Immigration in SW Series: Are we truly providing culturally competent care?
Wednesday, August 27, 2025
This article is part of a collaborative series that focuses on the issue of immigration and how it impacts our work as social workers. Stay tuned for additional articles that seek to help inform Michigan social workers about the unique issues that affect those living with varying immigration statuses across micro, mezzo and macro practice areas. This series is being organized, developed and implemented by: - Jenny Bishop LMSW, Therapist & Co-Owner of Elevated Therapeutic Services LLC
- Holly DeVivo DSW(s), LMSW, Therapist & Co-Owner of Elevated Therapeutic Services LLC
- Sara Camilleri, LMSW, QIDP, Solo Practitioner of Sand River Therapy
The primary motivation behind this article is to clarify some of the confusion surrounding the social worker’s role providing linguistically appropriate services to the clients in our care. Far too often, we see our well-intentioned colleagues referring out clients to other clinics or providers because they don’t speak the client’s language, or even flat-out refusing to provide care to those who don’t speak English. We want to be very clear from the start: linguistically competent care is not a privilege, it is a right. As social workers, it is our responsibility to ensure we are providing linguistically competent care no matter our work setting, especially since more than 200,000 Michiganders are limited English proficient (LEP). It is imperative for the wellbeing of those we serve, our agencies and our profession that we understand and ensure access to linguistically competent care in compliance with the Civil Rights Act, Michigan law, and our own Code of Ethics. Picture this, you are on vacation in a foreign country where no one speaks English. Someone in your party has a medical emergency and you arrive in the ER. You are trying to communicate with the receptionist, but no one can understand you and you can’t understand them. The person you are with needs care now. Yet, no one is listening. You are terrified, you are frustrated, and most of all, your loved one is suffering because no one can understand you. This is the experience of millions of Americans on a daily basis in a wide variety of settings. From things as little as calling to schedule an appointment, figure out why a bill went up, communicate what’s wrong with your car to the mechanic, every single thing in your life that requires language would present additional barriers that others do not have to experience. Before we get into the nitty gritty of linguistically competent care, the authors of this article want to be very clear that we are not attorney’s, nor do we pretend to be. We are, however, highly trained and experienced in culturally and linguistically competent care, especially within the realm of private practice. With that being said, should you have questions about practices in your agency or for yourself, we recommend speaking to an attorney. The Ins and Outs of Linguistically Competent Care Linguistically Competent Care refers to the ability of a profession or agency to communicate effectively with clients in their preferred language. This includes providing services in one’s primary language, using trained interpreters or bilingual staff, translating forms and documents into preferred languages and ensuring comprehension and informed decision making. Oftentimes, linguistic competent care is enmeshed with culturally competent care. While care cannot be culturally competent without being linguistically competent, linguistic competency ensures access to care, while cultural competency ensures appropriate and effective care. In order to provide linguistically competent care, we first want to acknowledge that accessing and ensuring appropriate linguistic services does often place a financial burden on agencies and individual social workers. While we recognize that this is a barrier, we also recognize it shouldn’t be this way. However, it doesn’t change the fact that we hold the responsibility to ensure that language is not a barrier to accessing services. That often means we will have to pay more than we’d like to provide interpreters and translated documents. A mistake often seen is confusing interpretation vs. translation. Language translation and interpretation both involve converting one language into another, but they differ in form, medium, and purpose. Translation is the process of converting written text from one language to another, often allowing time for careful consideration of meaning, tone, and context. In contrast, interpretation deals with spoken language and is typically done in real time, requiring the interpreter to quickly convey meaning between speakers. While translation emphasizes accuracy and refinement over time, interpretation prioritizes speed, clarity, and the ability to think on one’s feet. Both require deep cultural and linguistic knowledge, but they demand different skill sets and approaches. Another common mistake we see is not utilizing a professional interpreter. It’s easy for agencies to rely on loved ones to facilitate translation and interpretation, but we want to be very clear, this is not appropriate for any services in relation to client care. It is the agency's responsibility to provide documents in the client’s primary language, and interpretation services during the services. However, if there is a staff member that is multilingual in the client’s primary language, they can be utilized in some circumstances, if they have training in interpretation. Being bilingual is not the only qualification for interpreting, and many fully bilingual individuals are, frankly, very poor interpreters. It is important to remember that medical interpretation is a specialty and for good reason. Additionally, HIPAA regulations make it very important to use a HIPAA-compliant interpreter. Consider the privacy implications of using a friend or family member to discuss sensitive information such as substance use, sexually transmitted infections, criminal history, etc. Using family or friends to interpret in these situations is disrespectful to the client’s privacy and autonomy, and should be avoided in all but the most urgent situations. When