Challenges of Treating Spanish Bilingual Patients in a Primarily English-Speaking Setting

by Ivy Ruths, PhD; Kenia Velasquez, BS; Ydalith Rivera-Pérez, MA; Thröstur Björgvinsson, PhD

 Dr. Ivy Ruths, PhD, is a bilingual licensed psychologist and the newest behavior therapist at the Houston OCD Program. She specializes in treating and assessing childhood anxiety, depressive, and disruptive disorders and has extensive experience treating OCD and trichotillomania.

 Mrs. Rivera-Perez, MA, is a bilingual licensed professional counselor and a clinical psychology PhD student at Fielding Graduate University. She is a practicum student at the Houston OCD Program and has been working in the field of mental health for the last 14 years. 

 Dr. Thröstur Björgvinsson, PhD, ABPP, is the program director and founder of the Houston OCD Program. He is the director of the Behavioral Health Partial Program at McLean Hospital and co-director of psychology training at McLean Hospital/Harvard Medical School.

This article was initially published in the Winter 2015 edition of the OCD Newsletter

Imagine meeting a panic-ridden and severely depressed fourteen-year-old Mexican American teenager for the first time. She is suffering from scrupulosity obsessions and contamination fears and spending more and more time engaging in rituals. Her presentation is nothing out of the ordinary and you, trained and qualified, are prepared to offer her treatment utilizing cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) treatment. However, when she walks into your office she is accompanied by her mother who speaks only Spanish. Your new adolescent patient sits in front of you, ready to play translator, as she has for every important school meeting and doctor’s appointment she has had for as long as she can remember. A familiar scenario has now turned into a novel set of challenges: how do you, as her therapist, build rapport with her and her mother simultaneously, understand the complex, multigenerational family dynamic wrought with the effects of different levels of acculturation, and pick up on the minute culturally driven decisions that form the family unit and maintain this teenager’s distress?

Consider this statistic: almost 63 million Americans over the age of five speak a language other than English at home.1 Not surprisingly, the US actually has the second largest Spanish-speaking population in the world.2 Forty-one million Americans speak primarily Spanish at home1 and another 11.6 million Americans are bilingual, mainly children of Spanish-speaking immigrants.2 In Houston, TX 37 percent of persons five years and older speak Spanish at home as compared to the 29 percent and 13 percent, respectively for the rest of Texas and the US.3 In other words, the need for mental health professionals to serve the US Spanish-speaking population is painstakingly clear, yet there are few mental health professionals that have the training to do so.4 Providing quality services to bilingual patients and families requires both language and cultural competence.

The Challenges Posed by Language

The therapist and patient are able to successfully work together to modify behavior, explore problematic thinking patterns, and build a meaningful relationship, all through the use of language. Unfortunately, linguistic differences can be grave barriers in treatment. First of all, there are many variations in the way Spanish is spoken across multiple Spanish-speaking populations of the world. As a result, a Spanish-English bilingual therapist in the US must be proficient, flexible, creative, and willing to make mistakes and clarify meaning. Bilingual therapists who serve a diverse group of Spanish speaking patients will find they have to learn to elaborate, use descriptive terminology, utilize examples, analogies, synonyms, and visual and sensory descriptors in order to bypass variations in the Spanish language while still enhancing understanding and building rapport. Because clarity may not always be immediate, the bilingual therapist must learn to be especially attuned to difficulties their patients face when navigating through a primarily English-speaking environment in which they are often misunderstood and underinformed. This in and of itself is often useful when cementing the therapeutic relationship and instilling hope that accompanies feeling connected and understood.

Proper Training in Cultural Competence

It is safe to say that most bilingual therapists practicing in the US today received their clinical training primarily in English. It can also be assumed that most interactions trainees had with Spanish-speaking patients while in their clinical programs were likely supervised by an English-only speaking supervisor. As a result, it becomes the responsibility of the bilingual therapist to acquire resources, seek training, and honestly consider personal limitations in language proficiency and cultural competence before electing to conduct therapy in Spanish.

