Possibilities and Challenges in Providing Psychotherapeutic Interventions to Meet the Needs of the Latinx Population in the United States

Abstract

The mental health system in the United States faces challenges in adequately engaging the Latinx population with modalities that conform to the Latinx worldview, which demands incorporating holistic, family-centric, and trauma-informed models of treatment. Service provision and innovation is hampered by lack of research focusing on this population, the low numbers of Latinx clinicians available, and the lack of treatment adaptations to meet their needs. Psychotherapeutic interventions employed in the Latin American context are potentially useful when working with acculturating Latinx. In this article attention is given to barriers and facilitators for incorporating Family constellation therapy—a holistic trauma-informed treatment modality that offers conflict resolution through connection with ancestry.

“Caring for myself is not self-indulgence, it is self-preservation and that is an act of political warfare”

Audre Lorde

1. Introduction

Although they are identified as Hispanic or Latino in the United States, people in Latin America distinguish themselves based on nationality. The usage of the term Hispanic came from the passage of public law 94–311 in 1976, which was created to identify those who were of Spanish origin or descent (Lopez et al. 2020). In 1997, the Office of Management and Budget added the term Latino (Taylor et al. 2012), which focuses on geography and refers to those who come from Latin America. These terms are often used interchangeably and have led to the homogenizing and racializing of different ethnicities, creating an othering effect that erases the heterogeneity that exists in the close to twenty countries that compose the Spanish speaking part of Latin America. Nevertheless, information gathered in the United States about Spanish speakers follows this trend and its usage is inescapable. The term Latinx is currently used to reflect inclusivity of various gender identifications within this population (Lopez et al. 2020) and will thus be utilized throughout this paper.

Latinx not only share the history of colonization but they also have experiences of other devastating and traumatic situations impacting their countries of origin in common. During the 70s and 80s many Latin American countries experienced dictator regimes that brought about the disappearance and torture of many of its citizens (Hipsher 1996; Hollander 1997; Karl 1990; Navarro 2001). Additionally, the pressures of globalization, effects of neoliberal policies imposed by entities such as the International Monetary Fund (IMF) (Johnston and Almeida 2006; Walton 1998), and political mismanagement continue to greatly impact the livelihood of those in these formally colonized countries. Many leave their homes in search for safety or better economic opportunities. Recently, as measured by border captures, there was an increase in families attempting to enter the United States (Bialik 2019), signaling a deterioration in conditions faced in their home countries. In fact, the most notable increase in arrivals to the US southern border was found in people coming from Guatemala, El Salvador, and Honduras, countries that place among the top ten in the world with incidences of murder (Cohn et al. 2017; World Population Review 2019).

Authorized and unauthorized immigration are integral to the success of the United States. Whether it be the forced migration of Africans starting as early as 1619 (Stewart 2019), the use of residents of commonwealth states to fill labor shortages (Ngai 2004), or the current use of 11 million undocumented people (Batalova et al. 2020), who work in low wage agricultural and service jobs; the US has and continues to benefit from the labor of authorized and unauthorized immigrants. Therefore, it makes sense that the United States (US) anticipates a significant increase in ethnic diversity over the next three decades (U.S. Census Bureau 2015).

Of this projected ethnic diversity, Latinx are anticipated to account for 29% of the US population by 2060 (U.S. Census Bureau 2015). Among the many implications of this growth is the potential increase in mental health service utilization by members of the Latinx community, including by survivors of and descendants of those who experienced trauma. This presents a unique opportunity for mental health providers. However, there remains a challenge that Latinx have underutilized available mental health care services and might continue to do so (Alegria et al. 2002; United States Department of Health and Human Services 2001). Therefore, increasing the availability of treatments that reflect Latinx’s preferences within talk therapy (psychotherapy) will be important in meeting the mental health needs of this growing segment of the US population.