utilizing an interpreter during service delivery, the interpreter should introduce themselves to you, give their license number and credentials. Professional interpreters are trained to interpret meaning-for-meaning, everything that is said. This means that they will interpret everything you say, and everything the client says, in ways that make sense culturally and linguistically. Not everything translates from one language to the other, so sometimes an interpreter may have to explain things to you or the client. They should be transparent when doing so, saying things like “the interpreter needs to clarify with the client” or “the interpreter needs to provide an explanation because this concept doesn’t exist in this country” etc. The interpreter will refer to themselves in the third person, and will use first person for the speaker. For example, if the client is experiencing panic attacks, the interpreter may say “I sometimes feel like I can’t breathe” in reference to the client. It is important for you, the provider, to always speak directly to the client, do NOT speak directly to the interpreter, that is considered rude and disrespectful in many cultures. Your role is to treat the client the same as you would if you both spoke the same language. The interpreter is there as a linguistic and cultural conduit, they are not a support person for the client; they are not their “friend.” If you are working with an interpreter in-person, it can be helpful to arrange the room in a triangle formation, where you and the client sit across from one another, and the interpreter sits next-to and slightly behind you. This facilitates eye contact between you and the client, yet allows for the interpreter to view client body language that could be helpful in determining tone. Interpreters will interpret profanity, anger, sarcasm, etc. and should not censor the client’s speech. This is particularly relevant with Deaf clients as the interpreter is their voice and will reflect the mood and tone of the client in their interpretation. At no point should the interpreter have side conversations with either you or the client, and the interpreter should leave the room if either you or the client do so. Again, they are not there to “help” the client or be their support person. They are there to allow you to provide linguistically and culturally competent care, and allow the client to communicate in their preferred language. They should be treated professionally and respectfully at all times, as they are highly educated and trained professionals providing an invaluable service for you and your clients.
Real-World Implications So after reading all of this you may be asking yourself, “this all sounds nice and everything, but I’ve been using friends and family and it’s been fine.” Or “I use Google Translate and some basic Spanish I learned in undergrad and we get by okay,” Are you sure about that? How can you be sure you got accurate or complete information? Did the friend or family member, or Google Translate, explain to you the cultural nuances that might have been crucial in providing a diagnosis? Case management? Did you truly provide culturally competent care? Or do you just hope that you did? Let’s remember that our work has real-life implications for the communities we serve, and when we don’t have the whole picture, we can’t truly care for the whole person. Perhaps one of the most famous cases in which culturally competent care could have resulted in much better outcomes, is the story of Willie Ramirez. Mr. Ramirez was a young man of Cuban descent living in southern Florida. One night, after going out with friends to a new burger restaurant, he began complaining of a headache. Several hours later, his mother and girlfriend, both of whom were Spanish-speaking only, found him unconscious and rushed him to the emergency room. When the physician came to speak to them, he did not use an interpreter, instead relying on his limited Spanish skills, to get background information about Wilie. Willie’s mother and girlfriend kept using the word intoxicado which the doctor understood to mean “intoxicated” or “drugged.” He then assumed that Willie was experiencing a drug overdose and provided care accordingly. However, the physician was unaware that in Cuba, intoxicado can also refer to food poisoning. Willie’s mother and girlfriend thought he had gotten food poisoning from the burger restaurant he had visited earlier that night. Doctors treated Willie for a drug overdose for three days until they realized he had actually suffered a massive brain hemorrhage. By the time they brought Willie to surgery, so much damage had been done that although he survived, he was left as a quadriplegic. Willie’s family subsequently sued the physician and the hospital for failure to provide interpretation services, and were awarded more than $70 million to provide care for Willie for the remainder of his life. No amount of money, however, will give Willie back the ability to use his body, and his physician will have to carry with him the knowledge that his failure to provide culturally and linguistically appropriate care caused a young, otherwise healthy man to become paralyzed. Willie’s story highlights what can happen when we, as providers, do not offer interpreters to our clients. It’s not just the monetary penalties, which can be substantial, but it's also the human cost. We chose to be social workers because we want to serve our community, but we forget that our community includes those who don’t speak our language. We can’t meet people where they’re at if we don’t understand when they try to tell us where they are. Using interpreters when we don’t speak a client’s language allows us to build bridges between ourselves and the vulnerable communities we seek to serve. We provide truly trauma-informed care when we allow our clients to tell their stories in their own language, rather than trying to force them to come to us in ours. Our diagnoses are more accurate, and our treatment planning and case management are more reflective of a client’s actual needs, rather than our Western and English-based perceptions of their needs. To truly care for our clients, we must connect with them in their preferred language, not ours.
