“It took me months to find you,” said Luciana, during her intake session, discussing the difficulty of finding a clinician with whom she could converse in her native Portuguese language. While there are mental health settings in the Boston area that serve Portuguese speaking individuals and families, these resources pale in contrast to the significant Brazilian population in the area. In addition, individuals are often not aware of the resources available to them. For the purposes of this paper, “Luciana” represents a composite case study. I am utilizing a pseudonym for this symbolic client, as well as disguising features of her presentation by merging details from multiple individuals I have encountered in my clinical work and my phenomenological research with Brazilian immigrant women (Bessa, 2013). Luciana’s story is not presented as a story representative of all Brazilian immigrants—indeed, there is no such prototypical story (Martes, 2011). However, the details I have chosen to include are present for many individuals migrating from their home country, including difficulties with identity negotiation, stress related to documentation status and acculturation, and alienation from family and larger society. Luciana’s case is comprised of non-fictitious details drawn from the lives of multiple Brazilian immigrants I have encountered in my work to elucidate key clinical considerations when working with this population, and to suggest that many of these considerations may be relevant for working with underrepresented groups, particularly immigrant populations.

Luciana sought treatment in order to address depressive symptoms related to her immigration experience. She had migrated to the United States several years ago from Brazil, during which time she felt she “had not accomplished anything” in her life. She felt a lack of purpose, as well as significant disappointment in herself for her difficulty with motivation. She felt ashamed for not having mastered the English language yet, stating, “I feel stupid.” She had attempted several times to engage in English classes, only to drop out in frustration. She had left most of her family behind in Brazil and planned, one day, to return home, but found her timeline extending steadily with every year she remained in the U.S. She lived with her husband and daughter, who learned English in school, and who spoke more English than Portuguese, even at home. She had migrated to the U.S. two years after her husband, and her daughter had been born in the U.S. “It is difficult for me to have a serious conversation with her,” Luciana stated, “since I stutter my way through the conversation, as I struggle to communicate with her in English.” She had worked cleaning houses, sometimes three or four in one day, but had been unemployed over the past couple of years. She described feeling somewhat connected to a church community, but experiencing feelings of alienation, superficiality in her social connections, and intensely missing her family in Brazil. She also described living in consistent anxiety due to her undocumented status.

The Brazilian immigrant population in the United States has been referred to as an “invisible minority” (Margolis, 1994). Although Brazilians and Brazilian Americans are a fast-growing group in the U.S., there is a dearth of psychological literature on this population. Brazilian migration to the U.S. began in earnest in the 1980s, a period of economic instability for many Latin American countries. In 2007, the Brazilian government estimated the Brazilian population in the U.S. to be 1.1 million, which was four times higher than the official census figures at the time (Bernstein & Dwoskin, 2007). This discrepancy may be due, in part, to underestimation of immigrant populations with a large number of undocumented individuals, in addition to Brazilian respondents not being substantially accounted for by the Census (Margolis, 2003; Siqueira & Jansen, 2008). Margolis (1994), an anthropologist who conducted an ethnography of Brazilians in New York City, estimates the undercount of the Brazilian population to have been 80% or higher in 1990. The possibility that official demographic data can be so discrepant with the reality of population numbers has significant implications for effective needs assessments and distribution of services to underrepresented groups. At the same time, as mental health practitioners, it is critical for us to recognize cultural competence as an essential aspect of clinical competence (Sue & Sue, 2012).

The immigration experience is a significant life transition necessitating a re-negotiation of the self. This often means a re-negotiation of one’s role in the home, one’s role in society, and even one’s racial/ethnic identity. Immigration experiences can also lead to significant shifts within family systems, sometimes leading to more egalitarian financial arrangements, occasionally leading to increased relational strain as partners, parents, and children acculturate at different rates and in different ways (DeBiaggi, 2002; Hervis, Shea, & Kaminsky, 2009; Hondagneu-Sotelo, 1994; Min, 2001; Smart & Smart, 1995). Research on acculturation and acculturative stress is an important and growing body of work that increasingly suggests a process marked by complexity, individual differences, and nuanced blending of native and host cultures (Nguyen & Benet-Martinez, 2007). The Brazilian immigrant population is only one example of many immigrant populations that are currently underrepresented, understudied, and underserved.

