Brief Psychotherapy with the Latino Immigrant Client

Marlene D De Rios

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317789079
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Understand the unique needs, beliefs, and values of your Latino immigrant clients!Brief Psychotherapy with the Latino Immigrant Client is a manual for the practicing psychotherapist or student, with tips on the assessment process and suggested interventions that work efficiently. With this book you will explore the influence of medical anthropological concepts on Latino immigrant populations in North America. The author draws on her experience as both a medical anthropologist and a licensed psychotherapist and on her extensive fieldwork in the Amazon for help in developing psychosociocultural assessments of Spanish-speaking migrants. This valuable book examines which kinds of therapy work for the growing Latino immigrant population and looks at metaphors (dichos) that can be used to help in brief interventions for clinical issues. In relation to the specific beliefs, values, and sentiments of these clients, Brief Psychotherapy with the Latino Immigrant Client presents:

• hypnosis techniques that work with this population
• behavior modification and cognitive restructuring techniques
• specific culturally appropriate metaphors for distinctive clinical issues
• an examination of alcohol issues in this population
• psychological issues that go along with tuberculosis
• hints for the non-Latino therapist who deals with Latino clients
• case studies that illustrate the book's principles of care and assessment
• shamanic techniques of healing that can provide a model for treating these clients

Brief Psychotherapy with the Latino Immigrant Client includes a glossary of Spanish terms, appendixes on hypnotic pain control inductions, sample tests, scales and diagrams, several case studies, and listings of Spanish language resources. Every therapist who treats Latino immigrants should own this book!

Chapter 1
An Anthropologist Becomes a Psychotherapist: Lessons from Shamanistic Healing

The morning dawned with a rooster's crow. It was 1978. I heard my father-in-law, Don Hilde, get up (it was 6:00 a.m.), as a knock sounded on the clinic door in his ramshackle house located in the outskirts of the small Amazonian city of Pucallpa, Peru. It signaled the entry of his first patient of the day. As a medical anthropologist and the wife of his oldest son, Yando, whom I met when I studied healing in Iquitos, Peru, some ten years earlier, I watched from early in the morning to late at night as this traditional third world urban folk healer treated men, women, and children tormented by physical and psychological disorders. His clients' problems ran the entire gamut of a psychiatric manual, from marital troubles, to psychotic behaviors, to drug and alcohol abuse, to depression and anxiety. He even treated witchcraft hexes and rectified his clients' misfortunes. To ensure success in my research, I acted as an intake nurse might in a hospital clinic and busily gathered data for my sabbatical research project by administering a questionnaire to all Don Hilde's patients—almost 100 people—for a month, as they sought help from this urban shaman. I discovered a new culturespecific disorder, called saladera, which I wrote about for a cultural psychiatry journal.

Over the years, as I continued my studies of folk healing, called in Spanish curanderismo, and traditional Peruvian folk healing, and as I taught university courses on medical anthropology and traditional healing, I never imagined that I would return to graduate school and become a psychotherapist myself. As time went on, however, I felt impelled to see if I could use the knowledge that I had gained living among traditional shamanic healers, in third world Amazonian slums, in a practical hands-on way in my own society. Nor did I realize in the 1980s when I began my second career as a psychotherapist that my field experiences in the Amazon and on the coast of Peru where I studied with more than twenty-five different traditional healers would provide me with a set of strategies to help me as I began to treat Latino immigrants in Southern California.

This manual is the result of the confluence of my two careers—in medical anthropology and clinical psychology. For me, it has been very useful to understand the psychological outlook and stressors facing individuals who were raised in Latin America, and then apply this knowledge to design short-term psychological treatments for recent immigrants now in U.S. urban centers. I hope that this knowledge will serve other therapists as well, Latino or otherwise, who treat the urban immigrant poor—those men and women who escape poverty, a lack of education, and few opportunities for betterment by translocating to a new country. They climb fences, swim rivers, board planes, and somehow manage to set up themselves up in a new environment.

As a Southern California psychotherapist who has worked both in private practice and as part of a multidisciplinary university independent provider association largely involved in time-limited treatment, I have treated Spanish-speaking men, women, and children for the past fifteen years. During the course of working with these clients for three, five, six, or ten visits, 1 have drawn on my understanding of the third world urban poor to guide me in the assessment and treatment of Latinos, and in particular to develop and use culturally resonant techniques that are meaningful to this population. I lived among similar peoples and experienced and learned about their poverty, their beliefs and values, and the way that their societies were structured, as well as their goals and their hopes for the future. Over the past nine years, licensed as a marriage and family therapist in California, I have treated more than 370 Spanish-speaking individuals, families, and children, most of them referred by managed care organizations. This database forms an ethnographic foundation upon which I offer advice for other psychotherapists to assess and intervene with Latino immigrant clients.