Understanding factors that affect the mental health of Latinx will be crucial for adopting service changes that can meet their needs. One of these factors is a client’s degree of acculturation, which refers to the level of a person’s adaptation into a different culture (Romero et al. 2013). In the case of Latinx in the US, they are required to adapt to the dominant White American culture, which has a history of oppression towards the indigenous and African cultures from which many Latinx descend. Research shows that, for recent Latinx immigrants, lack of bilingual therapists, stigma associated with mental health problems, concerns about immigration issues, racism, and fears of cultural miscommunication are elements that lead to the underutilization of mental health services (Rastogi et al. 2012). On the other hand, studies show that a lack of spirituality in treatment plays a role in the decreased likelihood of seeking mental health services for more acculturated Latinx (Turner and Llamas 2017).

It is also important to consider a person’s interpretation of health as a concept. Latinx’s understanding of illness and health is wide-ranging and can be quite different from health concepts adhered to in the US system, which often relies on the biomedical model (Maduro 1983; Viladrich 2006). Within the US mental health system, cultural factors utilized by some Latinx might be misinterpreted as signs of mental illness (Romero et al. 2013) and could prove detrimental for engagement in mental health care. Thus, it is imperative that the US mental health system find ways to adequately engage Latinx, a task that demands the incorporation of holistic models of treatment that include spirituality.

This paper will address the gap between mental health services based on US practices and the needs of the Latinx population. While Latinx are a heterogenous group with many differences, this paper begins by outlining the worldviews they have in common and their shared treatment preferences in the context of mental health care. The paper will then discuss the areas in which Latinx experience exclusion in the US. Finally, the review will highlight psychotherapeutic interventions that are rooted in the Latin American experience as a means to counteract or resist these exclusions. Particular attention will be given to a holistic therapeutic modality and factors that impact the probability of its adoption in the US.

2. Latinx Worldview and Preferences

When a dominant cultural group sets the tone of mental healing, it limits and excludes the treatment preferences and psychological experiences of clients that do not belong to it. For example, a lack of proficiency in and understanding of Latinx worldview beliefs such as personalismo (the preference of personal contacts over institutional ones) and sympatia (the valuing of pleasant and approachable demeanor) can hinder the therapeutic relationship between clients and their health providers (Gallardo 2013; McNeill et al. 2001). While lack of knowledge of folk illnesses such as susto (fright), ataque de nervios (attack of nerves), or pena moral (broken heart)—which also form part of how they understand the world (their worldview)—could lead to misdiagnosing and can be specifically damaging to the therapeutic relationship (Arboleda-Flórez 2001). The importance of being proficient in a client’s worldview is reflected in Viladrich’s (2007) ethnographic study where she used qualitative methods to look into Argentine immigrants’ access to health providers in New York City. In her research, she found that Argentinians—who, unlike most Latinx, actually have a positive view of psychotherapy and believe in the efficacy of Western medicine—distrusted US providers and created informal networks that granted them access to Argentinian health providers, which they viewed as caring and trustworthy.

In addition to treatment preferences, the client–therapist relationship and service utilization of therapeutic services are impacted by attitudes towards illness and mental health (Abramson et al. 2002). Latinx have different ideas and expectations about what constitutes illness, what kinds of treatment procedures are appropriate and effective, and what health services are most compatible with their lifestyles (Maduro 1983). Specifically, sociosoma, which are modes of causation that explain sickness by factors such as social relationships, the intrusion of unwelcome spirits, and living circumstances (Viladrich 2006) might influence how Latinx approach and understand their mental health. As Latinx can attribute illness to emotional states, lack of balance, dislocation of real or imaginary parts of the body, sorcery, evil spirits, or angry saints (Maduro 1983; Viladrich 2006), a lack of understanding of these cultural factors within US mental health systems might lead to misinterpreting these beliefs as signs of mental illness. This may generate unnecessary pathologizing, medicating, or even hospitalizing of those who express these beliefs. For some Latinx clients who are able to overcome the many barriers they face in order to obtain healing, this gap in cultural knowledge could prove detrimental to their engagement with the US mental health system.