The Good, the Bad, and the Unfair Reality Maybe you’re convinced of the importance of providing interpreters to your clients, but have concerns about the practicalities of it? We understand that interpreters can be expensive, and insurance will not reimburse for them (CMS is very clear that 90785 should not be used for interpreters), so sometimes you end up paying to see the client. It can also be cumbersome to work with another person in the room, or you’re not sure how to work with interpreters. These are all important, and very real, factors that come into play when providing culturally and linguistically appropriate services, but at the end of the day none of them are reason enough to deny such services. We are not only obligated by our Code of Ethics to provide interpreters, we are also required to by state and federal law. Title VI of the Civil Rights Act of 1964 prohibits discrimination based on national origin, which includes English-language proficiency. The Affordable Care Act requires healthcare providers to provide culturally and linguistically appropriate services, and strongly discourages the use of family and friends as interpreters, except in the case of life-threatening emergencies. Perhaps most importantly, the State of Michigan recently enacted the Meaningful Language Access to State Services Act that requires agencies who receive state funding to provide meaningful language access to their clients. This means that any agency who receives state funding (including Medicaid payments) must provide interpreters to individuals who are limited English proficient. Failure to do so constitutes a civil rights violation, which comes with stiff financial penalties which would likely far outweigh the hourly cost of an interpreter. It is also important to note that many professional liability and malpractice insurance providers do not provide coverage for civil rights violations, which potentially increases the personal liability of a provider who refuses to provide culturally and linguistically appropriate services. While these legal requirements and potential penalties are incredibly important and relevant to the field of social work, the human cost of ethnocentric care is even greater. When we only provide services to those who speak our language, we essentially tell others from traditionally marginalized or vulnerable communities that their needs don’t matter as much as our own. Our biases take over, and we lead with “I can’t do that” rather than “Let me see how I can do that.” This isn’t to say that we shouldn’t advocate for changes in the racist structures that make it difficult and costly to provide interpretation services, we absolutely should! We need to call upon CMS to allow for billing for interpretation, and for insurance companies to reimburse for those services. We need to make room at the table and in our agencies for social workers from non-English speaking communities to enter the field, to be able to provide direct services to clients. But we also need to stop relying on our local CMH to provide interpreters when we are required to do so as well. Referring clients to other agencies solely because they cannot speak English is discriminatory and as a profession, we need to change this practice. This will take time, but as social workers we are uniquely qualified to undertake this challenge. Ensuring equitable access to services means making intentional policies and practices on both the organizational and individual level. At an organizational level this includes but is not limited to policy development and implementing language access plans. For individual social workers, this means advocacy, continuous training and awareness, partnering with community resources and knowing how to access professional interpreters.
Let’s Make a Plan For the organization, actionable, clear policies should be developed to ensure a clear road map on an agency level. This policy should clearly state that sign professional sign language and spoken interpreters would be provided for free to clients, translated materials available in most commonly used languages in the service area, and documentation of the clients preferred language. It is critical to ensure clients are aware of their rights and this is included in your informed consent policy. Ensuring the client has access to translated documents or an interpreter prior to signing is the only way true consent can be obtained. We want to note that just because a staff member speaks another language, does not mean they are qualified to be an interpreter. It’s important to assess this on an individual basis. It’s also important to incorporate Culturally and Linguistically Appropriate Services (CLAS) standards into trainings as well as knowledge on language access laws such as Title VI of the Civil Rights Act. Below is an example of a language access policy: Language Access Policy Effective Date: [Insert Date]
Approved by: [Executive Director or Board] 1. Purpose This policy ensures that all clients, regardless of their English language proficiency or hearing status, have meaningful and equitable access to [Agency Name] services and programs. 2. Policy Statement [Agency Name] is committed to providing linguistically appropriate services. No person will be denied services based on limited English proficiency (LEP) or the need for sign language interpretation. We will take reasonable steps to provide free, timely, and competent language assistance. 3. Scope This policy applies to all programs, staff, interns, volunteers, and contractors associated with [Agency Name]. 4. Definitions - LEP (Limited English Proficiency): Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English.
