Latinos

The rapidly growing population of Latinos/as in the United States underscores the profound need for counselors to broaden their clinical treatment approaches to attend to specific culture-related concerns. Latinos/as are faced with a number of social, health, and psychological difficulties that affect their need for mental health services. The negative impact of these life circumstances has made Latinos/as susceptible to a variety of mental health problems. However, because of a number of institutional and cultural barriers to treatment, Latinos/as tend not to make use of available mental health services in U.S. society. To increase utilization and effectiveness of treatment, and decrease early termination, the Latino/a population requires counseling services that will meet their needs in ways that are culturally relevant. The more mental health services reflect the culture of the Latino/a client, the more likely the services will be utilized and effective.

Latinos/as are an ethnically diverse group that includes Mexican Americans, Puerto Ricans, Cubans, Dominicans, and Central and South Americans. The cultural roots of each Latino/a country are a distinct mixture of indigenous, European, and African influences, resulting in differences in cultures for each country and differences in racial makeup of the individuals of that country. As a result of this blending of cultures, the term Hispanics has often been rejected by groups who believe the term excludes the indigenous and African influences, while others believe that the term Hispanics is a generic term imposed on Latinos/as by the U.S. Census to calculate the numbers of a new population group. Consequently, the term Latinos/as rather than Hispanics is used in this entry to reflect a more inclusive and politically progressive term. Furthermore, because of the differences in ancestry among and within each country, Latinos/as vary greatly in terms of racial makeup, with a blend of Spanish, Native American, Black, and Asian descent.

Therefore, the term Latinos/as emerges not only as an inclusive ethnic term, but also as a term that contains a racial component as well, leading others to claim the term is somewhat ambiguous.

Latinos/as make up the largest racial/ethnic group in the United States, comprising an estimated 37.4 million people, which is equivalent to 13.3% of the U.S. population. Projections for comparative growth rates indicate that the Latino/a population will increase at a rate 3 to 5 times faster than the general population with an estimated 100 million by the year 2050, resulting in one in four Americans identifying themselves as Latino/a. Currently, Mexican Americans comprise the majority of Latinos/as in the United States, followed by Central and South Americans, Puerto Ricans, Cubans, and other Latinos/as. The Latino/a population is geographically concentrated, with 87% residing in 10 states: California, Texas, New Mexico, Colorado, New York, Florida, Illinois, New Jersey, Arizona, and Massachusetts.

Because the Latino/a population is a rapidly growing ethnic group, the need for services to address their mental health concerns is tantamount. Latinos/ as face a number of sociocultural, physical, and mental health problems, including immigration and acculturation stress, language barriers, disrespect for their culture, discrimination in employment and education, and poverty. This constellation of negative life circumstances makes Latinos/as vulnerable to mental health problems that require specific psycho-therapeutic services.

Mental Health Needs of Latinos

For Latinos/as who immigrate to the United States, immigration can be a source of considerable stress. As a result of being transplanted into a foreign culture and away from the familiarity of his or her own culture, the individual can experience a negative impact on his or her mental health. Moreover, some immigrants arrive in the United States as political refugees with the additional psychological distress of the experiences of war and violence in their native countries. Furthermore, many Latinos/as immigrate to this country without family members, resulting in a lack of a social support network and feelings of loss and guilt for the family members they left behind. Additionally, many Latinos/as settle into poverty-stricken neighborhoods, often with dilapidated housing conditions and high crime rates, where illegal drugs and gangs are often present. These are persistent stressors that adversely impact the new immigrants.

In addition to the stress associated with relocation to the United States, immigrants may experience stress caused by the cultural conflict between their own culture and the new culture in the United States; this is termed acculturative stress. Stress of acculturation is associated with high levels of depression, anxiety, and physical health problems. Furthermore, the differences in the level of acculturation among Latino/a family members may lead to family discord and stress. The school system allows for children to become more quickly acculturated than their parents, resulting in a form of cultural conflict within the family. Parents are often not able to speak English or feel uncomfortable speaking English, a situation that can lead to their children serving as social and legal mediators for them, giving rise to a power imbalance in the relationship between the children and parents. Children who find themselves in the roles of social and legal mediators experience heightened stress and anxiety due to the increased sense of responsibility and authority in these roles.