Managed care, with its inherently lower costs to the consumer, has been very popular with growing segments of the Spanish-speaking immigrant community. Access issues regarding this underserved population have changed since Karno and Edgeston's (1969) pioneering studies. Among the working poor, it is becoming more common for at least one member of the family to obtain mental health insurance. Studies of a large national sample of legal immigrants since the Immigration Reform and Control Act of 1986 (IRCA) document that almost 50 percent of such immigrants do have access to health insurance. More and more individuals are finding their way into managed care settings. With or without interpreters, clinicians find that they must acquire new techniques to be successful with these patients.

The majority of my clients have hailed from Mexico, and South and Central America. Puerto Rican and Cuban clients are much fewer in number in the western United States. However, Mexican immigrants constitute more than 80 percent of Latin Americans in the United States, and their numbers greatly impact managed care. I include research Findings that heighten diversity issues to distinguish particular needs of all three major Latino groups in the United States: Central and South Americans, Cubans, and Puerto Ricans.

In a seminal article, Dr. Lillian Comas-Diaz (1992) looked at the future of psychotherapy over the next twenty years or so. As with other scholars responding to the "browning of America," she argues that changing demographics in the United States and throughout the world make it essential for us to reform health care delivery so that psychotherapy is resonant and meaningful to the client's cultural background.

Latinos, the fastest growing minority group in the United States, need culturally specific therapies that make sense to them, and which consider their unique sociocultural reality and worldview. Much can be learned from the Latin American tradition of shamanistic healing, which is a time-limited intervention that can assist managed care practitioners. Additionally, we need to carefully assess what techniques will be helpful for this population's mental health treatment.

Medical Anthropology Concepts

Medical anthropologists study the multiple ways that people define and treat mental and physical disorders: from tribal healers in tropical rain forests of Peru, to an Andean highland curandero scattering flower petals on the path to capture the lost soul of his client, to the urban healer's fortunetelling diagnosis of the client's distress, to the herbalist's preparation of plant teas for a client, to the spiritist maestro's elaborate curing ritual, to the urban clinic of a large anonymous hospital—there are certain paradigms and beliefs that we can learn about and integrate into our own practice of psychotherapy to make it meaningful to a changing client base. Our choices are few: if we insist upon simply translating old wine into new bottles, our clients will not return or will hesitate to seek help for their psychological distresses and dysfunctions. So many immigrants have pulled up roots and disrupted their lives to start anew elsewhere. They have more than their share of adjustments and accommodations to make to their new environments.

In the new field of clinically applied medical anthropology, mental health providers are drawing on the lessons of anthropology to realize that the cultural background of clients has an important influence on their beliefs, behaviors, perceptions, emotions, family structure, and body image, to name a few. Moreover, no culture is ever homogeneous in a psychological sense, even small-scale tribal societies. The medical anthropologist has to bridge the gap between the biomedical concept of disease—the Western physician's perspective on illness drawn from rational scientific medicine—and patients' perspectives on illness—that is, how their lives have been disrupted, their understandings of their problems, and their expectations of treatment.

Arthur Kleinman (1980), a psychiatrist and medical anthropologist, argues for the importance of understanding clients' explanatory models of their illness and their own concepts of etiology, the timing of the illness, and appropriate treatments. The use of metaphor is a major way that the mental health provider can bridge the realm of his or her own explanatory model of science and biomedicine to the different explanatory world of the client. The mental health provider must have a coherent system of explanation and must find solutions to the client's personal human problems. Any healer's system must symbolically connect to the client's world of personal experience, social relations, and cultural meanings. As Helman (1994) has argued, the healer must activate a symbolic bridge to convince the client that the problem can be explained in terms of the healer's theory. As the sayings (dichos) and metaphors in this book will show, we can link the phenomenological world of the Latino immigrant with the symbols and metaphors available to us to relate to the particular problem and situation of the client in treatment. Just as a traditional healer guides therapeutic change by manipulating the symbols of the client's world, the psychotherapist must help the client reevaluate and reframe his or her past and present experiences. This new narrative has been examined by recent therapists who see this new story of their suffering and distress reframed into a success story. The therapist has to set the stage and create a mood of expectation and hope.