Research supports the idea that Latinx would engage in mental health services if these are accessible in their preferred language and include culturally relevant elements. Rastogi et al. (2012) conducted a qualitative study using five focus groups with eighteen Latinx adults, with ages ranging from 27 to 50 to explore how Latinx in the Midwest viewed mental health services, their perceived barriers to treatment, and their recommendations for improving utilization. The study found that participants had a high preference for services in Spanish and were likely to seek services related to family or child concerns. In addition, participants in the study reported using friends, family, faith healers, and medical doctors for mental health needs. Participants reported that fear of racism, legal issues, and cultural miscommunication were barriers to service utilization. Further barriers to engagement in mental health treatment are citizenship and health care coverage. Data from the National Latino and Asian American Study showed that noncitizens and naturalized citizens were about 40% less likely to report using any mental health service than US-born citizens (Lee and Matejkowski 2012). Noncitizens were about half as likely as US-born citizens to report using specialty mental health care services and they were less likely than their US-born and naturalized citizen counterparts to have health insurance. Among noncitizens, those who had insurance were more likely to receive mental health services, as compared to their uninsured counterparts (Lee and Matejkowski 2012). Thus, efforts to engage and retain Latinx that are new to the US, in psychotherapy may require not only affordable or free service delivery in Spanish but also therapists who understand the environmental and social dimensions of acculturation stress faced by this population. This kind of service provision might sound impossible to some, yet to Spanish-speaking psychotherapists, community-based organizations located in areas with large Latinx populations, and organizations that provide services to immigrants and refugees, it might be reasonable.

3. Latinx Needs within US Mental Health

The field of mental health is constructed as one geared to helping others and preventing harm; it is presumed to possess the ethics of responsibility—to use Weber’s (1946) term—where the culture of helping is at the heart of the profession. Mental health, therefore, can be seen as a cultural sphere filled with the promise for alleviating and correcting the wrongs faced by minorities in the US who seek mental health treatment. Yet, systems in place within the field of mental health continue to replicate the outside environment.

Currently mental health services in the US are largely delivered by white therapists. According to Lin et al. (2018), the psychology workforce in the US is composed of only five percent Asian, five percent Latinx, and four percent Black/African American. These percentages have—as Weber (1946) would put it—a socially intended meaning; they reflect the infiltration of the racial hierarchical order in the US mental health field (Fanon 1978). An illustration of the tension and harm caused when there are differences between the lifeworld of client and clinician are highlighted in the 2017 article titled Why I left my White Therapist (Babu 2017). Here, Chaya Babu, an Asian woman, writes about the difficulty she faced when her white therapist could neither acknowledge nor hear her experiences as a woman of color. Babu further stated feeling unsafe sharing her thoughts and feelings with a white person about what it was like to live in a brown body in a white world.

Given that most services are provided by people who are likely to have internalized the racial hierarchical order—from which they benefit—it is important to look at the systems in place, such as research, that may help neutralize the effects of this phenomenon. Environmental elements such as racism, which impacts the Latinx community (Abad-Merino et al. 2013; Brotherton and Barrios 2011; De Leon 2015), are mirrored in the lack of research focusing on this population. Bernal and Rodriguez (2009) reviewed articles from 1960 to 2008 on children or families in any field and found that more than 99% of the psychological literature made no references to Latinx. They did, however, find an increase in the percentage of references to Latinx children and families for each subsequent decade. Still, the overall research on Latinx children and families according to Bernal and Rodriguez (2009) was less than 0.005% of the publications in this area, an alarming fact given that Latinx are the largest ethnic minority in the US. Additionally, reviews of research in cognitive behavioral modalities aimed at addressing anxiety (Bernal et al. 2018), stress (Cardemil et al. 2018), and depression (Ngo and Miranda 2018) found a corresponding low level of research focusing on Latinx, and these are even lower for Spanish-speaking Latinx. Therefore, a sense of racism and exclusion is compounded by the fact that psychotherapeutic model efficacy—models that were created predominantly by White European Americans—is validated by research done on that same population.