A word of caution is in order, however: Clinicians should not assume that a client’s immigrant status is the primary presenting concern—or, indeed, a treatment concern at all. Interventions should be tailored to the ideographic needs of the individual client in the room. While we should remain open to the possibility of exploring themes such as those described above, we should avoid attempting to apply a rigid nomothetic framework based on our own assumptions or preconceived notions. As mental health professionals working with clients from a variety of cultural and ethnic backgrounds, we must be aware of the complexity of the acculturative process, as well as cognizant of our role in establishing safety, rapport, and trust within the therapeutic relationship. We must also be willing to be lifelong learners, aware that cultural competence is never achieved, but is marked by curiosity and open engagement, rather than rigid generalizations about groups (Sue & Sue, 2012). Rogers-Sirin, Melendez, Refano, and Zegarra (2015) conducted a qualitative study of immigrant perceptions of the cultural competence of therapists, with several categories emerging: openness on the therapist’s part to learn about the client’s culture, addressing cultural differences appropriately, separating cultural issues from treatment concerns when appropriate, responding to client with patience and support, and exhibiting empathy. This study represents an important, but nascent, body of research.

Clinical Recommendations

As mental health professionals, it is essential we strive to serve the needs of our clients in the most effective and ethical manner, adhering to standards of best practices. To that end, the following list of clinical recommendations is provided as a non-exhaustive list of points to keep in mind when working with immigrant clients, based upon my clinical and research experiences with Brazilian immigrant women, as well as research on cultural competence, the relationship between immigration experience and mental health, and the particular experiences of Brazilian immigrants.

Be aware of your positionality

For Luciana, it was important to meet with a clinician who spoke her native language. While this was, in part, due to concern about her limited English fluency, it was also, in large part, due to a concern about the potential for relating to, and being understood by, her provider. As clinicians, it is essential to be aware of our own multiple identities (e.g., race, nationality, gender, sexual orientation, SES), our relationship to each of those identities, our own areas of privilege and marginalization, and ways in which our multiple identities interact with those of our clients. It is also essential to be aware of how we set and adjust our clinical boundaries, such as choices about self-disclosure, choices about whether or not to engage in physical touch (e.g., hand shaking; allowing for a hug hello or goodbye) at the client’s initiative, and choices about therapeutic techniques (e.g., being more or less directive). Are our boundaries rigid in ways that might damage therapeutic alliance building, or that is more related to our habits and own cultural lens than about what is therapeutically appropriate? What may be perceived as professional by one client may be perceived as cold or impersonal by another.

Awareness of our positionality in relation to our clients is not something we do alone, but rather in clinical consultation as necessary, as well as in dialogue with the client. While we can consult resources about cultural norm differences, or potential areas to consider when working with certain cultural groups, there is no substitute for assessing those factors for the individual sitting in the room with us. Research shows that the acculturation process is far from standard, and that different individuals have vastly different approaches to relating to their host and native cultures (Berry, 1997; Berry, Phinney, Sam, & Vedder, 2006; Nguyen & Benet-Martinez, 2007). Understanding how the clients sitting in front of us make sense of their experiences, and relate to us, is of utmost importance, rather than assuming knowledge or basing our case conceptualization on group generalizations, or even our own experience. Assumptions can include beliefs about a client’s experiences, a client’s preferred language for self-identification, and expectations about what language a client may wish to receive treatment in, to name a few.

Inquire (gently) as to client’s immigration experience and documentation status

Luciana described to me the terror she felt, upon beginning her life in the United States, every time a plane flew overhead. She had made her way to the U.S. illegally by utilizing a “coyote” (a travel broker), traveling with a group of other immigrants. In addition to facing the risk of being detained or returned to her home country at any moment, she also faced the risk of losing thousands of dollars (that she did not have)—the fee charged to utilize a coyote’s services, which is often paid in part up front, the rest to be paid off upon arrival to the destination country, but which individuals are responsible for, regardless of whether or not they are deported at some point. Luciana also described the fear of sexual assault that haunted her throughout her migration journey, indicating a stranger posed as her husband for protection. For the first several months of her stay in the U.S., every time a plane flew overhead, she was afraid she would be identified as an illegal immigrant and deported. She reported avoiding leaving the house due to this fear, as well.

Experiences of fear, abuse, and other traumas in transit, or before migration, have significant implications for mental health, and for areas to be explored and addressed in mental health treatment (Foster, 2001). To that end, it is important to assess for immigration trauma in addition to other mental health factors at intake, as well as throughout treatment. These experiences may be related to traumatic stress reactions (e.g., feelings of fear, discomfort, and alienation) and may potentially serve as barriers to treatment. When meeting with a client of undocumented status, it may be particularly important to delineate client rights to confidentiality and focus immediately on psychotherapy as a safe space.