What are some of the lessons of shamanistic healing that psychotherapists can incorporate into their assessments and treatments of Latin American immigrants? To answer this question, I turn to my research in traditional shamanistic folk healing in Peru, which I conducted over several periods of fieldwork, in the summer of 1967, from June 1968 to July 1969, during the fall of 1977, and from 1978 to 1979. I also draw upon my university teaching experience in the areas of shamanism and medical anthropology, which I have taught at both the graduate and undergraduate levels. Additionally, I coedited and contributed to a publication in 1989 on shamanism and altered states of consciousness (de Rios and Winkelman, 1989).

The Biology of Hope

In my book Amazon Healer (de Rios, 1992), which is based on the life and work of one urban healer, Don Hilde (who happens to be my father-in-law), I wrote about folk healers around the world who are involved in health care delivery in third world nations, including Latin America. Indeed, many of the Latino immigrants whom we see in managed care are familiar with their own nation's local traditions of health care—either directly or indirectly. Traditional healing is important because it throws light on a particular culture or cultures and allows us to understand health care systems in different parts of the world. We can understand universal as well as culturally particular features of the healing process as we compare indigenous healing with biomedical and psychiatric care.

Briefly, I want to compare one folk healer, Don Hilde, and his symbolic world with the clients I see in my Southern California private practice. Healers such as Don Hilde are appreciated by their communities for their abilities and skills as counselors, for their knowledge of plant medicines, and for their supposed access to spiritual realms. Many more women than men consult folk healers. Stressors from poverty, unemployment, malnutrition, and overcrowding in the Amazon echo similar stressors in urban America—cities such as Santa Ana or Anaheim, California—which propel clients to seek help. The patients of urban folk healers average two or three visits, not unlike the statistics for the Latino immigrant managed care patients whom I see, who are not psychologically savvy and do not expect long-term treatments. They expect to resolve their problems as quickly as possible. Transference concepts are not easy to document in short-term managed care of Latino immigrants. Recognizing and applying psychoanalytic constructs are just not pertinent in cultures with a high illiteracy rate and a lack of understanding of Freudian concepts.

Don Hilde's patients have had access to cosmopolitan medicine as it is practiced in small cities of the Amazon or even the capital city of Lima. Many of the managed care clients whom I treat have access, as well, to family physicians and specialists as their needs demand. What are the typical procedures that a shamanistic healer such as Don Hilde uses compared to the techniques of psychotherapy? Can we, as psychotherapists, learn from shamans to enhance our own proficiency in treating this population?

For starters, most urban folk healers do not splurge on fancy consultation rooms or display signs of success. Don Hilde's consultation room can only be called a cubbyhole! Perhaps this comes from Latin American concepts of envy (envidia) or limited good, meaning that one person's good luck and affluence is often seen as the result of depriving someone else of good fortune. In the summer of 1967, I lived in a Peruvian coastal community, Salas, which was reputed to have more than 100 men and women healers. At that time, I interviewed ten healers, most of whom lived in very modest circumstances. They preferred not to display any wealth, and they meticulously avoided provoking the envy of others who might be motivated to pay a witch to hex them in turn. The only "conspicuous consumption" that I observed was a brick chapel that healers erected to honor St. Cipriano, a presumed Roman Catholic patron saint of folk healers.

Like their shamanic forebears in the rain forest, urban healers such as Don Hilde do not question patients about their symptoms but rather present themselves in an omnipotent, all-knowing manner. Folk healers around the world often enter into trance states, but less frequently in agriculture-based societies. Indeed, among shamanistic healers in rural, agricultural settings, these altered states are quite incidental, except when hallucinogenic plants are used, as in Peru, or in some Brazilian spiritualist religions such as the União do Vegetal. Healers in mestizo cultures of Latin America generally do not engage in trances. Rather they learn spells, formulas, rituals, and techniques to foretell the future, and they use a range of other treatment modalities to heal. Don Hilde and others like him are generally of above average economic status and may survive more comfortably than the farmers around them who lack a skill that can be converted to cash or that enables them to receive gifts (Winkelman, 1989).

Healers adopt a positive and confident manner, which is expected and even demanded of them. They are renowned for the preparation of medicinal brews, which they give to clients to treat their varied ailments. Don Hilde is no exception. In his backyard he grows therapeutic plants, which he brews each day as his clients patiently wait in his front room. At least once or twice a month, he makes a trip to nearby lagoons where he gathers medicinal plants for further preparation. Teas, poultices, and salves are all commonly provided as part of his overall treatment. Many are mixed with pharmaceutical medicines that he purchases from the numerous stores in his small city's downtown area. The shaman creates rapport with clients in Latin America by providing medications and commanding their trust and respect. The Western psychotherapist, in contrast, needs to show an interest in the effects on clients of drugs being provided by the psychiatrist. It is important, too, to inquire into any additional herbal teas or preparations that the Latino client may be currently taking.

