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Providing Therapy Across Different Cultures


This is TALK OF THE NATION. I'm Neal Conan, in Washington. Mental health professionals believe that many of those most in need are among the most difficult to reach. According to census data, 40 million immigrants live in the United States. Almost all come from different cultural traditions, and many speak English as a second language. Relatively few practitioners are trained to work through the barriers of tradition, culture and language. It's been reported, for example, that most Latinos who seek mental heath services never return after that first visit.

If you're a practitioner or a client, call and tell us about the challenges: 800-989-8255. Email us: talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, the latest skirmishes in the shadow war between Iran and Israel. But first, Stacey Lambert joins us from a studio at Wellesley College. She directs the Latino Mental Health program at the Massachusetts School of Professional Psychology in Boston.

Nice to have you with us today.

STACEY LAMBERT: Hi. Thank you, Neal. I'm happy to be with you.

CONAN: And I wonder if there's a patient you could tell us about who exemplifies the need for specialized training.

LAMBERT: Sure. Well, you know what? I've treated many clients from a Latino background, and one in particular stands out, a woman who had schizoaffective disorder, which is a form of psychosis. And she presented for treatment with her family. And this was earlier in my training. And my first thought was: Let's meet with her individually and talk a little bit about what he life goals are, and taking that very individualistic approach with her, and really having to learn that - through trial and error, that the Latino population tends to have much more of a collectivist orientation, and the family is very critical.

And so that was my first mistake, learning that person could only get as well as the family will allow, and that family supports can be tremendously helpful in recovery. And so working with her and learning about engaging the family and letting go some of the earlier Eurocentric ideas I have had from my training - for example, one of the things we tend to think about from American culture is the concept of separation and individuation: the importance of going to college and, you know, going to live by yourself and establishing your own identity in those type of ways.

And so as she came in and we were trying to stabilize her psychotic symptoms and generate a treatment plan and did she want to go to college and what were her options, having to think through the difference - as I was saying - between what an American ideal would be versus what the family felt was appropriate about when she should leave home or not leave home. For example, many Latino families feel that the person belongs to the family unit until marriage.

CONAN: And I assume that language was some degree of a problem, as well.

LAMBERT: Actually, that's a very good point, because in this particular case, the client was bilingual and - as well as the father. But the mother was not very acculturated, and so she only spoke Spanish. And so having to engage the mother through being language-competent to provide services in Spanish was a critical element.

CONAN: So experiences like that, I assume, led you to the understanding that cross-cultural therapy was something that needed to be explored.

LAMBERT: Exactly. Exactly. I think that for - I'm a little bit older now, as a clinician. So - but when I went back to - when I was in graduate school, the training really didn't include a heavy emphasis on cultural competency. And when you go out and practice in reality and you realize that people come from many different backgrounds with many different world views about the ideology of mental illness and - related to what you believe causes mental illness, therefore what treatment you might accept to remedy the mental illness.

And so learning about the different backgrounds really - I ended up learning that later on. And so now, as an educator, it's very important that we integrate that into the training work for new mental health providers.

CONAN: It's interesting, we have an email, this with us from Skip in Little Rock: In the late 1960s and early 1970s, I lived in Asmara, Eritrea, which was then part of Ethiopia. I was stationed there as an Arabic linguist, and remained there, participating in archeological digs while learning Tigrinya, the local language. A decade later, while working as an occupational therapy assistant in Boston Psych Hospital, an acutely ill patient, a refugee from Eritrea, came under my care. Her traumatic condition caused her temporarily to lose her English, so my ability with Tigrinya - such as it was - proved essential in her treatment.

I served as translator during several psychological exams, including a Rorschach test, one of the most demanding and humbling experiences of my life, since her care depended on my ability to interpret her words. Fortunately, she was as resilient as are most of her compatriots and soon recovered her English and psychological well-being. So that's just an example of, well, a relatively obscure language being called into practice. But there are any number of examples of, well, kind of those cultural misunderstandings that, Stacey Lambert, those come up all the time.