4. Trauma Treatment among Latinx: Opportunities within Psychotherapy

Using a trauma lens can be useful in meeting the mental health needs of those who are invisibilized and marginalized. According to the American Psychological Association (2020), “trauma is an emotional response to a terrible event like an accident, rape or natural disaster” and induces reactions like unpredictable emotions, flashbacks, strained relationships, and physical symptoms like headaches. While these reactions are normal, given the lived or witnessed experience, when symptoms persist and do not decrease in severity it might indicate the development of post-traumatic stress disorder (PTSD) (U.S. Department of Veterans Affairs 2020). When considering the mental healing of the Latinx community, it is therefore important to consider the role of trauma and areas of opportunities for engagement that are specific to this population.

The health and well-being of acculturating Latinx is negatively impacted at all levels of the immigration process. The traumatic events experienced at the country of origin, during the journey to the United States, and once here, might include extreme poverty, natural disasters, rape, political persecution, community violence, and racism (Chavez-Dueñas et al. 2019). These traumatic experiences can impact the mental health of Latinx, impairing functioning and manifesting as post-traumatic stress symptoms. Research shows that prior trauma exposure is highly associated with post-traumatic stress disorder (PTSD). In addition, the negative effects of acculturative stress include a higher risk of mood and anxiety disorders (Cardemil et al. 2018). Thus, Latinx are found to have a higher prevalence of symptoms for PTSD (Cardemil et al. 2018). The implications of the effects of trauma are concerning, as trauma not only impacts the individuals but can be transferred from parents to children, affecting generations (Doucet and Rovers 2010).

Given acculturating Latinx’s probability of exposure to traumatic experiences prior to, during, and after immigration, and the disruptive nature and lasting effects of trauma, trauma treatment is an area of mental health that merits investigation. Trauma treatment presents a potential area in which the right circumstances may encourage the engagement of Latinx. Since trauma influences one’s sense of self, one’s relationships with others, and an individual’s concept of spirituality (Smith 2004), considering spirituality when working with Latinx trauma survivors is important.

Spirituality

In their overview of mental health research focusing on assessing and treating Latinos, Romero et al. (2013), found that “treatments that acknowledge culture-specific illness manifestation and folk treatments, as well as using storytelling and integrating spiritual beliefs” are important for use with Latinx (p. 338). The significance of spirituality when treating Latinx can be further observed in a research study that looked at the role of therapy fears, ethnic identity, and spirituality on access to mental health treatment among Latinx college students. Turner and Llamas (2017) found that Latinx college students who had not utilized counseling services indicated higher levels of belief in spirituality than those who reported seeking counseling. This signals that Latinx might meet their mental health needs through their spiritual communities.

Spirituality and mental health can be complementary. Latinx that attribute psychological distress to supernatural forces turn to spiritual and traditional healing practices through curanderos or folk healers (Turner and Llamas 2017). When asked why their clients sought consultation, traditional healers reported stressful living circumstances, family and marital issues, and mental conditions such as depression (Viladrich 2006), which are the same reasons why most people consult mental health practitioners. In addition to finding treatment within a spiritual context, when they visit a curandero, Latinx receive services in their community in Spanish and are spared the need to complete complicated paperwork, provide identification, or endure long lines (Viladrich 2006).

Although spirituality is important for Latinx, spiritual education is currently not part of practitioners’ core education. O’Connor (2004) found that limited literature exists on formal counselor education courses that speak to the spiritual aspects of counseling, despite the need for courses in the spiritual dimensions of counseling and textbooks that explore the overlapping areas of psychotherapy and spirituality. Furthermore, most psychologists report never having received training on religious and spiritual issues (Hathaway 2008). Even clinicians who receive training from the religious professions and professional psychology rarely receive training in traditions outside their own (Hathaway 2008). Therefore, it is worth looking at modalities that touch on spirituality while addressing mental health issues.