We know that cultural competency has a dramatic effect on the effectiveness of treatment.6 Because of this, all American Psychological Association (APA) and American Counseling Association (ACA) accredited training programs began requiring multicultural training in 2002.6 A culturally competent bilingual therapist is taught to tailor treatment to meet a patient’s social, cultural, and linguistic needs while taking into account an individual or family’s values and beliefs.7 In doing so, a properly trained bilingual therapist provides treatment that research has found is four times more effective than treatment not individualized to incorporate cultural factors.8 Similar to the amount of diversity found within the Spanish language already noted, culture and customs in different Spanish speaking countries of the world are just as variable. A bilingual therapist may not know every detail or the specifics about a patient’s background from the beginning of treatment and therefore should never assume they understand the ins and outs of a patient’s culture.6 Instead, an effective bilingual therapist must be open and willing to learn. Research shows that despite any limitations in competency that may exist at the outset of treatment, it is possible to keep these factors from interfering with the therapeutic alliance if the patient feels understood and respected.6

Research regarding emotion expression and retrieval provides an example of the importance of being culturally aware. Research suggests that autobiographical memories tend to be more emotionally expressive in a person’s native language. Specifically, there is evidence that when bilingual patients express early childhood trauma, they express the five modalities of traumatic memory (affective, visual, tactile, auditory, and olfactory memories) at a higher intensity when speaking in their native language.9 Affect expression is also associated with language. It appears that when Spanish-English bilingual individuals speak about traumatic events in their native Spanish, they display more affect (e.g., becoming visibly tearful) when recalling traumatic memories in Spanish rather than in English. Research suggests these individuals provide vivid details and descriptions of the trauma in Spanish but seem more detached when recalling memories in English.9 Therefore, providing treatment in a patient’s native language may play a vital role in eliciting and further understanding a patient’s psychological distress.

Tips / Best Practices for Bilingual English–Spanish Therapists

  • Make no assumptions! Take the diversity of Hispanic individuals into account when conceptualizing treatment. Always seek appropriate supervision and consultation regarding cultural differences.
  • Honestly assess your language and cultural limitations and seek training and resources when necessary.
  • Consider purchasing a guide or manual to help facilitate your knowledge of clinical and medical terminology.
  • Be aware of your own worldviews, beliefs, and values and how these might interact or conflict with your patients’ worldviews, beliefs, and values.
  • Flexibility and creativity are keys to success! Collaborating with your patient and continued assessment ensures understanding.
  • Don’t forget the basics: Be curious, focus on rapport building, individualize treatment, and develop a respectful and safe environment for your bilingual patients.


As Spanish-English bilingual therapists, it has been each of our experiences independently and across multiple settings that we are often the only individuals on staff able to communicate, translate, and connect with Spanish-speaking patients or individuals seeking services. At times, this can place a great burden on a bilingual therapist. However, “to whom much is given, much is expected.” At the Houston OCD Program, for example, we are significantly expanding our Spanish-speaking services through providing outpatient services in Spanish and by having several Spanish speaking staff and therapists in our residential program.  You can imagine the feeling at the end of the first session with your new Mexican-American teenage patient and her mother, who, with tears streaming down her face, thanks you profusely for being able to understand her as she expresses grief and concern about her only daughter. She says you have given her hope for her daughter’s future. And she communicates it all without her daughter having to translate. The two leave your office and the mother turns around once more, grabs you by the hands, and says, “Gracias, Gracias. Ay, Gracias.”

 Resources for therapists:

  • The Bilingual Counselor’s Guide to Spanish by Roberto Swazo
  • Spanish for Mental Health Professionals: A Step by Step Handbook by Deborah E. Bender
  • The Routledge Spanish Bilingual Dictionary of Psychology and Psychiatry by Stephen M. Kaplan
  • An English-Spanish Manual for Mental Health Professionals by Veronica Gutierrez, Cher Rafice, Erin Kelly Bartelma, and Veronica Guerra
  • Spanish Mental Health Glossary by the Cross Cultural Healthcare Program
  • Life as a Bilingual blog by François Grosjean on