Employ a systems- and family-informed lens to treatment

Luciana had originally come to the United States to work for a “couple of years” with her husband and return to Brazil more financially stable, but instead they remained in the country for 10 years. In the meantime, she and her husband had exhibited different styles of acculturation. While he practiced English at his restaurant job and was able to respond to their American-born daughter in English, he nevertheless struggled with Luciana’s newfound financial freedom. While Luciana appreciated the chance to contribute financially to the home, and in some ways felt increased agency, she rejected many aspects of American culture and clung to the idea of returning “home.” She struggled with feelings of alienation, not only from the broader culture, but also from her own immediate family.

In our clinical work, it is important to ask: Where does this client fit into the culture of origin, family, and broader society? How does the client identify ethnically/racially/culturally? Be aware of potential aspects of identity negotiation to be addressed in treatment, including gender role renegotiation and conflict, potential difficulties in relating to family members in the U.S. and in the native country, and potential feelings of alienation from family members, cultural group, and greater society. For example, clients may have a strong support network with other people in their cultural communities, but may feel alienated and lack confidence when visiting their children’s schools and interacting with other parents or teachers. It is crucial to recognize the social context in which the client is embedded, and help the client navigate potential struggles in renegotiating a sense of self.

Foster (2001), in her review of the literature on immigration and mental health and discussion of related treatment guidelines, discusses the importance of approaching the assessment process with sensitivity, urging clinicians to be attentive to cultural and relational factors and to avoid over-pathologizing of clients. A client speaking in a non-native language may exhibit detached affect while struggling to communicate effectively, which may be related to language difficulties, as well as relational factors; clinicians should avoid simply assuming “affective blunting” related to “more severe psychological states” (p.165). Foster (2001) states, “The fear and frustration of not being understood—particularly when such high stakes as psychiatric hospitalization are involved—can be paralyzing for some” (p.166).

Provide treatment through a lens informed by particular barriers faced by client

After several sessions, Luciana obtained employment at a fast-food restaurant and informed me she would be starting the following week. Given the fact that her lack of employment over the past couple of years had been a significant contributor to her depressive symptoms, both she and I agreed taking the job would be helpful in fostering her sense of purpose and boosting sense of self. However, this was also a job where shifts were assigned on a week-to-week basis, and she felt the pressure to be available during large chunks of time, which meant she was quite reluctant to continue having a standing appointment time with me. As much as Luciana discussed her appreciation for our sessions, and indicated improvement in her mood in the time we had met, she felt the need to prioritize her job and expressed anxiety about informing her employer she was unavailable at a given time on a regular basis. Although I discussed her right to mental health treatment, and her legal right to prioritize her physical and mental health, including offering to write a letter confirming her attendance in treatment, Luciana chose to terminate treatment at that time in service of prioritizing availability to her employer, with the understanding that she could re-engage in treatment at any time.

Conclusions

In working with immigrant clients, it may be necessary to adjust treatment goals based on internal and external barriers to treatment. Effective clinical intervention requires informing clients of their legal rights, emphasizing confidentiality in session and utilizing an approach that is collaborative, curious, and flexible to the client’s needs. Ethical treatment may include being less rigid with treatment structure and being aware of our own biases and assumptions for what treatment ‘should’ look like. For example, it may be necessary to adjust treatment frequency when clients experience difficulty in obtaining child care. We may need to re-examine our assumptions around physical touch: while one client may identify with a religion that bars physical contact with non-family members, another client may wish to extend a hand or hug a therapist, seeing complete lack of physical contact as a barrier to the therapeutic alliance. Ethical treatment may also include addressing anxieties clients face about the therapeutic process, such as concerns about the therapeutic alliance, worries about being misunderstood, and concerns about the stigma of therapy. Although we as clinicians may value cultural competence, we do not always have a clear understanding of the ways in which individual clients negotiate aspects of their identity, the immigration experience, or the presenting concerns that bring them to treatment. We should strive to continually expand our cultural competence generally, as well as engage in an ongoing conversation with our clients about their needs, experiences, and goals for treatment. Both in research and clinical work, it is also critical to be aware of our positionality given our own multiple identities, and our own experiences of privilege and marginalization.

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Luana Bessa, Ph.D.