5. Latinx-Centric Modalities

Viewing interventions and modalities that are rooted in the Latin American experience offers a resistance-focused alternative to the dominant mental health treatment paradigm in the US. A wide exposure to these would mean that psychotherapist working with Latinx—particularly with those in the acculturation process in the US could then turn to liberation psychology, testimonio, or family constellation to provide Latinx-centered care. Created within the Salvadorian context by Ignacio Martín-Baró, a Spanish Jesuit priest who made El Salvador his home, liberation psychology calls for an acknowledgement of history, a move away from neutrality in the face of injustice, and a recognition of collective trauma (Gaztambide 2019; Hollander 1997). Liberation psychology was spread in Latin America by psychotherapists who were themselves targeted because of their engagement in activism, and their treatment of political dissidents of oppressive regimes posed a threat to those in power (Hollander 1997). Under similar circumstances, testimonio (testimony) was created in Chile as a therapeutic tool for bearing witness to and supporting in the speaking the unspeakable by those silenced during the Pinochet dictatorship (Aron 1992; Lira 2020). Testimonio allows for the accounting of injustices and their effect on people who have lived through them, thus making it relevant to psychotherapist who work with survivors of trauma.

Looking to Latin America for solutions in Latinx care reveals a far-reaching use of alternative and holistic therapies. There, psychologists are already incorporating alternative therapies into their clinical work. In their qualitative study, Tamargo et al. (2015) interviewed nine psychologist in Venezuela who say the inclusion of alternative therapies in their treatment allows for spirituality, provides a fast and efficient way of getting at issues and results, is in alignment with psychologists’ humanistic training, and serves as a criticism of rigid psychoanalysis. One particular modality that gained popularity—family constellation therapy (FCT)—incorporates elements important to Latinx and can be used to address trauma. In the 1990s, FCT was created by Bert Hellinger, a German priest who spent 16 years with the South African Zulus where he learned their language, worldview, and the use of ancestral reverence. He later trained in psychoanalysis and other therapy models, eventually creating a modality that is rooted in family systems theory, incorporates the ancestral reverence of the South African Zulus, raises awareness of collective traumas and connection to the body, to bring healing of transgenerational traumas and conflicts (Cohen 2006; Duncan 2017; Longo-Lockspeiser 2018). In a family constellation, an individual addresses a current issue by connecting with the ancestral field to uncover trans-generational situations they are not aware of. The intervention can be carried out in groups or in a one-on-one setting and involves the representation of family members or the issue itself by either group members or objects, allowing connection with multiple sensory experiences that unearth the root of what is causing the present issue in the individual (Longo-Lockspeiser 2018; Pritzker and Duncan 2019; Stiefel et al. 2002). The constellation is a “three-dimensional matrix of the ancestral lineage that is not generally presented to consciousness” (Cohen 2006, p. 229) without the need of a narrative, but rather by tuning in to movements and feelings followed by the repetition of instructed phrases transgenerational wounds are healed in the individual and the family. As stated by Stiefel et al. (2002, p. 43), the family constellation model assumes that “we are body-spirit units connected at different levels with mankind, the past, and higher spiritual planes”, thus as an approach that is trauma-focused, incorporates spirituality, and resonates with communities of color, it holds promise for incorporation in psychotherapy with Latinx in the US.

Currently, FCT is used in Europe, Asia, and Latin America but it is rare in the US. Although quantitative research on family constellations is scarce, Hunger et al.’s (2015) work provides evidence of its efficacy. They looked at the mid- and long-term efficacy of family constellation seminars in a general population sample in Germany, specifically assessing psychological distress, motivational incongruence, the individual’s experience in their personal social systems, and overall goal attainment. The study found that family constellation seminars improved psychological functioning at eight and twelve-month follow ups. Because family constellations focus on the individual while still incorporating the family and utilizing important aspects of indigenous traditions, Duncan (2017) suggests that family constellation therapy is a better fit for Oaxaca, Mexico (an area with a significant and diverse indigenous population) than traditional forms of psychotherapy. Family constellation therapy promotes “a type of self-knowing by articulating with local cultural frameworks and forms of sociality that allows participants to work within the matrix of intergenerational familial life” (Duncan 2017, p. 491). Furthermore, in Latin America, the family constellation modality is widely used not only with individuals but also to address issues within systemic structures. For instance, Gómez Gómez and Doñoro (2005) investigated the application of family and organizational constellations on interpersonal relationships within an organization. If mental health services in Latin America are incorporating family constellations into treatment, that leaves us to question what it would take to see the same here in the US. Viewing the facilitators and barriers of incorporating this intervention in the US may move us closer to the answer.

