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Working with Latino/a and Hispanic Patients

Prepared by Lisa Fortuna, M.D.

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The Hispanic Population

Latinos/as/ or Hispanics in the United States are a fast growing population, expanding from a small, regionally concentrated group of fewer than 6 million in 1960 to a now widely dispersed population of well more than 50 million (or 16 percent of the nation’s population).

Latinos are a diverse community. There are many misconceptions and stereotypes about who Latinos are and about the history and presence of Latinos in the United States, including the difference between Latinos and Hispanics. While Hispanic refers to language and those whose ancestry comes from a country where Spanish is spoken, Latino refers to geography. Specifically, to Latin America, to people from the Caribbean, South America, and Central America.

Latinos are a multiracial, multicultural group.”

Some Mexican Americans have been in the US for many generations. In fact most of California and the Southwest was once part of Mexico. New immigrants from South America, Central America and the Spanish speaking Caribbean continue to be part of the growing presence of Latinos. However since 2000, the primary source of Latino population growth has swung from immigration to native births.

Spanish is the official language spoken throughout Latin America, but not all Latinos/as speak Spanish. Latinos are a multiracial, multicultural group. Latinos include indigenous people who speak their own native tongues (e.g. Quechua a Native South American language family spoken primarily in the Andes, derived from a common ancestral language).

Largest 5 U.S. Hispanic Populations, by Origin:

  1. Mexicans – 64.9% of Hispanics
  2. Puerto Ricans – 9.2% of Hispanics
  3. Cubans – 3.7% of Hispanics
  4. Salvadorans – 3.6% of Hispanics
  5. Dominicans – 3.0% of Hispanics

(Pew Research, 2012)

Significant History – Events which influenced the community and contextualize assessment and treatment

Mexican Americans represent the largest Latino group in the US. Technically, the first significant influx of Latino immigrants to the U.S. occurred just after most of the modern boundary between the U.S. and Mexico was established at the end of the U.S.-Mexican War (1846-48), a war during which Mexico lost a significant portion of their land to the U.S.

The island of Puerto Rico became an “unincorporated territory” of the U.S. after Spain ceded the island and other colonial possessions at the end of the Spanish-American War of 1898. One distinctive characteristic of Puerto Rican migration is that the second Organic Act, or Jones Act, of 1917 granted Puerto Ricans U.S. citizenship. Economic prospects in the US brought many Puerto Ricans first to the Northeast.

The demographic landscape of Latino America began to change dramatically in the 1960s as a result of a confluence of economic and geopolitical trends. In 1959, a revolutionary insurgency in Cuba created a virtually overnight exodus. A second wave of Cuban immigration occurred between 1965 and the early 1970s. First, an elite group of Cubans came, but emigration continued with balseros, people who make the dangerous crossing to the United States by makeshift watercraft. Some of these immigrants, such as the educated professionals who came to the United States during the early phase of Cuban migration, have become well established, whereas others who arrived with few economic resources are less so. Unlike immigrants from several other countries, many Cubans have gained access to citizenship and federal support through their status as political refugees.

Political turmoil elsewhere in Latin America during the 1970s and 1980s—particularly in the Central American nations of El Salvador, Guatemala, Honduras, and Nicaragua—also contributed to significant new Latin American immigration to the U.S. in the 1970s and 1980s. A unprecedented wave of migrants from Central Americans—many of them undocumented—fled the violence of their homelands to enter the U.S. Currently, post civil war gang violence and drug crime have increased the number of refugee immigrants, including children and women, entering the US from Central America. Although the specific social, historical, and political contexts differ in El Salvador, Guatemala, and Nicaragua, conflicts in those countries led to a significant emigration of their citizens.

The prevalence of mental health problems vary amongst Latino subgroups and are a reflection of the diversity of experiences and circumstances. Given the tremendous amount of diversity that exists among Latino/Hispanic individuals, it is important to understand the impact that this diversity has on what we understand regarding Latinos seeking or needing treatment.

Culture-Bound Syndromes in Hispanic Patients

Culture has an impact on symptom presentation. For example, Ataques de nervios or attack of the nerves is a cultural bound syndrome of distress which includes such symptoms as uncontrollable screaming or shouting, crying, trembling, sensations of heat rising in the chest and head, dissociative experiences, and verbal or physical aggression. Ataques de nervios is associated with high rates of comorbidity with several anxiety disorders including PTSD, generalized anxiety disorder and panic disorder. In general, less acculturated Latinos who have experienced trauma are more likely to experience dissociative type symptoms than their more acculturated counterparts.

Recent Latino immigrants are at risk for traumatic exposure both before and after migration, PTSD, depression and stress associated with the immigration experience and the challenges of integration vs. marginalization in the US. Individuals who come from countries with a history of political violence often have multiple traumatic experiences. This suggests a need for systematic screening for trauma and related psychiatric disorders in these populations. Specific outreach interventions focused on perceptions of need could be helpful for subgroups of Latinos including men who are particularly underrepresented in mental health services but who exhibit significant trauma histories. Youth from the growing Central American exodus (aka, unaccompanied refugee minors) have high rates of traumatic exposure, PTSD and anxiety. US citizen children of undocumented parents are also at risk of anxiety given their parents tenuous legal status and the fear of deportation.

