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Therapy approaches to effectively support immigrant clients

Learn counseling strategies for immigrant clients that honor culture, build trust, and address trauma, transition, and acculturation stress in therapy.

January 9, 2026

By Ryan DeCook, LCSW

7 min read

By Ryan DeCook, LCSW

The therapeutic frameworks we’re trained in don’t always translate cleanly across cultures. A client’s expectations of therapy, their understanding of distress, and what healing looks like can vary widely based on their background and migration experience. According to Pew Research, as of summer 2025, there were 51.9 million immigrants living in the U.S., accounting for about 15.4% of all U.S. residents. Whether you specialize in working with immigrant populations or not, you’ll encounter clients from diverse backgrounds. They will bring with them a diversity of stories, trauma histories, and cultural frameworks that require thoughtful preparation.  

Understanding the immigrant and refugee experience

People immigrate to the United States for many reasons, including work, education, family reunification, and safety. Some individuals—particularly refugees and asylum seekers—arrive after fleeing war, violence, persecution, or natural disasters. In one study on migrants from several Central American countries, 83% reported violence as a reason for fleeing their country.

Refugees and asylum seekers may face elevated psychological risk due to pre-migration trauma, dangerous migration journeys, and post-migration stressors such as legal uncertainty, discrimination, language barriers, and limited access to care. These challenges can contribute to higher rates of anxiety, depression, and post-traumatic stress.

But immigrants as a whole should not be generalized. Those who aren’t refugees may experience different versions of acculturation stress, which is the psychological impact of trying to adjust to a new environment with different language, values, and societal norms. Acculturation stress can lead to higher rates of depression, anxiety, and suicidal ideation. Clinicians should avoid assumptions based on immigration status alone and instead take an individualized approach that considers both risk factors and strengths, including resilience, family support, and cultural protective factors.

The impact of trauma on mental health presentation 

Presentations and understandings of trauma symptoms can vary widely across cultures depending on cultural narratives, belief systems, and localized idioms of distress. If a clinician were to only listen for language outlined in the DSM criteria for PTSD, for example, they may miss or interpret distress. Given that the DSM-5-TR is formed from a western-centric viewpoint, there are limitations to the scope of what it can grasp. 

Understanding localized idioms helps with accurate assessment, rapport, and culturally responsive care without abandoning diagnostic frameworks. Examples of alternative cultural idioms of distress include “qaracan” for Somali refugees, being victims of black magic for some of the Rohingya population, or the term “susto” for certain Latino individuals. These cultural conceptualizations and experiences can have overlap with DSM-based PTSD criteria, but may also go outside the lines of westernized explanations. 

Navigating cultural identity and belonging

Individuals who have immigrated may face a complex mix of challenges in regards to identity, belonging, and intergenerational conflict. It can be difficult for clients who are in a new country to retain a strong sense of self and find social belonging. 

To help with cultural integration, research from the British Journal for Social Psychology recommends helping individuals to consider dual identities, dual social groups, and the primary language of the new country. For therapists this can look like supporting clients in identifying their struggles, helping them retain their cultural identity, helping finding new relationships via technology, maintaining old relationships that are rooted in their home culture, encouraging and brainstorming ways to try and build relationships with people in their new environment, and encouraging learning more of the country’s first language if necessary. This approach supports clients in honoring both their cultural heritage and their current circumstances, integrating these into a coherent sense of self.  

Building cultural competence in your practice

Cultural competence in practice is the ability to respect the unique identities, values, and experiences of clients while effectively delivering care that meets the social, cultural, and linguistic needs of your client. Given the complicated and diverse backgrounds, worldviews, and experiences of immigrant populations, it's essential that you use this type of competence to understand their clients who have immigrated, even if you’re an immigrant yourself. Then, you can work to build rapport and not overlook or misunderstand their mental health experiences, or inadvertently become a barrier to care. 

However, simply because you took a training on cultural competence doesn't make you an expert — and it doesn't fill all the gaps for all immigrants everywhere. Providers should start using principles of culturally competent care like curiosity rather than judgement, centering your client as the expert.

Cultural competence has expanded to include…

  • Cultural safety: Where care is perceived as safe by your clients and their communities
  • Structural competence: An awareness and advocacy against systemic factors that impact care
  • Cultural humility: The ongoing process of self-awareness and learning from clients

Cultural competence that studies other cultures is useful and necessary but runs the risk of perpetuating stereotypes. This is what makes the element of cultural humility and safety so necessary. 

Developing awareness of your own cultural lens

One of the key elements of cultural humility is self-examination and looking at your own cultural background, biases, and assumptions. This awareness is the foundation of not perpetuating harm and creating safe environments for clients. A therapist who operates without this awareness can cause your client to feel othered, judged, or put in a box. A therapist who has cultivated their own cultural awareness can facilitate better dialogue with your client, avoid potential words or ideas that might cause harm, and thus build more safety and rapport with clients. 