6. Barriers and Facilitators of Latinx-Centric Modalities

When a service is widely available, we can find numerous organizations offering it along with training for those interested in the delivery of such services. Theories that reveal factors impacting organizations provide information about the probability of these adopting a new method. Institutional theory explains forces, patterns, and trends found within and amongst organizations. It states that change in organizations is impacted by matters such as the distribution of resources, the governing field, and the systems in place when organizational change happens (Washington and Ventresca 2004). Notably, a factor that affects organizations and how they operate is the pursuit of legitimacy. To obtain legitimacy, organizations mirror the actions of organizations that already have it (Meyer and Rowand 1977). Since successful organizations tend to hold power, the drive for achieving legitimacy leads to organizations’ conforming to existing ideals and practices (Suchman 1995). Therefore, organizations that want to offer different forms of practice might need to first find a substantial base of support (Suchman 1995). This framework shows that innovation is tied not only to the service but to the reputation of the organization providing it (Zucker 1987). Legitimacy, socially constructed realities, and formal blueprints therefore play influential roles in an organization’s decision to take on a new endeavor, such as the adoption of a psychotherapeutic intervention that incorporates spirituality.

Institutional theory introduces the notion that “dominant logic guides resource allocation, sets the terms of organizational politics, and establishes routines and capabilities that create precedent for further innovation” (Washington and Ventresca 2004, p. 84). Currently, in the US, the dominant logic is individualism, which guides modalities that are taught and utilized by mental health clinicians. Individualistic psychotherapeutic approaches widely used in the US operate from the understanding that the client’s primary relationship is with themselves, and relationships with community and family are secondary (La Roche 2005). Not only do these systems fail to incorporate families, which are central to the Latinx worldview, but by their nature, systems operating on an individual level fail to address patterns of discrimination and oppression (La Roche 2005). Therefore, the therapeutic relationship between clients of different cultural backgrounds and their therapists based on the individualist model has the risk of being negatively impacted by the individualistic model’s alignment with the status quo. This status quo, then, encourages clients to adjust to a culture that oppresses them (La Roche 2005). The logic of individualism in psychotherapy is important in understanding the lack of Latinx engagement in the US mental health system; the majority of mental health services are delivered by non-Latinx practitioners and the dominant logic is one that does not reflect a collectivist worldview commonly held by Latinx clients.

Another dominant logic in the US is the use of evidence-based practices to provide mental health services. These practices are based on quantitative research in controlled environments. Evidence-based psychological practice and psychotherapeutic models are advanced and validated by intervention research (Bernal and Rodriguez 2009). This type of research, in turn, is based on the post-positivist worldview that holds standards of objectivity, reliability, and validity in high regard (Creswell and Creswell 2018). Nevertheless, this dominant evidence-based logic can often lead to the use of “research methods that reflect cultural biases and to findings that may diminish the influence of cultural, historical, and other contextual variables on clinical outcomes” (La Roche 2005, p. 174) yielding samples composed of those most easily engaged for disorders that are most common in contexts that are most easily controlled (Bernal and Rodriguez 2009). Thus, much psychotherapeutic research creates a body of knowledge primarily focused on European American populations, which do not reflect Latinx treatment needs or the suitability of modalities for the Latinx population. In contrast, phenomenological methodologies either follow a constructivist worldview or a transformative worldview. Concretely, the constructivism worldview relies on open-ended questioning and on the participant’s view of the situation being studied, while the transformative worldview adheres to research inquiry that includes a political change focus to confront social oppression (Creswell and Creswell 2018). Research conducted following these worldviews leads to information that seeks to understand or empower clients, rather than to simply measure them and is therefore more in alignment with the preferences and current needs of Latinx in the US.