LAMBERT: Absolutely. The language is particularly prominent for the Latino population, because there are a large percentage of Latinos that don't speak English or don't speak English at least as a primary language. And then if you look at the demographics on the number of Latinos, about 16 percent of the American population is Latino, and only about 2 percent of mental health providers report being able to be ethnically matched, as well as language-competent to be able to provide the services.

So there's a real supply-and-demand problem, and what ends up happening in mental health facilities is that you may, as a client who doesn't speak English, wait longer. You'll stay on a waiting list to get services, or people will end up having to use a translator. And a lot of times, if there isn't a translator available, you might use a family member. And when you're discussing very intimate issues, you don't always want to bring your grandmother or your child in to serve as a translator for you.

CONAN: Now, let's see if we can get a caller in on the conversation: 800-989-8255. Email: talk@npr.org. Matthew's with us from Myrtle Beach in South Carolina.

MATTHEW: Hello. I'm on the air?

CONAN: Yes, you're on the air. Go ahead, please.

MATTHEW: OK. Hi. First of all, love the show.

CONAN: Thank you.

MATTHEW: I'm calling - I worked at a - as a tech at a geriatric facility. And we had a patient who spoke no English. And we were - it was on the report that he spoke Spanish. But no one spoke Spanish. Some of the nurses thought it was Portuguese he was speaking. One was - swore up and down that it was Italian. But - and - so he didn't understand a single thing. We're saying we don't understand what we're talking to him about. And on top of all this, he has advanced dementia.

So we don't know whether he's not understanding us just because we're - our grasp of the Spanish language poor, or if we're not speaking the right language, or if just the words wouldn't be reaching him even if he understood us. So it just made everything extremely difficult on a number of levels.

CONAN: Were you able to eventually cross that divide?

MATTHEW: No. We never really were. He was in a pretty advanced state. I honestly don't even know if the poor guy is still alive. But, ultimately, we just sort made do the best we could. And, I mean, a lot of it is, you know, gestures and sort of - there's a lot of common, you know, interactions. But, I mean, you could tell that it obviously frustrated us, and you could tell how badly it frustrated him.

CONAN: Yeah. Dementia obviously more than bad enough, but how much more lonely and confused he must have felt under those circumstances.

MATTHEW: Yeah. Absolutely.

CONAN: Matthew, thanks very much for the call.

MATTHEW: All right. Thank you.

CONAN: And those are the kinds of situations, Stacey Lambert - well, how do we get out of this veil of ignorance?

LAMBERT: Well, I think one of the things is training the new providers to be linguistically, as well as culturally, competent. And so that really is very critical. One of the programs that we have at Massachusetts School of Professional Psychology is, in addition to the general doctoral curriculum, is we offer special courses in understanding the Latino culture, as well as language training. And we send our students to South America for - and Central America for two summers to be able to gain some cultural and language competence that will enable them to provide services.

So I think it's really about education. But also, I think we've been focusing a lot of the linguistic competence as a barrier, but in addition to that, I think there are a lot of systemic factors, as well, that lead to health care disparities, that we don't have proper office hours or clinics that are located in the communities that all of these clients reside in. Clients sometimes can't access services because services happen during bankers' hours, and they don't have child care or they work two jobs. So there are a lot of other factors that lead into this, as well.

CONAN: You mentioned sending students to study in other countries. Why to Mexico or Puerto Rico or someplace like that, as opposed to just a Spanish-language community right there in Boston?

LAMBERT: That's a very - it's a very good question. One of the things that we feel is most important is the social-cultural experience. And so our students will actually reside with families that only speak Spanish. So, even under duress, where the student wants to eat and they're hungry and they don't know how to say something, they're going to have to learn how to say it in Spanish or use gestures. And - but we really feel that emersion is very important to learning.

