and clinician, patients report greater satisfaction, more interpersonal care, and more health education (4). However, this ideal scenario is not always possible, and interpreters can play a meaningful role when patients and clinicians do not speak the same language. I have had the privilege to work with very capable and sociable interpreters. They are needed. The integration of additional interpreter roles that go beyond interpreters’ traditional functions, such as cultural broker, advocate, and clarifier, may enhance interpreter-mediated care by strengthening the therapeutic alliance and cultural understanding (5). Clinicians may be better able to understand Hispanic patients with LEP by augmenting the role of interpreters than by attending well-intentioned but limited sessions of diversity training.

Supply

In recent decades there has been a decrease in the practice of psychotherapy among psychiatrists. Between 1996 and 2005, the percentage of psychiatry office visits in which psychotherapy was provided decreased from 44% to 29% (6). Psychiatrists who offer extended psychotherapy often do so at rates unaffordable to many immigrant Hispanic patients and do not accept insurance for these services. Few psychiatrists are Hispanic, and even fewer are fluent in Spanish, relative to the general population. Even rarer is the psychiatrist who is fluent in Spanish and who offers affordable psychotherapy.

What do the future generations of psychiatric psychotherapists look like? In 2019, among 1,621 Electronic Residency Application Service (ERAS) applicants from doctor of medicine–granting U.S. medical schools to psychiatry residency programs, only 111 (7%) were Hispanic. For various reasons, this finding does not suggest that the same percentage of applicants were fluent in Spanish. For example, some non-Hispanic students are fluent in Spanish, although it is difficult to determine the exact number.

In September 2020, the Psychotherapy Caucus of the American Psychiatric Association (APA) hosted a virtual residency fair for medical students seeking strong psychotherapy training. All 260 program directors were contacted through the American Association of Directors of Psychiatry Residency Training (AADPRT). Only 37 (14%) programs offered strong psychotherapy training opportunities and expressed interest in participating. As a member of the planning committee, I recognize that more programs may offer strong psychotherapy training but did not register because they lacked an available representative during the proposed dates. Additionally, they may not have wished to court more applicants, given estimates of increased applications due to virtual interviews during the 2020–2021 ERAS cycle. Of the 37 registered programs, 26 (70%) stated that Spanish fluency would be an asset to their program. However, only 29 (10%) registered students applying to a psychiatry residency in this cycle stated that they had Spanish fluency.

Experience

A physician’s Hispanic last name does not guarantee fluency in Spanish. A disappointment of medical school was learning how few of my classmates with Hispanic backgrounds spoke Spanish fluently. It has been a humbling opportunity to serve Hispanic immigrant patients because I am often the only fluent Spanish speaker for a given service. I have sincere respect for people from other ethnic backgrounds who have learned Spanish through their own efforts. Yet, in addition to language skills, knowledge of the cultural idiosyncrasies and of the diverse beliefs within this patient population are necessary to establish a robust therapeutic relationship. It is this knowledge, combined with fluency in the patient’s preferred language, that allows for the most direct and comprehensive service to those with the greatest needs.

A deeper and often neglected point in patient care is that Hispanics in the United States, especially immigrants, tend to have higher levels of religious participation than non-Hispanic Whites (7). This discrepancy is even more stark when compared with average historical levels of religious affiliation among psychiatrists (8). However, psychiatrists need not have any religious affiliation nor share the tradition of the patient; a sincere openness to understanding the general philosophical and theological commitments of the average Hispanic immigrant patient may strengthen the therapeutic relationship. This effort may help clinicians more respectfully address and better understand concerns of suffering and meaning that patients may consider central to their situation. The promise of fourth-wave psychotherapies and their openness to a diversity of worldviews may help to address the unique needs of Hispanics and other minority groups (9). A recent meta-analysis has found that, compared with standard approaches, religious and spiritually accommodated psychotherapies are equally effective in reducing psychological distress and result in greater spiritual well-being in patients with religious or spiritual commitments (10). These psychotherapies may be effective avenues to better engage this population with psychiatric care and with psychotherapy, specifically.

Opportunities

There are several potential opportunities to increase the number of psychiatrists practicing psychotherapy in the United States who speak Spanish fluently. The Waco Family Medicine Residency Program in Texas has a Spanish-language track aimed at equipping residents to better serve the unique needs of Hispanic patients. Psychiatry programs may consider adopting similar opportunities parallel to specific psychotherapy tracks.

Bodies within organized psychiatry, such as the APA and the American Academy of Addiction Psychiatry, have attempted to recruit more students from underrepresented groups into the field. However, more specific efforts to recruit bilingual medical students into psychiatry may increase the workforce capable of better serving the Hispanic patient population. This need highlights a potential opportunity for collaboration between the APA Psychotherapy Caucus, APA Hispanic Caucus, American Society of Hispanic Psychiatry, AADPRT, and the American Academy of Psychoanalysis and Dynamic Psychiatry.

Understanding the economic capacity of the average immigrant and offering pro bono or reduced-cost psychotherapy may partially serve to meet patient needs. However, cost reduction is not a service that can be mandated, and it will not solve the problem of limited capacity. Increasing access via greater psychotherapy coverage by insurance plans of all types may have longer lasting effects. These efforts may be further strengthened if organized psychiatry places a greater emphasis on the need for psychotherapy, especially among lower-income patients.

For the near future, the national need for Spanish-language psychiatric care will continue to be larger than the current supply of bilingual clinicians can meet. This need may be partially met by increasing coverage for interpreters and strengthening training for both interpreters working in psychotherapy and for clinicians working with interpreters.

Unique training allows psychiatrists to integrate biological and psychological perspectives. As such, psychiatrists should not abandon psychotherapy. To do so may further exacerbate the unmet needs and preferences of various Hispanic immigrant patients with LEP.