Communication is an integral element to alcoholism treatment, but what happens when the client and the therapist are literally speaking different languages? Alcoholism treatment programs for non-English-speaking individuals, or for individuals who speak English as a second language (ESL), have to bridge cultural and linguistic gaps, and the ability to do so can be what determines the success of a treatment intervention.
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The Language Barrier
The language barrier between a foreign-born client and a local therapist is an example of one the areas of stress that immigrants face. It is on the same level as outright discrimination and racism, as well as adapting to local norms, that are “migration stressors,” in the words of the Journal of Nervous and Mental Disease. A foreign-born client experiencing an inability to communicate in their native language will struggle to get a job, go to school, get directions, or ask for help with the inherent difficulty that comes with moving to, and living, in a place where they are not understood. This sense of frustration feeds into the homesickness that many immigrants feel. Trapped by their new surroundings and an inability to express themselves, they fall into a spiral of anxiety, depression, and the temptation to abuse alcohol (or other drugs) to bury their feelings.
Adjusting to a new country brings with it many psychological changes, a process known as “acculturation.” Some of these changes are more of a struggle than others, and the language barrier is one of the biggest challenges facing many immigrants, especially those who have mental health concerns, which are not always immediately evident and need complex explanations. Various research has found that the positives and negatives of acculturation have a role to play in how newcomers engage with alcohol; some adopt increased drinking habits to better fit in with coworkers and classmates while others drink more to overcome their fears and frustrations about settling into a new home.
This has given rise to the “acculturative stress model,” where immigrants have been found to abuse alcohol (or other drugs) as a direct response to the stress caused by isolation, alienation, conflicts, legal difficulties, exploitation, or any other threats to wellbeing that stem from the language barrier.
The Substance Abuse and Mental Health Services Administration agrees, and adds that enhancing communication between English therapists and non-English-speaking clients goes beyond the construct of language. In certain cultures, like those from South Asia, discussing mental health and substance abuse issues with an outsider (and, at that, someone who is not from that particular culture) would be a serious taboo. In cultures where drinking is deeply ingrained in life (like Russia), denial is a good thing, and having a Russian translator in the room will accomplish little given the importance of deconstructing denial in alcoholism treatment.
As important as it is for a therapist and a client to be able to communicate linguistically, even with the help of a translator, it is especially vital that the counselor be culturally sensitive to people for whom English (or Western) customs are unfamiliar. In 2006, the Psychotherapy journal listed a number of characteristics of culturally adaptive mental health services, which include alcoholism and substance abuse treatment. The researchers writing in the journal noted that treatment programs that targeted specific cultural groups, instead of targeting “mixed cultural settings,” were four times more effective. Additionally, treatment that was offered in the client’s native language showed double the effectiveness of offering English-only treatment.
The Psychotherapy report shows that adapting treatment to compensate for language barriers is a big part of making alcoholism treatment more culturally sensitive. The findings were echoed by the Transcultural Psychiatry journal in 1997, which quoted the World Health Organization in saying that penetrating the language barrier was key to effective treatment outcomes. This would entail:
- Developing a system to ensure not only linguistic understanding, but also equivalence, in translations
- Understanding that certain words and phrases (especially those that are clinical in nature) have different meanings, and can be very subjective when used without explicit clarification
- Choosing the tools to determine in which language to conduct treatment when clients are multilingual
- Ensuring that translators are capable of communicating both the nuances of emotional expression, and the technicalities of treatment, to ensure that both the therapist and the client are equally represented
To bring all these concepts together, the Substance Abuse and Mental Health Services Administration created the Multi-Language Initiative, as a way of adapting its official alcoholism and mental health guidelines into as many languages as possible. The move came after the Alcoholism: Clinical and Experimental Research journal wrote in 2003 that there was a lack of “culturally responsive addiction treatment” programs that addressed the precise needs of different ethnic groups, especially when it came to communicating with those groups in their respective native languages.
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Language Problems and Corrections
The challenge for treatment providers when working with clients who do not speak English as a first language is to ensure that the client can apply the treatment and recovery principles far beyond the confines of formal treatment. This is not guaranteed even with clients who understand English; the possibility of a communication gap creates an even greater imperative to ensure that the specialized recovery tools imparted during therapy are utilized to their fullest extent. Clients who struggle to understand their therapist might not even see a rehab program through to completion, and there is a strong possibility that a therapist could unwittingly misdiagnose a mental health issue behind the client’s alcoholism.