And so they become part of the communities, and we take a real social justice perspective, that we want to give back to these communities, as well. So we're taking from them in terms of learning the language and their cultural mores, and we are giving back to the students while they live with these host families. They're also volunteering, and the community providing much-needed services for communities that, for thousands of people, may have one psychological provider.

CONAN: Let's get another caller in. This is Gabriel, Gabriel with us from Fargo, in North Dakota.

GABRIEL: Hello. Can you hear me all right?

CONAN: Yeah. You're on the air. Go ahead.

GABRIEL: All right, lovely. Well, my experience - this was before I started graduate school. I'm doing graduate school for college counseling currently. But I worked in a psychiatric intensive care unit, and we see a lot of refugees. We had a gentleman from Bosnia come in, and he - his English wasn't quite there. So I found out he spoke German by first finding out what the Bosnian term for German was, and thankfully, through an education cultural background, I was able to alternate between that Bosnian and German, and then English, and kind of became the go-to with this gentleman. But, yeah, I guess that's my story. And...

CONAN: Were you able to help him?

GABRIEL: I was very much able to help him, as much as we could in that setting, with someone having (unintelligible). But, yeah, I was - I mean, I guess I would say I was able to help improve his quality of stay while he was at our facility.

CONAN: Well, thanks very much, Gabriel. Appreciate it.

GABRIEL: Thank you.

CONAN: We're talking about counseling and cross-cultural differences and language barriers. If you're a therapist or visit one and you've run into issues, call - with this, call us and tell us about the challenges: 800-989-8255. Drop us an email. The address is talk@npr.org. When we come back, we'll be talking with Karen Hanscom, executive director of Advocates for Survivors of Torture and Trauma, and about the special challenges that entails. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION, from NPR News.


CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan.

We're talking about the issues that arise when mental health professionals try to treat immigrants, many of whom come from different cultures and don't necessarily speak English as a native. If you're a practitioner or a client, call and tell us about the challenges you've encountered when offering or seeking help. 800-989-8255. Email us: talk@npr.org. You could also join the conversation on our website. That's at npr.org, click on TALK OF THE NATION.

Our guest, Stacey Lambert, director of the Latino mental health program at the Massachusetts School of Professional Psychology, a program that helps students understand the differences between Latino groups and the economic and social factors that can affect their mental health. And the gaps in understanding can be especially wide when clients are refugees from war torn countries.

Joining us here in Studio 3A is Karen Hanscom, executive director of Advocates for Survivors of Torture and Trauma. Her organization provides free counseling and specialized training for professionals who deal with torture survivors. It's nice to have you with us.


LAMBERT: Thank you.

CONAN: And, again, I was wondering if there was a story of one of your clients that would illustrate some of the problems that we've been talking about.

HANSCOM: One of the first clients that I saw from another country was from Asia. And this client had been diagnosed at a hospital as being psychotic. When I first met with the client, I immediately became aware that this person wasn't acting like a psychotic person. In fact, what the person was reportedly doing is something that was very common in her culture, which was getting into quiet places and speaking with her deceased ancestors. It was not psychosis. It was very much just part of the culture. And yet seeing it in the Western views, she appeared psychotic.

CONAN: So, a grand success. Congratulations.


CONAN: But I assume there are other situations that are much more intractable.

HANSCOM: Yes. You know, particularly in the individuals that we see, we see torture survivors. And of that large group of refugees, that was defined, within that there are a conservative estimate of 500,000 torture survivors in the United States today. And they show up in clinics and in our churches, in our neighborhood.

CONAN: And there's no registry of these people?

HANSCOM: No. There's no registry. And they bring with them some particularly - other difficult things. For example, while most all refugees have experienced war trauma, these individuals have experienced the trauma of torture. And so in addition - an additional part of therapy is to first establishing that safety and trust is critical to moving forward with the client. Next is the - determining what the person's view of what the therapist's role might be.

