Cultural and linguistic proficiency in mental health care: a crucial aspect of professional competence

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”– Nelson Mandela

The United States (U.S.) population is becoming increasingly older and more ethnically and racially diverse, a trend that mirrors that of many other countries across the world. It is projected that by 2043, the U.S. will become a majority-minority nation, where no ethnic/racial group comprises a majority of the population (U.S. Census Bureau, 2012). Nearly 21% of the U.S. population, or over 60 million people, speak a language other than English at home. Of those, 41% report not speaking English very well, and thus may be considered persons with limited English proficiency (Ryan, 2013). It is becoming increasingly recognized that mental health systems in the U.S. are not prepared to serve the current and growing numbers of culturally and linguistically diverse clients, which has prompted a call for action in the field of mental health (Mental Health America, 2016).

The involvement of professional, well-trained language interpreters is undoubtedly paramount to the provision of linguistically appropriate health services, particularly when the patients being served speak a language that is used by a very small portion of the population in that country or region. The paper by Wand and colleagues (this issue) (2019) describes important considerations for the use of interpreters in the mental health assessment of older people and provides strategies to enhance clinical services delivery in this context. In their well-thought-out paper, the authors describe the importance of interpreter training and experience and the impact that the relational context involving interpreter, clinician, and patient might have on mental health assessments.

As noted by Wand and colleagues (2019), the use of interpreters in the assessment of psychiatric symptoms might pose special challenges. Since psychiatric evaluation hinges on obtaining a thorough history, and a good diagnosis often depends on clear, accurate descriptions of symptoms, language barriers can prevent recognizing and labeling mental health problems and can interfere with successful communication about treatment needs and care options (Kim et al., 2011). Having the mental health provider be able to communicate with the patient in their language might be particularly important when working with patients with certain conditions, such as neurocognitive disorders. Such disorders, particularly those associated with Alzheimer’s disease, vascular and related etiologies, are quite prevalent among older adults. Per the Diagnostic and Statistical Manual for Mental Disorders-fifth edition (DSM-V) criteria, the gold standard for the diagnosis of neurocognitive disorders necessitates objective neurocognitive data. There are many language-related issues that warrant special consideration in neuropsychological assessments, including the importance of utilizing cognitive tests that have been developed in the language of the patient and normed in a population representative of the examinee, and the importance of training in the administration of such tests in order to maximize accuracy of the data collected. In addition, real-time translation does not allow for careful consideration of complex clinical issues. These factors are important even when screening for dementia (Pachana et al., 2010). The use of interpreters in neuropsychological testing can greatly influence neuropsychological test results, particularly verbally based tests (Casas et al., 2012). Thus, the use of interpreters in neurocognitive assessments is highly discouraged whenever practically possible.

Wand and colleagues (2019) also discuss two strategies to improve access to culturally appropriate care: (1) training clinicians to work effectively with interpreters and patients of culturally and linguistically diverse backgrounds, and (2) training and employing clinicians from culturally and linguistically diverse backgrounds. While we recognize the value of a multidimensional approach to improve the mental health care of culturally and linguistically diverse individuals, we find this latter point by Wand and colleagues (2019) particularly relevant in the context of the current demographic trends and state of mental health care in the U.S.

Among the many individuals who speak a language other than English in the U.S., 62% or over 37 million people speak Spanish at home (Ryan, 2013). The current number of Spanish speakers in the U.S. comes second to only one other country in the world (Mexico) and surpasses the number of Spanish speakers in Spain. While there is a role to be played by well-trained language interpreters in the provision of mental health services, this should not be the primary strategy when providing services to people from a majority minority language, particularly a language that has been historically and currently spoken by a very large number of people in that country. The more culturally responsible and ethical approach is to assure that there are sufficient well-trained mental health professionals who are linguistically and culturally proficient to serve this population.

Cultural and linguistic competence in the delivery of mental health services can have a profound effect on access to and quality of care among ethnic/racial minorities. Vital for the delivery of such services is a diverse workforce that also represents the population (Sanchez et al., 2016). Hispanic/Latino adults with limited English proficiency are less likely to utilize mental health services, when compared to their peers who are proficient or fluent in English (Kim et al., 2011; Ohtani et al., 2015). In addition, a qualitative study found that the single factor that contributed most to use of the mental health services by individuals with limited English proficiency was access to providers who spoke their native languages (Patel et al., 2013). Taken together, these results suggest that language, in addition to cultural factors, plays a role in the gaps in mental health treatment seeking behavior and access and indicates that having a diverse workforce might help mitigate this issue.

There are no comprehensive data on the number of mental health care professionals who speak Spanish in the U.S. Yet, the data available suggest a notable underrepresentation of members of ethnic/racial and language minority groups among mental health providers (Sanchez et al., 2016; Velasco-Mondragon et al., 2016). The American Psychiatric Association (2017) has described the shortage of bilingual and linguistically trained mental health professionals as one of the important barriers to mental health care for Hispanics/Latinos in the U.S. (American Psychiatric Association, 2017). There is a need to develop concerted strategies to identify, recruit, retain, and support potential mental health providers from diverse backgrounds starting early on in their careers. It is also crucial to provide them with continued support, resources, and incentives to practice in culturally and linguistically diverse communities.

The use of lay health workers (e.g. community health workers, peers) might also effectively engage older adults from racial/ethnic minority groups since they are less likely than their White counterparts to seek care from conventional mental health providers (Jimenez et al., 2013). Previous studies have found that lay health workers contribute to low attrition and high session attendance (Weaver and Lapidos, 2018). Lay health workers are part of the communities in which they work – ethnically, socioeconomically, and experientially. They possess an intimate understanding of community social networks, strengths, and health needs; communicate in a similar language; and recognize and incorporate culture to promote improved mental health outcomes (Waitzkin et al., 2011). Lay health workers can effectively deliver evidence-based treatments (Reynolds and Albert, 2010). Therefore, it is possible that their roles and responsibilities domestically could be expanded to meet the needs of communities with access and utilization disparities. Potentially, community health workers may be mobilized to step into the role of primary providers of evidence-based treatments in settings with severe workforce shortages, but even in higher resourced settings they may be involved in evidence-based treatment delivery for individuals with lower levels of need, such as those who would benefit from prevention services (Barnett et al., 2018). Lay health-worker-delivered prevention and early intervention services would allow trained mental health professionals to focus their expertise on individuals who require more intensive services (Acevedo-Polakovich et al., 2013).

The utilization of telemedicine in mental health care of the elderly has considerably expanded over the past few years and is another useful tool for the provision of culturally and linguistically competent mental health care for the elderly (Ramos-Rios et al., 2012). Another approach is to train members of the majority culture in the provision of cross-cultural services and provide them the opportunity and resources to learn the language of particular populations in which they might be interested and able to serve. We recognize that it will likely take years for the results of such efforts to become evident. In the meantime, mental health professionals will continue to confront practical dilemmas related to the provision of services to culturally and linguistically diverse population. The use of well-trained interpreters and lay workers may be some approaches that can be implemented more readily, but it is important that these approaches are not viewed as the sole or best way to serve the vast, growing, and often underserved segment of the population with limited English proficiency in the U.S. We must rise to the challenge and have language and cultural proficiency of mental health care providers take center stage, as it is a crucial aspect of professional competence.