Another source of stress experienced by Latinos/as that could account for higher incidences of mental health problems is the discrimination and racism they experience as minorities. Discrimination and racism can take the form of denial of services, difficulty on the job, firing from the job, demeaning insults, or more severe events, such as hate crimes and other violence. Psychological distress, reduced self-esteem, feelings of disempowerment, depression, and poorer physical health are cited frequently as psychological and physical consequences of discrimination and racism.

Poverty is yet another source of stress for Latinos/as. Latinos/as are twice as likely to live below the poverty level as the total U.S. population. In 1999, 23% of Latinos/as lived below the poverty level compared with 8% of European Americans. Additionally, 40% of Latino/a children living in the United States live below the poverty level. There is substantial evidence that psychological disorders are most common and severe among the impoverished and lowest socioeconomic classes. Research has indicated that lower-socioeconomic individuals suffer from a mental illness at a rate of 2 to 3 times higher than those in the higher socioeconomic arena. Some of the adverse psychological affects associated with poverty and a lower-socioeconomic stratum include anxiety, depression, low self-esteem, and loneliness.

Some of the contributory factors to the higher rate of poverty among Latinos/as can be attributed to relocating to the United States, lack of educational attainment, discrepancy in occupation, and disparity in occupational pay. Many Latinos/as leave their native country without any financial means on which to live. Additionally, in some cases, they arrive illegally without an ability to get government support or decent-paying jobs. In addition, Latinos/as have the lowest high school and college completion rates (51.3% and 9.7%, respectively) compared with African Americans (66.7% and 11.5%, respectively), Whites (79.9% and 22.2%, respectively), and Asian Americans (81.8% and 39.1%, respectively). As a result of low educational attainment, Latinos/as tend to procure jobs that are lower paying, less stable, and more hazardous. Furthermore, these jobs tend to have no medical or long-term financial benefits. Among the types of occupations procured by Latinos/as, 52% have labor and craft jobs, whereas only 6% are employed in professional or technical occupations. Latinos/as with the same educational level as European Americans earn less in monthly income. Latinos/as with high school diplomas earn an average of $1,092 per month, whereas European Americans earn $1,405 per month. Additionally, this inconsistency can also be found in Latinos/as with master’s degrees (monthly income of $2,840) as compared with European Americans with master’s degrees (monthly income of $3,248). As a result of the discrepancy in education, types of occupations, and pay, Latinos/as experience feelings of disempowerment, stress, anxiety, and depression.

Still another area that impacts the needs of mental health services for Latinos/as is the high rates of health-related complications. These health issues may result in a number of negative consequences, such as educational setbacks, unemployment, family problems, and marital discord. Latinas are getting pregnant at a rate of 51% before the age of 20, compared with the national average of 30%. Additionally, Latinas currently have the highest birth rate of all ethnic groups, approximately twice the national average.

Latinos/as are also disproportionately represented among the population in their use of drugs and alcohol. Latino men (31%) have higher rates of alcohol use and dependence than European American men (21%). Furthermore, many substance abuse programs appear to have difficulty recruiting, retaining, and successfully treating minority clients. Consequently, Latinos/as are less likely than other ethnic groups to seek substance abuse treatment and to complete treatment.

Furthermore, Latinos/as are overrepresented in the diagnosis of human immunodeficiency virus (HIV); Latinos/as account for 17% of adult male cases, 20% of adult female cases, and 27% of pediatric cases. For Latinos/as ages 25 through 44, HIV/AIDS infection is the second leading cause of death.

In summary, as the population of Latinos/as increases, so will their need for mental health services. Latinos/as suffer heightened stress related to acculturation, discrimination, poverty, lower-paying occupations, lack of educational attainment, discrepancy in pay, pregnancy, drug use, and HIV/AIDS. To the extent that stress leads to mental health problems, Latinos/as experience unique situations that generate a greater risk of psychological problems and need for mental health services, creating a necessity to find ways to address Latinos/as’ unique mental health needs.

Latinos/as and Mental Health Services

Although there is an evidenced association between Latinos/as’ experiences and psychological distress, review of the research indicates that Latinos/as tend not to make use of available mental health services. Latinos/as tend to severely underutilize community outpatient services and university counseling centers and overutilize inpatient services. For instance, Latinos/as were less likely (8.4%) than their European American counterparts (16.8%) to visit a mental health professional, and Latinos/as reported greater delays in receiving psychological services than European Americans (22.7% and 10.7%, respectively). Furthermore, Latinos/as tend to drop out of treatment very quickly, with 50% dropping out after the first session compared with 30% for European Americans. Length of treatment is an important factor in mental health treatment: Findings indicate that the longer clients stay in treatment, the more beneficial the outcomes are.