And then we have the therapist's view of what the therapist needs to be. We have to find where that converges and what the two hold in common and be sure that we educate each other about what we perceive as what's going to happen in the sessions with us.

CONAN: I remember speaking with - doing a series of stories about the survivors of Batan, you know, the camps in the Philippines and then the hell ships that sent them to Japan. And it was fascinating because so many of these men that I spoke with had never spoken about this in public or with their families. There was a moment, three of them were in a room and we were interviewing them. One of their wives came in with tea and they immediately quieted as she served the tea, waited until she left and then started speaking again.

And I assume the difficulties that these people in our culture that we're so familiar with had, speaking about their experiences, very horrific, obviously, this could be totally exacerbated when you're speaking with people from a different culture, and, again, the language barrier.

HANSCOM: Yes. Absolutely. And it is very difficult that most of the individuals that we see have never told another family member or anyone else about the experiences that they've had. So this is sometimes the very first time that they've spoken about these things.

CONAN: Stacey Lambert, I wondered if you had any insight on this.

LAMBERT: No, I agree. I think she had a very good idea about it. It's a collaborative that we can learn from the client and have them help us to understand their culture 'cause it would be certainly impossible to be an expert on every culture. And I think clients appreciate that when we ask them, help us understand from your point of view.

CONAN: Let's see if we get another caller in on the conversation. Let's go to Mark. And Mark is with us from St. Louis.

MARK: Good afternoon. This is a really good program. I am a substance abuse counselor, and for a time I worked with an assertive community treatment team, working with the severely mentally ill living in the community. The idea being we want to keep them in the community, keep them in their own places. It's a better quality of life and a lot more cost effective in terms of providing services.

But we had an incident where a translator was called to an emergency room because the emergency room people had this Mexican guy who appeared to be - well, he was reporting hearing voices. So they thought he was schizophrenic. She sits down with him and says, I understand you're hearing voices when no one is there. And he says, yes, that's right. And she says, well, what are the voices saying? He says, I don't know. She says, can you not hear them? And he says, oh, I can hear them just fine, but they're speaking in English.

So he's having oratory hallucinations in a language he doesn't speak, which is unusual, to say the least.

CONAN: Yeah.

MARK: And at that point, the page clicks in and says, Dr. Jones to the emergency room. And he looks at the translator and says, you see? There it is again.


MARK: The issue being that the people who he was talking to in the first place didn't have a sufficient command of the language to differentiate between actual hallucinations and what he was experiencing. Sometimes the words don't literally translate from one to another, and creating enormous amount of confusion.

CONAN: I can understand. Of course, he had no - probably no experience with paging systems before. So, there you go. Mark, thanks very much. It's interesting.

Here's an email from John in New Mexico. While serving as a court-appointed attorney in a competency hearing in the 1970s, the client wouldn't talk or care for herself. And the recommendation from a medical professional was commit her. And she was obviously Japanese. I asked a Japanese person I knew to speak with her, and found out she was estranged from her son and husband, had just died. She was a military bride and felt she would be ostracized back in Japan by her family.

With that knowledge we were able to engage the Japanese embassy to my knowledge. She returned to Japan instead of going to a state hospital. And that speaks to the difficulties that Karen Hanscom, some of the people you deal with - they are just isolated.

HANSCOM: Yes, that's really true. Because some of the other elements that we're dealing with is our different worldviews. Different views of why bad things happen to good people. For example, we have some people believe that their trauma is related to karma. Others believe that they're being tested by God. So these worldviews are part of how the client is seen. Their religions take a real prominence in treatment.

In the United States we're taught, as psychologists, that we really don't get into one's religion. Yet with the torture survivors that we see, to not do so, would be quite an error. Because, for most people, that's what has kept them alive and continues to help them through time.

CONAN: Let's go next to Jordan. Jordan with us from San Antonio.

