A Ukrainian woman in her forties sits across from a therapist who, until two years ago, had a fairly typical caseload in a small clinic on the outskirts of Warsaw. Her waiting room is now crowded with people who express their sorrow in a language that most Polish doctors are unable to understand. In halting English, the woman first attempts to explain what transpired in her village. Then she comes to a halt. She switches to Ukrainian. Her shoulders start to loosen. The therapist, who happens to be bilingual due to a family history, nods and allows her to go on. It’s a brief moment. However, this is the kind of moment that is subtly changing the way the mental health community views who is qualified to assist whom.
For many years, cultural competence in therapy was viewed as a checkbox that could be checked with a few additional readings and a weekend of training. Strangely enough, language was left out of that discussion. The field seemed to believe that translation was a practical problem that could be resolved with the help of interpreters and goodwill. More and more research points to the opposite. According to one meta-analysis, therapy given in a client’s mother tongue was about twice as effective as therapy given in English to clients whose first language was not English. twice. It’s not a rounding error. The profession is still catching up to that structural finding.
This question became public due to the displacement crisis in Ukraine. Research on refugees who left after February 2022 revealed that more than 90% of those polled in the initial weeks had acute stress disorder. All of a sudden, therapists throughout Europe were faced with waiting lists that they had no clear way out of. Only to a certain extent were interpreters helpful. Clinicians started to acknowledge that even well-trained ones changed the room’s texture. What could be said was altered by a third presence. Relay translation appears to be particularly difficult with grief. Shame also does.
Decades ago, Carl Rogers maintained that empathy, authenticity, and unconditional positive regard were the therapeutic prerequisites. Perhaps because he was working primarily with English speakers in mid-century America, he didn’t say much about language. But in retrospect, it’s almost clear how language conveys those attributes. When empathy is conveyed through a translator, it takes longer. Authenticity with an asterisk is authenticity via an interpreter.
The numbers in the United States tell their own story. Spanish is spoken at home by more than 41 million people. In their daily lives, about one in five Americans speak a language other than English. However, the number of bilingual therapists has not kept up, especially in the fields of clinical psychology and psychiatry. There are still very few counselors in the workforce who are proficient in two languages and, more crucially, two cultural registers. Over the past 20 years, systematic reviews of bilingual counseling have mostly relied on the reports of therapists. Strangely, the client’s viewpoint is under-theorized. Training is the same. Instead of treating bilingualism as a clinical skill deserving of its own pedagogy, the majority of graduate programs still view it as a soft asset.
The asymmetry is difficult to ignore. For the same compensation, a bilingual therapist frequently performs twice as much emotional work. Colleagues automatically turn to them for their most challenging cross-cultural situations. Some people do well in that position. Others burn out in silence. The risk of over-identification, in which a therapist hears their own family history in a client’s story and loses sight of what the client truly needs, is another risk that is not sufficiently discussed.
Even so, it’s difficult to deny that the field is heading in the wrong direction as this develops. Language match is starting to be flagged as a quality metric by insurance companies. Bilingual specializations are being quietly developed by training programs in Los Angeles, Toronto, and Berlin. It’s genuinely unclear if any of this will grow quickly enough to satisfy the demand brought on by migration, war, and climate displacement. Before any of this started, the mental health workforce was already overworked.
The fact that language is no longer viewed as a logistical tool seems more difficult to argue against. In clinical discourse, it’s evolving into something more akin to medicine.
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