Researchers have attempted to hypothesize explanations for underutilization of mental health services by Latinos/as. Currently, two different theories have been proposed: the institutional barrier theory and the cultural barrier theory. The institutional barrier theory posits that Latinos/as desire services, but factors inherent in the mental health institutional system pose barriers to utilization. The cultural barrier theory assumes that clients want help, but aspects within the Latino/a culture hamper them from seeking out mental health services.

The institutional barrier theory pertains to the barriers found within the institution, or in the structural components of the institution, that provides psychological services. These variables include the geographic location of the mental health service center, cost of treatment, schedule of services, and lack of culturally relevant treatments. The location of the organization is a key factor in serving the Latino/a population. To better serve this population, mental health services need to be located within the Latino/a community, near public transportation, or both. Additionally, the monetary cost of the mental health treatment must not cause a financial burden on the family. With many Latinos/as living at or below the poverty level and being unemployed or having lower-paying jobs and less-stable employment, psychological treatment is considered a luxury. Therefore, consideration of finances must be taken into account when offering psychological services. Mental health services should be offered in the evening and weekends because family members may have difficulty taking time off from work. Additionally, requiring clients to come in on a weekly basis may not be feasible for many Latino/a families. Many Latinos/as are not employed in occupations that have benefits that allow for time off, and child care may be an additional financial issue. Lastly, mental health services should include interventions that are culturally relevant to the Latino/a client by considering Latino/a cultural worldview, beliefs, and values. By providing services that reflect the culture of the Latino/a client, the more likely the services will be effective.

Culturally Relevant Mental Health Services for Latinos/as

Latinos/as comprise persons of various ethnic, racial, and national backgrounds, and yet there are many commonalities among them. Many times, Latino/a cultural beliefs and values are antithetical to the beliefs and values that are found within the traditional Western-based psychotherapies, thus requiring counselors to adapt new ways of approaching therapy. Additionally, providing effective services to the Latino/a population requires counselors to assume roles that are at times different from the traditional counselor role. Counselors must also consider the language of the client when providing mental health services. Lastly, counselors need to be aware of and assess the societal factors impacting the Latino/a client. A therapist’s failure to consider these variables can result in early termination and ineffective treatment.

Latinos/as live with a collectivistic worldview in which immediate and extended family, community, and social networks are valued more than the individual and emphasis is on interdependence rather than independence. Traditional psychotherapies share an individualistic worldview, with concentration on the individual and independence in therapy. An intense focus on the individual and independence would be completely foreign to a Latino or Latina client and may cause uneasiness, resulting in early termination and ineffective treatment. In terms of consideration of the collectivistic worldview, a therapist should consider incorporating interdependence as a continued goal and including immediate and extended family members in therapy.

Psychotherapy is not value free, even when the counselor intends to stay neutral. In fact, values play a significant role in counseling, influencing theories of personality and pathology, interventions, goals of treatment, and treatment outcome. As a result, a counselor’s value system affects his or her perception of the nature of the client-counselor relationship, as well as the process and outcome of treatment. The client also enters counseling with a value system, which includes beliefs about the appropriateness of counseling, nature of the client-counselor relationship, and expectations for treatment. Therefore, in terms of mental health treatment, if a counselor’s value system is opposed to that of the client’s value system, then these differences in value system may lead to the counselor labeling a client as “pathological” or “resistant to treatment,” and/or the client prematurely terminating treatment and/or receiving treatment that results in ineffective outcomes. Consequently, it would be in the counselor’s best interest to work within the value system of the client. When working with a Latino/a client, one would incorporate the following values that are inherent within the Latino/a culture: familismo, simpatia, per-sonalismo, respeto, machismo, marianismo, religiosity, and folk illness beliefs.