JORDAN: Yes. Thanks for having me on. I just wanted to speak from a research-oriented perspective and just talk about how language plays a really important role in something we call the informed consent procedure. I work with a mostly Spanish-speaking population here in San Antonio, and previously when I worked at a (unintelligible) pediatric burn hospital in Galveston.

And you really have to be able to command the language completely in order to explain to someone what you might be doing to them in a research setting. It's really important that you can make the patient understand absolutely everything about the procedure. And a lot of times when you invite either a family member or possibly someone, you know, a nurse who says they speak Spanish, you can't communicate exactly what you are intending in the process.

Words might be lost - literally lost in translation. And it's very important that the whole of the understanding of the informed consent process is preserved.

CONAN: That's interesting. Stacey Lambert, I'm not sure informed consent in terms of research comes up often in your practice, but you must have to explain what certain drugs may do and what the side effects may be - that sort of thing.

LAMBERT: Absolutely. And that's why the communication and the language barrier becomes such a problem because people have to - we have to be sure that people understand their choices, their options in a way that they can make informed decisions about them.

CONAN: Thanks very much for the call, Jordan.

Informed consent, Karen Hanscom?

HANSCOM: Well, I'm thinking of even more than in informed consent, I'm thinking that, you know, in general, well, interpreters are awesome people because they're not only explaining the language, but they're doing many other things simultaneously. We currently have a project under way called The Voice of Love. We are training interpreters how to do the specific work of dealing with torture and trauma survivors.

The symptoms that they might see such as dissociation occurring right in the session, these sort of things. But interpreters are just so very, very valuable to our work.

CONAN: This is an email from Ann. This reminds of the need for court interpreters. Your guest noticed the problems with relying on a family member to translate. Using a staff member with knowledge of a patient's language can be equally troubling. Court interpreters have a strict set of ethics they may follow. Are there any ethical guidelines for patient translators? In your experience, Karen Hanscom?

HANSCOM: Yes. I understand there are many specific ethical rules that are - interpreters are bound by.

CONAN: And I think, Stacey Lambert, you were talking sometimes about having to use family members, particularly when languages are less easy to come by. That may be also difficult, too, ethically.

LAMBERT: Absolutely, because clients don't always feel comfortable to self-disclose very intimate issues in front of family members. And we also - you have the other issue. One of the callers, I think, had mentioned the concept of using a nurse or - but where, in certain clinics - maybe you're in rural areas where you don't have full access of professional staff - you sometimes end up pulling out a front desk clerk or something of that nature, and you're putting - you know, talking about very sophisticated issues in front of people that are - create ethical issues.

CONAN: And not just a family member who may not be willing to disclose something in front of their, as you said, their grandmother or their child, but maybe a grandmother or a child not wiling to translate what they've been told.

LAMBERT: That is true. That's a huge problem with using nonprofessional interpreters is that they will edit, and so you'll get half of the story because they may be saying something about the private family dynamics that they don't want the laundry aired.

CONAN: Here's an email that we have, this from Matt: Not only can this misunderstanding of culture happen through immigrants and language barriers, but even within our own diverse nation. I know an ER doctor who was beginning to fill out paperwork to have a woman given a psych evaluation because she claimed the Sunbeams were driving her mad. They wouldn't stop talking, no matter what she tried or offered them. This doctor had just moved to Provo, Utah, from the East Coast, had no idea that the Sunbeams is the name of the nursery program in the LDS church, and she was speaking to the director of the nursery who was having a nervous breakdown. Needless to say, the new ER doctor was quickly brought up to speed on the new cultural norms that she would be living with.

So, yes, of course we can have regional and local variants, that our ignorance can be profound on those levels too. We're talking with Stacey Lambert, director of Latino Mental Health Program at the Massachusetts School of Professional Psychology. Also with us, Karen Hanscom, executive director of Advocates for Survivors of Torture and Trauma. You're listening to TALK OF THE NATION, which is coming to you from NPR News.

Shelly's on the line, Shelly with us from Honolulu.