Research has shown that language is the primary barrier that limits therapy from being as effective as it should be; with this in mind, many treatment centers in the country have taken steps to address the deficit. Hiring translators, using technology, and having bilingual signage are just some ways that the gulf between English-speaking therapists and their non-English-speaking clients is slowly being reduced.
An example of this comes from the Mahoning County Mental Health Recovery Board in Ohio, which offered free bilingual communications training for 14 counselor assistants. The training covered both language, as well as addiction treatment. Instructors and participants engaged in role-playing exercises to identify problematic ways of dealing with communication incidents that arise when speaking across different languages, and juxtaposing those with more productive ways of interacting.
Linguistic and Cultural Concerns
In most cases, Spanish is the language that is the most frequently offered in bilingual or multilingual treatment centers. As of 2015, there were more than 41 million Spanish-speaking individuals in the United States (more than the entire country of Spain itself), and the Alcohol and Alcoholism journal found that despite variances within respective Hispanic communities, “Hispanics have a higher risk of alcoholism.” The Journal of Ethnicity in Substance Abuse posited that since many of the people coming from Mexico, El Salvador, Guatemala, and Honduras enter the United States illegally, they face more triggers for the development of anxiety and stress disorders, and may feel unsafe seeking help for their resultant alcoholism if it means that they might be apprehended by immigration authorities.
Speaking to the Latin Times, Carlos F. Ríos-Bedoya, the Alcohol and Alcoholism study’s lead author, noted that Mexican Americans abused alcohol at a rate double that of Caucasian Americans, and Puerto Ricans were three times as likely to be alcoholics. Even though Puerto Ricans are American citizens and can travel freely within the United States, alcohol is much more prevalent in Puerto Rican culture than it is in typical white American culture, and Puerto Rican children are exposed to alcohol at a much younger age than their white American counterparts. When looking for professional help for alcoholism, cultural differences like these exacerbate the language barrier that exists between client and counselor.
Ríos-Bedoya pointed out that Hispanics are the fastest growing community in the United States, and it behooves treatment providers to bridge the communication gap to avoid a public health epidemic. In addition to providing Spanish-language services, alcoholism treatment practitioners would also have to be sensitive to the inherent differences within Hispanic culture. Puerto Ricans, Mexican Americans and Cuban Americans might share a root language, but they are very different ethnicities, and assuming that they will all respond in the same way to treatment overtures and methods could easily do more harm than good.
Involving Family in Second-Language Programs
Offering bilingual or multilingual treatment is not just a vital component of one-on-one therapy. Getting the client involved and engaged in group therapy, especially family therapy, is at the heart of the most effective treatment programs. Participation is a key element of these forms of treatment, and conversations can become emotional and animated. Giving clients a safe space to feel empowered to express themselves, and reassured that they will be fully understood, makes the goals of therapy that much easier to achieve.
Clients must be in a position to communicate not just with their therapist, but with fellow clients and, most importantly, their family members, all under the auspices of a counselor. The members of a family unit are likely to share the same language, so it becomes all the more important for the psychologist moderating the therapy to understand what is being said, and to understand the implications, nuances, and subtexts that often come with family communication. This entails speaking to each member of the family directly, as part of educating the family about how alcoholism develops and what the family can do, both individually and collectively, to help their loved one’s recovery.
Changing the Tide of Alcoholism
There is a belief that by expanding language options at treatment centers to include non-English speakers, the overall rate of alcoholism, especially among immigrants, may drop because more and more people will have access to customized, culturally sensitive rehabilitation and aftercare support. The Journal of Ethnicity in Substance Abuse notes that many immigrants from Latin America only go to alcoholism treatment programs because they were ordered to do so by a court, or if they suffered injuries that required emergency medical intervention. The journal notes that being trapped in this limbo means that Latino immigrants are at risk for “disproportionately severe health and legal consequences from substance abuse.” As much as 66 percent of the emergency department visits by Latino migrant workers are the result of alcohol misuse. These consequences could conceivably be minimized if there were more Spanish-language treatment programs available, and if the programs were culturally sensitive (i.e., mindful of the different family dynamics in Hispanic households, understanding that clients may be too scared of arrest or deportation to engage with a rehab program, etc.).
Offering a greater palette of alcoholism treatment programs for non-English-speaking clients, or clients who speak English as a second language, could therefore turn the tide against the public health epidemic of alcoholism.