When Pierluigi Mancini and his family navigated the behavioral healthcare system in Atlanta in the ‘80s, they faced barriers. Not because of language, though they’d recently moved from Colombia to the United States, but culturally. “My mother, who speaks three languages and has lived on three different continents, struggled to understand the clinicians,” he says. The way they spoke about Mancini’s addiction presented cultural barriers that left his mother in the dark. “They spoke of tough love, a concept that doesn’t make sense in Spanish.” Tough love, a problematic approach still perpetuated even today, would have perhaps made more sense if the clinicians had described it as “mano dura” (hard hand). Because of the disconnect, his mother felt helpless and unsure how best to aid her son, who, at the time, was a college student at Florida State University struggling with a substance use disorder. Years later, in 1999, Dr. Pierluigi Mancini founded CETPA, which provided affordable, linguistic, and culturally appropriate counseling services in Georgia.

Language is multidimensional and so too is proficiency, notes Dr. Mancini, who has been in recovery for 37 years and is an expert on linguistic and cultural competence in behavioral health. For example, a nonnative English speaker may know the nuances and terminology of their own profession but not have language mastery in other areas. “A mechanic might speak enough English to tell a customer what’s wrong with their car and what it’s going to take to fix it,” he says. “However, if you’d ask the same person how to get to the local library, they may not be able to tell you.” The same can be true if a provider asks a nonnative English speaker about their mental health. “Language proficiency is a continuum,” says Dr. Mancini. “Just because a person speaks some English doesn’t mean they have the language proficiency to express how they feel.”

Most behavioral health providers are aware of the therapeutic challenges a language barrier can create. However, they often default to using an array of interpreters, ranging from trained phone interpreter services like LanguageLine Solutions to pulling in family members to interpret during sessions. While professional interpreters can be helpful during a behavioral health crisis, it’s inappropriate to use them during ongoing therapy because they generally lack behavioral health expertise and training. Some providers, points out Dr. Mancini, will pull in any employee who speaks the patient’s language, regardless of training. Others will ask the person to bring their own interpreter. “The first is inappropriate, and the second is against the law,” he says. Without adequate clinical training, adding an interpreter to the mix can turn a therapeutic session into a game of Telephone: the therapist asks a question, the interpreter tries to guess what the therapist means, and the client responds to the misinterpretation. “There’s a vast margin of error,” says Dr. Mancini.

In other instances, community members, family members—even children, or friends are asked to interpret, leading to poor communication as mentioned previously and disclosure of personal information the person in treatment might not want to share. In situations of abuse, abusers can use interpretation as a tool of manipulation or to hide abuse. For example, if the patient is a victim of domestic violence but the abuser, or a family member of the abuser, is allowed to interpret, it enables them to shape the narrative and continue to control the victim. The same is true for situations of exploitation and human trafficking. I’ve written about cases in the U.S. where Iaw enforcement inadvertently furthered a person’s trafficking scheme by allowing the trafficker to interpret the conversation they had with a victim. For example, in North Carolina, police unwittingly allowed a trafficker—who they believed was the victim’s employer—to interpret. The trafficker used the moment as an opportunity to tell the victim that police required him to pay his alleged debt before he was free to leave. Exorbitant fees are a common means to keep a person in debt bondage. Having a professional interpreter would have quickly revealed the scheme and might have prevented the trafficker from trafficking others.

More than one million migrants arrive in the U.S. each year, often displaced and fleeing their homes because of civil unrest, fear of persecution, and natural disasters. China, India, and Mexico are the top birthplaces for U.S. immigrants. Asians are projected to become the largest immigrant group in the U.S., surpassing Hispanics by 2055. Many migrants have experienced trauma in their country of origin and often mistrust systems of care and the judicial system.  Linguistic proficiency is only one element in overcoming barriers to treatment, says Dr. Mancini. Clinicians must also have cultural concordance or literacy to develop rapport.

Racial and ethnic concordance between a provider and patient helps to build trust and improve health equity in psychiatric and physical healthcare, making it more likely that people will reach out for assistance before they experience a crisis. Dr. Mancini hopes that as states build out their crisis systems in preparation for 988, they include sustainable language and cultural competency funding. Telecom companies must make the three-digit number for mental health, substance use, and suicide emergencies live by July 16, 2022. Without proper outreach and cultural concordance or literacy, immigrants typically wait until their symptoms are critical and end up in the emergency room. “They don’t know where else to go and end up stuck with very, very high-cost bills,” he says. There’s an obvious ethical and person-centered argument for linguistic and cultural concordance as well as a strong economic one. “Emergency room services come at a high cost to patients, personally and financially,” notes Dr. Mancini, “and to hospital systems, which aren’t adequately equipped to address psychiatric needs.”

Cultural literacy isn’t stagnant but rather a continuous process. It’s critical not to clump racial or ethnic groups together, categorizations that have often been drawn somewhat arbitrarily by governments. For example, determining who falls under the Hispanic ethnic group—the Nixon administration coined the term for the U.S. census—is based on whether a person is “of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.” Dr. Mancini points out that each nation has its own specific cultural, socioeconomic, environmental, and geopolitical factors, so even bilingual, culturally literate clinicians still need to ensure they’re culturally competent on the nuances of a patient’s experience. “If I’m serving someone from a different background,” says Dr. Mancini, “I must try and learn as much as I can about where they come from because that’s going to affect my ability to understand what they’re trying to tell me.” Also, just because a person emigrated from Latin America doesn’t mean Spanish or Portuguese is their primary language or that they speak either. There are hundreds of indigenous languages in Latin America, including regional dialects of Quechua, the ancestral language of the Incas spoken in parts of Peru, Ecuador, Bolivia, Colombia, Argentina, and Chile.

Idioms and slang greatly vary from country to country, and so too can how people talk about mental or physical health and how they describe their symptoms. For example, Dr. Mancini had a client who complained of a ringing in his ears but wouldn’t let a physician take a look. The man’s explanation for the ear trouble was that he’d broken up with his girlfriend, and she put a curse on him. “That was his belief, and it shaped how he viewed his symptoms,” he says. The staff didn’t dismiss or counter the man’s beliefs but rather continued to ask him to see a physician. “How we react to people’s beliefs,” points out Dr. Mancini, “impacts how open the person is to receiving our help.” The client eventually agreed to see a doctor who diagnosed him with an inner ear infection.

Similarly, Dr. Mancini says the immigrant population he worked with in Georgia typically depended on home remedies for ailments, like teas and medicinal recipes passed down from generation to generation. So when CETPA’s psychiatrists gave patients medication samples, they soon found that patients were throwing the medication in the trash on the way out of the office. “They didn’t understand the purpose of the pills,” he says. “There was a cultural conflict.” The solution was for the nurse to explain medication management to the patient before the person met with the psychiatrist. “When the psychiatrist recommended medication, they’d also explain what it was and what it was supposed to do,” he says. Dr. Mancini’s staff was also trained to understand the diverse levels of acculturation and generational differences among their clients.

Investing in a bilingual workforce helps foster parity where supports and services are accessible in a language people understand. “You’re able to bring preventative programming—like suicide prevention and other public health topics like nutrition—into the community,” says Dr. Mancini. He witnessed the inaccessibility of public health messaging at the onset of the Covid pandemic, resulting in thousands of workers at poultry plants in Georgia who tested positive for the virus. “People blamed immigrant workers, but they work in cramped conditions and weren’t given personal protective equipment,” he says, “and no one told them there was a pandemic happening or how to protect themselves.” The lack of communication and precautions put the entire community at risk. “When we don’t do things in a way that helps every single member of society,” he says, “it harms everyone.”