SHELLY: Aloha. I'm a psychiatric clinical nurse specialist in private practice, and I got a referral from a place I used to work. It's a residential facility for homeless people. And I got a referral for a Japanese gentleman, and he didn't speak very much English. So I had to conduct my psychotherapy sessions in Japanese with him and explain medications and find out what was going on with him. He was psychotic.

CONAN: He was psychotic. So were you able to eventually help him?

SHELLY: Yes. My Japanese is OK. But in order to really find out what was going on, I think the bond you have as a therapist, you know, just the therapeutic sense of self and the sense of caring was what was most important with this particular gentleman, because he never discussed his mental illness with anyone else before. He told me about his voices and what the voices had said. He also had talked about the shame he was enduring for being mentally ill, losing his job, becoming homeless and feeling estranged from everyone.

CONAN: Sounds like your Japanese was more than OK.


CONAN: So, clearly, there was more than a language barrier involved here. It was trying to reach out to a person who was speaking not - maybe not in the same direct language you might expect from someone raised in New York.

SHELLY: Yes. And the other thing I wanted to add was that I - he needed a lot of social services. And when I tried to, you know, get a case manager for him, I found that it was like one size fits all. And I tried to explain that he did not want to be back in the Japanese community because of all the shame involved with his losses. And so I spent a lot of time discussing this with the case manager, and so we came up with a more individualized plan for him so that he could maintain his dignity.

CONAN: That's an interesting story, Shelly. Thanks very much. And I'm sure that...

SHELLY: Thank you. Aloha.

CONAN: Aloha to you, too. Here's an email question from Betsy(ph) in Denver: Aren't we still going by a white American cultural model by assuming it's always best for a person to talk through their traumatic memories?

I wonder, Karen Hanscom, if you could talk about that.

HANSCOM: Yes, we are. Well, first of all, we do know that particularly women - and also men in other cultures - often find ways that they sit together and talk in a group setting. For example, we have the old men that sit by the grocery store, or we have the women that are doing a common thing, like even the women who do quilts in the United States. So some degree of talking with others is always, by many cultures, seen as a help. We do need, however, to be - think broadly in terms of the types of treatment for people from other cultures, other ways in which they might be able to speak of and get help for the issues that they're dealing with.

For example, we do things like we have a photography group where people take photographs and then write about it, and various other art groups and things like that.

CONAN: I think, Stacey Lambert, these cultural assumptions must come up in your thinking all the time.

LAMBERT: Yes, absolutely. The concept of psychotherapy was originally referred to as the talking cure, but that is a very Eurocentric ideal. And we have many other ideals that are from - based on a white, middle-to-upper class culture. For example, even the concept of therapy, in and of itself, is about planning and insight and future-oriented, about what will I want my life to look like in six months, in a year. And for certain cultural groups who - and they have a correlation with lower socioeconomic status, this concept of future-oriented and planning isn't always an option.

For example, if you live in an inner city, planning what I'm going to do - be doing next year isn't something that's on my radar screen. So we definitely have to think about: How do we modify these - our psychotherapy practices to be suitable to clients from different backgrounds.

CONAN: Stacey Lambert, thanks very much for your time today. I appreciate it.

LAMBERT: Thank you.

CONAN: Stacey Lambert, director of the Latino Mental Health Program at the Massachusetts School of Professional Psychology. She joined us from a studio at Wellesley College. We apologize for that little electronic bolt that there was audible there just a second ago. Our thanks as well to Karen Hanscom, executive director of Advocates for Survivors of Torture and Trauma, based here in Washington, D.C. She was kind enough to join us here in Studio 3A. Thanks very much.

HANSCOM: Thank you.

CONAN: Coming up, Jackson Diehl of the Washington Post on what he described as Iran's measure of desperation, as evidenced by incidents this past week in Bangkok, in Tbilisi, in Georgia and most especially in New Delhi. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION, from NPR News. Transcript provided by NPR, Copyright NPR.