Familismo is described as a strong attachment of individuals to their families and strong feelings of loyalty, reciprocity, and solidarity. Latinos/as view the family as the single most important reference group, providing influence on decision making, reinforcement of traditional values and patterns, and emotional security. Culturally relevant therapy would involve asking about family members, including family members in therapy, and interviewing family members. By incorporating the immediate family members in therapy, Latinos/as may be able to work in an environment that most closely relates to their Latino/a values. Additionally, a counselor may also want to include extended family members and kinship ties such as compadrazgos (i.e., godparents) in the counseling sessions. In considering the strong attachment to the family, counselors should not focus treatment on independence from the family. In addition, individual family members are seen as a reflection of family functioning. Therefore, any negative personal information discussed is viewed as a reflection of the entire family functioning, and disclosing this information to “outsiders” is unacceptable and offensive. Furthermore, because family members are expected to turn to one another for support, then it may be perceived as an insult to the family if an individual family member relies on an “outsider” for support. When considering the value of familismo in therapy, the counselor needs to be sensitive to the client’s ability to openly disclose to an “outsider.” This uneasiness with disclosure should not be construed as pathological or resistant to treatment.

Latinos/as strongly adhere to the value of simpatia, which includes promoting social relationships that are pleasant and without conflict. As a result, there exists a tendency in Latinos/as to avoid interpersonal conflict and emphasize positive behaviors in agreeable situations. However, mainstream psychotherapy places a value on confronting problems, issues, and/or people. Consequently, when working with Latino/a clients, counselors should consider finding ways to approach conflict situations in a more positive way, for example, having the client approach the issue with the individual from a place of concern for the other person rather than an individualized place. Additionally, lack of confrontation or desire to confront by Latino/a clients should not be viewed as pathological.

Personalismo is defined as a valuing of connectedness with others and basing these connections on trust. There is a personal bond and sharing that exists in all interpersonal relationships, including professional relationships. However, many Western psychotherapies value a detached professional relationship that may seem foreign to Latinos/as that adhere to the value of close interpersonal relationships. Subsequently, when working with Latino/a clients, therapists should consider being less detached and using self-disclosure as a means to making the clients feel more comfortable.

The Latino/a value of respeto refers to deference afforded to those individuals with higher authority in the relationship, such as parents, elders, and authority figures (e.g., doctors, religious officials, and those with higher education). To the extent that adherence to the value of respeto mandates respect and credibility for those that are older and/or have a higher educational level, counselors would be highly respected and considered credible. As a result, a Latino/a client may put more value on, and agree more often with, the counselor’s suggestions or interpretations in session. Therefore, it is advised that counselors be aware of how the relationship may be strongly influenced by their behaviors.

The Hispanic value of machismo is used to describe male roles and attitudes, whereas marianismo is used to describe female roles and attitudes. These values are significant factors in which Latinos/as develop a sense of identity. Within the value of machismo, men are granted considerable freedom, whereas women are much more restricted. Moreover, machismo is associated with men having dominance over the affairs of the family and wife, but it also includes courage and protection of the family and wife. This Latino/a value conflicts with the mainstream psychotherapy value of egalitarian relationships; thus, counselors should consider the dominant and protective role of the husband and/or father that may exist when working with a Latino/a individual, couple, or family. Questioning the division of household responsibilities may also help a counselor understand Latino/a gender roles when seeing an individual, couple, or family. In a family that honors Latino/a traditional male and female gender roles, a counselor should consider greeting the male of the family first. In addition, men who adhere to machismo often prefer not to demonstrate or admit to any vulnerability or emotion. Consequently, counselors should not stress the expression of vulnerability and emotion when working with Latino clients. The value of marianismo pertains to the expectation that women aspire to be like the Virgin Mary by acquiring the characteristics of humbleness, self-sacrifice, and other-centeredness. Furthermore, the value of marianismo dictates that women must be willing to endure the suffering that motherhood often requires, live in the shadow of their husbands and children, and support their husbands and children by all means necessary. To work with a Latina client, a counselor needs to be aware that mothers and wives feel an honor in dedicating themselves completely to their family. A culturally sensitive counselor would not propose self-care to a mother who upholds the Latino/a value of marianismo, because self-care would be considered selfish and overindulgent. The recommended way of introducing self-care to a Latina client would be to emphasize that the client would be a better mother and/or wife if she took care of herself. Additionally, a culturally aware counselor should be sensitive to the attitude that some Latina women may feel uncomfortable discussing their own feelings and needs with their spouses or family.