Resource dependence theory explains the matter of organizations’ dependency on the outside environment. Pfeffer and Salancik (1978) state that organizations are generally constrained by the interests of others. This is especially salient within nonprofit organizations as they heavily rely on government funding (Saidel 1991). Wry et al. (2013) claim that when organizations are unable to reduce their dependence on government, they can seek to create or change government regulations to work in their favor. However, an organization’s ability to do this relies on its power and, therefore, impacts most small- and medium-sized organizations’ ability to influence agendas of policy makers (Child and Rodrigues 2011). Thus, if the dominant logic supports evidence-based practices and individualistic models, then not only will most organizations follow this script, but most economic resources will likely go to organizations that align with the dominant logic. In an environment where it is difficult to compete, organizations that utilize a different logic will probably be found among those that have a variety of funding sources or rely less on government funding. However, it may also be the case that organizations that have more legitimacy are those that can afford to take the risk of trying out or incorporating new interventions.

A major external force affecting organizations today is neoliberalism, a conservative policy framework that has been impacting the culture of service delivery in the United States since the 1970s (Abramovitz and Zelnick 2018). Neoliberalism has led to an outcome-focused service delivery resulting in an increase in requirements, monitoring, and standardization, with a corresponding decrease in a service organization’s cultural sensitivity (Yan 2008). This policy framework has imposed business principles, methods, and goals on service delivery that result in decreased flexibility and limited access which, in turn, negatively impact the client–provider relationship (Abramovitz and Zelnick 2018). Pressures for cost-effective treatment for mental disorders have led to measures such as the APA’s endorsement of evidence-based practice and the creation of short-term effective modalities, such as cognitive-behavioral treatments (Roysircar 2009). This use of managerial principles moves away from humanistic therapy to one that follows the medical model, discouraging both clinical judgement and adaptation to the individual client (Lees 2011). Entities that heavily rely on government funding, then, have a more difficult time adopting interventions that are not evidence-based. Consequently, private institutions are most likely to use a variety of modalities and interventions that do not adhere to a post-positivist worldview due to their economic independence from government and neoliberalist pressures.

Just as institutional logic and resource-based theories have aspects that explain barriers to implementing methodologies that incorporate spirituality and holistic care within the mental health sector in the US, they also possess aspects that point to likely facilitators to this process. Even though the dominant logic is one of individualistic models that prioritize evidence-based treatments, there is potential to adapt US medicine to respond to the cultural needs of Latinx. For example, similarities exist between curanderismo (folk healing) and Western psychotherapy. Both practices can use ceremonial interventions in areas such as family engagement; both have the ability to discover symbols or objects that carry deep meaning; and both have the ability to experience change through manipulation of symbols (Hoogasian and Lijtmaer 2010). Moreover, similarities between traditional healing and humanistic–existential counseling were noted (Chavez 2016; Yeh et al. 2004). These similarities suggest that efforts to integrate Latinx-responsive practices into counseling and psychotherapy are possible, especially given that these are now used in Latin America. Furthermore, even though individualistic models dominate the US mental health system, they are not the only form of therapy provided in the US. One can also find therapies that are delivered for groups, such as family and marriage therapy, and therapies that incorporate more collectivist viewpoints, such as culturally sensitive therapy and family systems therapy (Brave Heart et al. 2020; Stratton et al. 2015). Lastly, as the Latinx population grows in the US, one can also expect an increase in another resource—Latinx psychotherapists. With this increase, there will be a growing desire for and usage of holistic Latinx-centric interventions.

One element of institutional theory that holds promise for the incorporation of methodologies that integrate spirituality into psychotherapy is its claim that professionals are institutional agents that have the power to influence organizational decisions (Scott 2008). Scott highlights the role of cultural cognitive agents which “employ ‘cultural authority’, based on the dependence of client groups on the professional’s superior competence” ((Starr 1982) as cited in (Scott 2008, p. 225)). One such example is reflected in the Council on Social Work Education’s (CSWE) 2008 adoption of Educational Policy and Accreditation Standards (EPAS), which for the first time focused on diversity (Stoesz 2013). EPAS provides social work programs’ threshold for professional social work competence (Petracchi and Zastrow 2010) and in 2008, it switched to a model of assessing practice competencies, moving away from its traditional method of assessing program outcomes. Another example of institutional agents having the power to influence organizations is found in the existence of the National Association of Social Workers (NASW). In its preamble, the NASW’s code of ethics states that “social workers are sensitive to cultural and ethnic diversity and strive to end discrimination, oppression, poverty, and other forms of social injustice.” It goes on to state that “social workers seek to promote the responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems” (National Association of Social Workers 2017). Therefore, among the mental health providers that deliver services to Latinx, social workers may be well fitted to incorporate into their work holistic Latinx-centric interventions.