Suicide and substance use as well as many mental health disorders increase among second and third-generation Latinos as compared to first generation immigrants. This is part of what is known as the “immigrant paradox”, immigrants who despite multiple stressors appear relatively healthy as compared to their more acculturated counterparts. As Latinos are more exposed to discrimination and unsafe neighborhoods, poor educational systems and attainment and mental health issues become more prevalent. Childhood substance use and conduct disorders have been found to mediate the relationship between trauma and school dropout. Likelihood of dropout increases for Latinos as compared to non-Latino Whites as a function of psychiatric disorders and trauma and immigration to the U.S. during adolescence increases the risk of school dropout.

As Latinos reside longer in the US they lose some of the potentially protective effects of their culture.

Latino culture is known for its collectivist- family orientation, the importance of personalismo (personal connectedness in interactions) and respect for authority. Conversely, an increase in rates of psychiatric disorders and suicide is seen with increasing acculturation or assimilation into American culture. Being bicultural and bilingual is actually protective for youth both academically and for mental health. Being able to communicate in the language of both worlds maximizes the child’s capacity to draw upon available protective resources while at the same time it enables an adaptive response to the language demand. Conversely, non-linguistic aspects of bicultural competence in the child, family and extended social environment have an important protective role in Latino children of immigrants and minimize their distress.

Examples of Hispanic Culture-Bound Syndromes

Ataque de Nervios

Out-of-consciousness state resulting from evil spirits. See above for a more in-depth description.

Cólera

Anger and rage disturbing body balances leading to headache, screaming, stomach pain, loss of consciousness, and fatigue.

Mal de ojo

Medical problems, such as vomiting, fever, diarrhea, and mental problems (e.g., anxiety, depression), could result from the mal de ojo (evil eye) the individual experienced from another person.

Susto, Miedo, espanto, pasmo

Tiredness and weakness resulting from frightening and startling experiences.

Wind or Cold Illness

A fear of cold and the wind; feeling weakness and susceptibility to illness resulting from the belief that natural and supernatural elements are not balanced.

Source: Modified from Paniagua, F.A. (2000). Culture-bound syndromes, cultural variations, and psychopathology, in I. Cuéllar & F.A. Paniagua, Eds., Handbook of multicultural mental health: Assessment and treatment of diverse populations (pp. 140-141). New York: Academic Press.

A Few Cultural differences between Anglo Americans and Latinos

Anglo Americans Latinos (as)
Nuclear family oriented Extended family oriented (protective factor)
Do not emphasize supernatural forces Importance on the spiritual domain (supernatural forces, use of saints as intermediaries)
Autonomy from parental approval as hallmark of optimal adult development Respect for parental authority persists throughout life, e.g., not talking back
Direct communication Indirect communication (use of third persons, allusions, proverbs, metaphors, jokes, and stories to transmit information)
Business like (task oriented) Personalismo (high level of emotional resonance and personal involvement with family encounters or friends) Emotive style, person oriented Patriarchal (machismo)

(Derived from The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health)

For Latinos, having a mental illness or even receiving counseling can be stigmatizing. Poor access to care due to low rates of insurance, immigration status, language and cultural barriers in healthcare which can include differences between provider-patient in explanatory models of illness and families as the gate keepers can limit entry into treatment (Cortes et al, 2008). Availability of specialized mental health services or comparable integrated behavioral treatment within primary care could improve treatment access and retention.

Spirituality and religiosity are also important frames through which mental health is understood and addressed by many Latinos. Having a strong religious faith can be protective in reducing suicide attempts and/or decreasing risk of alcohol or substance use disorders for some Latinos. Visions of spirits and angels do not necessarily imply psychosis. In a study of hallucinatory experiences using a nationally representative data base, Latinos were more likely to attribute unidentified voices to their hallucinations and explained these experiences as relating to the realm of unidentified spirits, or forces which at times serve as protections or provide ominous warnings. Many of these themes fall into the context of spiritualist belief systems prevalent in many Latino cultures and are not considered ‘abnormal’ or ‘uncommon’ within those cultures.

Best Practices

A few best practices for working with Latinos

  1. Use a bio-psycho-social-cultural model of evaluation and treatment.
  2. Take the time to develop a cultural formulation, which includes a consideration for acculturation, community and family connection, immigration status/ history, education.
  3. Supporting collaborative care with Latinos is important for retention and success of care. Although this is a culture that respects authority, feeling misunderstood and not connected to a therapist often results in dropping out from treatment.

Future Needs

Despite the challenges, Latinos are a growing academic, political and financial force in the US. One-in-four newborns is Latino. Never before in this country’s history has a minority ethnic group made up so large a share of the youngest Americans. By force of numbers alone, the kinds of adults these young Latinos become will help shape the kind of society America becomes in the 21st century. A future filled with quality treatment, prevention and early intervention for Latinos will be best achieved by following six strategies: community partnerships; culturally and linguistically appropriate treatment; workforce development to sustain a culturally and linguistically competent mental health workforce; and community outreach and engagement.

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