Learning about client cultures and contexts

Another essential component to cultural humility is ongoing learning. This can be done on the therapist's own initiative through trusted resources (see below), but should always prioritize learning directly from your clients. Sharing power with your clients and trusting your clients’ expertise about their own stories and culture is crucial for culturally effective care. Learning directly from your clients helps to understand their uniqueness and the nuances of their experiences, thus avoiding stereotyping them. It is important to balance self-initiated learning and client-centered learning because clients shouldn't be burdened with being the sole cultural educators of their therapist. This responsibility can feel particularly triggering for certain clients and should be monitored by the therapist. 

Here are a few resources that can be helpful for therapists desiring to educate themselves: 

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Practical strategies for culturally responsive counseling

Effectively working cross-culturally requires a multifaceted approach. This can include individualized assessments (with tools such as the DSM Cultural Formation Interview), building rapport, ongoing learning, addressing barriers such as language, and adapting treatment approaches to meet the nuanced needs of your client.

Overcoming language barriers

If you’re a clinician who doesn’t speak multiple languages, you might refer your client to another counselor who does—or you could consider working with an interpreter. Helping clients select the best interpreter involves looking for those who have experience with mental health language and concepts and those whose gender, age, dialect, and cultural background will make your client feel most at ease. Briefing interpreters before the session about the goals, confidentiality, the importance of clearly conveying the psychological concepts, and avoiding paraphrasing can help support effectiveness. When conducting sessions with an interpreter, clinicians should consider speaking directly to your client and not the interpreter, using clear, simple language while avoiding clinical jargon, and monitoring for any signs of misunderstanding that need to be clarified.

Adapting therapeutic approaches

The American Psychiatric Association recommends trauma-informed care, reinforcing protective factors, narrative therapy, and CBT cognitive restructuring as treatment approaches that can be effective with immigrant populations. Cultural adaptations, including welcoming the cultural healing practices of your client, are key to treatment effectiveness. 

Flexibility of language and delivery, respect for client values, incorporation of complementary traditional practices, and acknowledgment of cultural idioms for mental health challenges are all examples of general adaptations. An example of an adaptation of CBT for a client from a Latin country might include incorporation of ancestral or spiritual wisdom into their cognitive restructuring. Narrative therapy could be adapted by the clinician incorporating metaphors that culturally make sense to your client and helping your client reframe their narrative around important values and larger group narratives (e.g. family honor, cultural narratives, tests of faith). 

Note that these examples illustrate possibilities rather than prescriptions. Adaptations should always be individualized based on each client's background and preferences. Overall, there is no “right” way to adapt therapy for immigrants, because every situation is unique.

Building trust and therapeutic alliance

For clients who have experienced trauma, oppression from authority figures, persecution, or discrimination, the development of trust and rapport is crucial to effective treatment. There may be a heightened sensitivity to power dynamics that can show up in the therapy room. Clients from certain cultures may respect and desire an “expert” authority, while others may bristle or be triggered by any hint of a power imbalance. Several approaches can help you navigate these dynamics to create a sense of safety and connection.

Creating a welcoming environment

The initial experience for your client will go a long way to making them feel welcomed and safe. Office decor will be noticed and can include items that are culturally diverse (tasteful without appropriating), signage, and reading materials that are multilingual, mindful sensory experiences for clients with sensory issues or significant trauma. Intake sessions are also important first steps and can include multilingual paperwork, greetings that feel respectful to their culture and play off their lead, explanations of privacy in order to foster safety, and offering ways for your client to speak in their native language — through interpreters or bilingual therapists.

Addressing stigma around mental health

Stigma has proven to be one of the biggest barriers for mental health treatment with immigrant clients. As therapists, we must be aware of this and communicate in ways that can lower these perceptions by using culturally relevant explanations to increase the chances of your client’s ongoing participation in therapy. Some strategies that can help frame therapy in acceptable ways include: emphasizing privacy, using culturally relevant terms and metaphors, highlighting practical benefits, emphasizing how therapy can help them better fulfill roles in the family and community, demonstrating respect of their beliefs, asking curious questions about their perspectives on treatment, and providing gentle psychoeducation to help address any concerns. General examples of terms that could be used to explain therapy’s benefits could include “balancing,” “strengthening your spirit,” or “storytelling to heal.” Terms like this should make sense for the specific culture and understanding of your client. 

Knowing when to refer out

Learning about cultural competency does not always mean you’re ready to work effectively with all clients across cultural backgrounds or presenting concerns. When a clinician determines that they lack the cultural, linguistic, or clinical competence required for a given case, referral is often the most appropriate and ethical clinical decision. In some situations, referring to a bilingual clinician may better support therapeutic alliance and treatment effectiveness than reliance on an interpreter. Prioritizing appropriate, high-quality care should take precedence over maintaining all clients within one’s practice.

Explore how Headway helps you support different client types

Headway provides the clinical support resources and flexibility to support a diverse range of clients. Curious about approaches for other clients? Here are more ideas from Headway:

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This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

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