- Language Assistance Services: Services that include oral interpretation and written translation.
- Vital Documents: Paper or digital documents that contain information critical for accessing services (e.g., consent forms, intake forms, safety plans).
5. Procedures A. Identifying Language Needs - At intake, staff must ask clients for their preferred spoken and written language.
- This information must be recorded in the client’s file and updated as needed.
B. Provision of Interpretation Services - Qualified interpreters (in-person, phone, or video) will be made available free of charge to all LEP clients or those requiring sign language.
- Staff may not use children, other clients, or untrained family members to interpret, except in emergencies.
- Bilingual staff must be tested and certified before acting as interpreters.
C. Provision of Translated Materials - Vital documents will be translated into the top [X] languages spoken by LEP populations in our service area, based on U.S. Census and agency data.
- A list of translated documents and their availability must be maintained and reviewed annually.
D. Staff Training - All staff must receive annual training on:
- How to identify LEP individuals
- How to access and work with interpreters
- Clients’ rights to language access services
- New employees will receive training as part of onboarding.
E. Notification of Language Access Rights - Signs in multiple languages will be posted in public areas stating:
- “You have the right to receive services in your preferred language at no cost.”
- Notification will also appear on agency websites, forms, and outreach materials.
F. Complaints and Monitoring - Clients can file a complaint if language services are not provided appropriately.
- Complaints will be reviewed by the Language Access Coordinator or designated supervisor.
- The agency will monitor usage of interpreter services and adjust resources as needed.
6. Roles and Responsibilities - Program Staff: Responsible for identifying language needs and accessing interpretation services.
- Supervisors: Ensure compliance with policy and support staff.
- Language Access Coordinator: Oversees implementation, training, compliance, and reporting.
7. Legal Compliance This policy complies with: - Title VI of the Civil Rights Act of 1964
- Americans with Disabilities Act (ADA)
- Michigan’s Meaningful Language Access to State Services Act
Evaluate Your Own Situation For individual social workers, it is important to evaluate your own organizations for compliance and should you find that there are no policies in place, advocate for access to linguistically competent care to be provided free of charge to those you serve. It is recommended that you attend training through continuous education courses. It is important to ensure your clients are aware of their rights to access services without language barriers. Resources that you can provide to your clients are listed below under resources. Additionally, every community has different resources available. Networking with those who work with those who need linguistically competent care and engaging with cultural centers. Wrapping it Up We have thrown a lot of information at you in this article, and some of it may have caused you to bristle. We get it, it’s perhaps very different from what you’ve done in the past and perhaps we’ve called you out for some of your current policies. However, we also want to invite you to lean into the discomfort, to use it to sharpen your growing edge. As social workers, we are called to constantly check our biases, and work to improve the lived experiences of the communities we serve. Providing culturally and linguistically appropriate care, including the use of professional interpreters, is just not optional for those of us who embrace the NASW Code of Ethics. It may require that we learn to do our work a bit differently, and we may have to pay more than what seems fair. We should absolutely advocate for better access for limited English proficient communities to mental health services, insurance reimbursement for interpretation services, and greater diversity within the field of social work. However, clients should not be compelled to bear the burden of these structural inequalities, and neither should low-income clinics and CMH centers. It falls to all of us to ensure that all members of our community have equal access to mental health services, regardless of the language they speak. At the end of the day, it is our responsibility as ethical social workers to build bridges and break down barriers to care. If we want to engage in this profession in ways that are just and equitable, we must fight for access to care for all, and be willing to provide that care ourselves. Agencies and References Agencies References
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