Resource dependency theory suggests that organizations must remain flexible and adaptive while dealing with technicalities necessary for change (Thompson 1967). The growth of the Latinx population in the US and the current lack of Latinx engagement in mental health present an opportunity for the introduction of interventions that may be more culturally compatible and appealing. The possibility of catering to a new niche will bring with it the need for training of mental health practitioners in the specific interventions that are more culturally compatible. Through institutional theory’s notion of normative isomorphism, we find the internalization of norms through professionals receiving similar training and interacting with associations that further engrain their worldview (Mizruchi and Fein 1999). Hence, looking to Latin America’s current institutes that provide training on family constellations could provide a model that may be replicated by US organizations that educate social workers. Because of their independence from government funding, institutes that train social workers on specific therapeutic modalities may possess the flexibility needed to adapt to the needs of Latinx in the US market.

Although legitimacy reflects dominant logic, clientele may be a factor that determines the type of legitimacy an organization seeks. An organization that has moral legitimacy adopts decisions that reflect its audience’s value system and embraces socially accepted techniques and procedures (Suchman 1995). Therefore, organizations with morally driven missions might be more inclined to embrace a modality that promises to better serve their clients and to counter exclusionary and racist paradigms. The links between spirituality in generational trauma (Doucet and Rovers 2010) point to family constellation work’s potential applicability with survivors of trauma, given the model’s focus on ancestry. Furthermore, trauma influences one’s sense of self, one’s relationships with others, and an individual’s concept of spirituality (Smith 2004). Taking into account that a large number of Latinx come to the US after escaping violent and traumatic situations in their home countries, individual therapists and organizations working with these populations could better serve them by the incorporation of family constellation work as an addition to the psychotherapeutic services they provide.

The proliferation of training opportunities in holistic interventions such as family constellation therapy, could better equip trauma therapists working with Latinx. Currently, there are a few entities in the US that provide training in family constellations, and these are located in California, Colorado, and New York. Normative isomorphism signals that success of the proliferation of training in family constellations in Latin America could potentially be replicated in other places that serve Latinx. The existence of a few entities providing training on family constellation in the US points to the potential growth in number of institutes that provide the same services. The current number of Latinx that do not utilize mental health services and the projected number of Latinx that will make up close to a third of the US population could provide an incentive for organizations that cater to clinical social workers and or trauma-focused clinicians to incorporate Latinx-centric holistic interventions that include spirituality in their training.

7. Conclusions

Exclusionary practices in the US reveal underlying racism toward the Latinx population. The treatment options for Latinx, especially those in the acculturating process, would be more promising if they utilize a historical and sociopolitical analysis, are trauma-informed, incorporate aspects important to Latinx, include spirituality, and are delivered in their native tongue. Therefore, the utilization of psychotherapeutic interventions rooted in the preferences and experiences of Latinx, such as liberation psychology, testimonio, and family constellation therapy, present a possibility to increase Latinx engagement in psychotherapy in the US.

Given the importance of spirituality to Latinx and the unpopularity of incorporating spirituality into psychotherapy in the US, family constellation therapy should be given special attention, particularly because family constellation therapy offers solutions for complicated issues like abuse and war (Stiefel et al. 2002) which are often faced by acculturating Latinx. In this paper, institutional and resource-based theory are used to gauge facilitators and barriers to the incorporation of this intervention into US mental health services. Due to the moral logic they subscribe to and the resource they symbolize, inclination to adopting family constellation therapy may be found in clinical social workers, Latinx psychotherapist, community-based organizations, and immigrant and refugee service organizations that provide therapy to survivors of trauma. Future investigation of these institutional agents could lead to further understanding of facilitators and barriers that psychotherapists face in delivering Latinx-centric holistic care.