Religiosity plays a significant role in the lives of Latinos/as, including a way of maintaining cultural identity and community connection. For many Latinos/as, social activities center in the church, allowing for social support and feelings of connectedness. Furthermore, the religious official is often a primary confidant to Latino/a patrons. Therefore, a counselor should explore the client’s spirituality and connectedness to the church in the assessment process and may consider including the client’s religious official as part of a multidisciplinary team in treatment.

Folk illnesses are sets of physical and personal symptoms believed to be caused by supernatural or natural events that are external to the individual. For example, Mal Puesto is characterized by severe psychological symptoms, such as hallucinations, mania, and delusions, resulting from a supernatural cause. Furthermore, the belief in folk illness includes a belief in folk healers, such as Espiritistas for Puerto Ricans, Santeros for Cuban Americans, and Curanderos for Mexican Americans. The reason Latinos/as may seek out folk healers may come from the desire to see someone that shares their cultural beliefs about the causes of and cures for mental health problems. This value is also contrary to the mainstream psychotherapy view that psychological problems are seen as residing within the individual and under the control of the individual. Therefore, it might be beneficial for a counselor to consult a spiritual leader, shaman, or medicine man/woman or to include a traditional folk healer reflective of the community culture as part of a multi-disciplinary team. Furthermore, some mental health clinics have included traditional activities for their clients, for example, sweat lodges, medicine wheels, talking circles, and so on. Although some Latinos/as may not consult traditional folk healers, they at times continue to subscribe to traditional folk remedies, such as herbs and tonics. A culturally sensitive counselor working with Latinos/as should be aware and accepting of these traditional supplements and, if experienced, may want to recommend some forms of them.

Another factor to consider when providing culturally relevant services to Latinos/as is the type of counselor role taken by the provider. Western-based therapies are often regimented to a role of providing services in an office setting within a specified treatment session time and getting clients to experience insight and/or catharsis; these may be factors that are irrelevant to the life experiences and needs of many Latinos/as. Some Latino/a clients do not have the financial means or time needed to travel to mental health centers; thus, counselors should consider leaving their offices and venturing into the client’s environment—into homes, schools, and community centers and programs. Additionally, by entering the client’s environment, counselors will then be better able to understand societal factors impacting their Latino/a clients and reach out to those individuals who are underserved. Counselors should also adjust the time in session to meet the needs of the client, including shorter sessions if the client is unable to attend for the traditional 50 minutes. Lastly, counselors should consider engaging in alternative roles to the traditional insight-oriented psychotherapy role, such as advocate, change agent, consultant, and advisor. For example, in the advocate role, counselors may take an active role in contacting bureaucratic organizations, whereas in the advisor role, counselors may advise their clients as to the possibility of difficulties and conflicts they may encounter as they attempt to adjust and live in their new culture.

Yet another element in providing culturally relevant treatment to Latinos/as is inclusion of culturally linguistic appropriate services. It is believed that words expressed in the bilingual’s first language may have richer meanings and allow for easier access to emotions. Therefore, having bilingual Latino/a clients talk about events in Spanish fosters them to experience their emotions more fully, whereas the use of English may allow them to use intellectual defenses that assist in distancing themselves from their emotions. Counselors may want to encourage Latino/a clients to switch between languages depending on the desired level of emotional expression. Even if the counselor is not bilingual, the counselor can be attuned to the nonverbal expression as the client speaks in Spanish, while allowing the Latino/a client to experience an emotional release.

Lastly, counselors need to be aware of the specific societal factors that impact their Latino/a clients. Counselors must make a full assessment of the client’s experience of political, social, and economic factors affecting his or her ability to adjust and live in the United States. Mental health service providers should then address these factors in the treatment in terms of prevention and remediation.

In conclusion, the growing Latino/a population will continue to be underserved and ineffectively served if mental health providers continue to base their treatment on Western-based, mainstream psychotherapy. It is essential that mental health providers understand the importance of the role of ethnicity in the psychological treatment of Latino/a clients. Subsequently, it is imperative to adjust traditional Western-based psychotherapy goals of treatment, interventions used in treatment, and treatment outcomes to reflect Latino/a cultural worldview, beliefs, and values. Furthermore, because of the increased risk of mental health problems associated with the political, social, and economic factors uniquely impacting the Latino/a population, it is essential that counselors consider these societal factors and address them accordingly in treatment.

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