Indeed, a growing area of research interest in pharmaceutical anthropology impacts the Latino immigrant in the United States. Over the past twenty-five to thirty years, pharmacies have become as common in small Latin American cities as gas stations are in the urban American landscape. International biomedical preparations originating in the United States, Europe, and Asia, available in glossy and colorful packaging, can be purchased without prescription in these pharmacies and are often misused, as no instructions are available for the client to consult.

The presentation of self is an important factor in the success of healers, who must be at ease and have faith in their own abilities. Most healers also have a good network of referrals that they use when their clients need surgery or hospitalization. Don Hilde touts the ability of these important others whom he will call upon to help his client if needed. Surely the psychotherapist, too, must also maintain a good referral network, particularly in employee assistance program (EAP) sessions, where it is expected that the provider will be familiar with community resources and even be expected to document this on billing forms.

In summarizing the success of a healer such as Don Hilde, who sees approximately 4,000 new patients a year, or 0.4 percent of the population of 120,000 in his home of Pucallpa, Peru, we need to understand the general psychological knowledge that folk healers or urban shamans call upon. They work with a culturally attuned symbolic system shared by their patients. They often focus on a natural versus a supernatural etiology of illness. In my work in the United States, interestingly enough, only the occasional Latino immigrant client continues to adhere to beliefs in hexes and brujeria (witchcraft). Healers, however, do generate exceptional emotional states in their clients through the clients' expectations and anticipation; on occasion, healers administer and themselves take plants that cause alterations in their normal waking consciousness—hallucinogenic substances—to diagnose illness. The psychiatrists who medicate our clients also create unusual states of consciousness through the medicines that they prescribe. Healers create a biology of hope to marshal the healing resources of the client's immune system by symbolic means. The psychotherapist perhaps unwittingly does the same. We call this a transducer effect, which converts energy from one form to another. In biomedicine, there appears to be little place for metaphors to explain the principles of healing. Our scientific worldview demands that we examine how healing occurs, what the biological markers are, and what actually goes on (Rossi, 1986). The folk healer, however, may not be interested in the cellular event, as it transforms to affective, cognitive, and social-interactional experience. He or she uses metaphors and symbols and is interested in outcomes but not process.

A focus on metaphors and storytelling is a way to enhance the wellbeing of the Latino immigrant client. This is an appropriate psychological technique and strategy similar to those used by shamanistic healers in non-Western cultures. Chapter 4 details the types of metaphors that are appropriate to particular psychiatric disorders of Latino clients and how they can be incorporated into psychotherapeutic communication. What we can discern is that the acculturative stresses that Latino immigrants face do impact their immune systems. All societies have psychological and social stresses and problems that face their members. When we examine the immune system of an individual, we are obliged to ask, "How does it respond to disease agents? How do belief systems, reiterated in metaphor, influence the immune competence of a person's body?"

Depression, for example, causes changes in the functioning of brain chemicals, and unavoidable stress—the type that gives rise to feelings of helplessness—may cause the depletion of catecholamines at the same time that corticosteroids are released in the body. These depress the immune system. This transducer mechanism shows that when people go through emotional, social, and environmental stresses that bring about changes in their lives, they may indeed experience somatic dysfunction.

Latino immigrants often experience unusual stress, which can lead them to a sense of helplessness, experienced as depression or despair (desesperacíon). Neurochemically, this translates into catecholamine depletion and a surplus of corticosteroid secretions in the body. The disease process has affective, psychological, neuroc...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Chapter 1. An Anthropologist Becomes a Psychotherapist: Lessons from Shamanistic Healing
• Chapter 2. Sociocultural and Psychological Assessment of the Latino Immigrant Managed Care Patient
• Chapter 3. Techniques That Work with the Spanish-Speaking Client
• Chapter 4. Metaphor and Misery: Does Everyone Think the Same Way?
• Chapter 5. The Typical Course of Therapy with the Spanish-Speaking, Time-Limited Patient
• Chapter 6. Clinical Issues
• Chapter 7. Alcohol, Tuberculosis, and the Spanish-Speaking Immigrant
• Chapter 8. Maria, the Murderer, and the Misogynist
• Chapter 9. The Non-Latino Psychotherapist and the Spanish-Speaking Patient
• Appendix A. Hypnotic Inductions in English and Spanish
• Appendix B. Tests, Scales, and Resources Available in Spanish
• Glossary
• References
• Index