Introduction

Approximately 58.9 million (18%) of the people in the United States (US) identify as Latinx Americans, making it the largest racial/ethnic minority group (US Census 2018). Only one in ten Latinx Americans with a mental health concern use mental health services from a general healthcare provider, and only one in 20 receive services from someone in the mental health field (American Psychiatric Association, APA 2017). When seeking to understand the reasons why this population is undertreated for mental health care, the following challenges have been reported (National Alliance on Mental Illness, NAMI 2020): mental illness stigma – negative attitudes, stereotypes, or fears about what it means to be diagnosed with a mental health concern and treatment seeking disproportionately affects ethnic minorities (Wong et al. 2017). Stigma is defined as a mark of disgrace that sets one apart from others (Pescosolido 2013), and is a well-established challenge in the lives of those with a mental health concern. Mental health concerns that are common, treatable, and potentially less serious (e.g., depression) can result in a reluctance to seek professional help due to such stigma (Vogel et al. 2006; Wang and Lai 2008). This can be observed within and outside of the US, and is considered a global challenge (Collins et al. 2011).

Discrimination from professionals who lack cultural competence also occurs and can deter individuals from returning for mental health treatment (Jimenez et al. 2013), and mistrust of professionals may impact the treatment gap in the Latinx population. This mistrust may stem from a previous negative help seeking experience, a lack of Spanish speaking professionals who they feel they can relate to, a lack of mental health information which can lead to misinformation and myths, or fear of deportation and retaliation. Finally, the notion of la ropa sucia se lava en casa, or don’t air your dirty laundry in public (NAMI 2020) prevents many Latinx individuals from seeking help for a mental health concern.

In addition to these fears and gaps in appropriate treatment for Latinx individuals, many in this cultural group tend to rely on other supports (e.g., family, friends) rather than professionals when facing a mental health concern (Campbell and Long 2014; Mascayano et al. 2016). Religious faith and spirituality are often used instead of formal treatments (NAMI 2020), and natural medicine and home remedies often replace Western pharmaceuticals and traditional talk therapy (NAMI 2020). Seeking support and comfort from family (immediate, family of origin, and split families with members both in the US and home countries) is another cultural norm that may replace the mainstream trend of mental health care in the US.

Particular Latinx norms are also counter to the act of seeking support for a mental health concern when it may arise (Campbell and Long 2014; Mascayano et al. 2016). Familismo, compadrazgo, machismo, and dignidad y respeto are a few that have been applied specifically to mental health concerns and help seeking. Familismo includes family obligations, support from family, and family as reference (important decisions are made with the best interest of the entire family). Compadrazgo values warm and caring relationships even within professional relationships. Machismo references the patriarchal structure whereby the man is the protector and provider of the family. Dignidad y respeto represents valuing the intrinsic worth of all individuals and is associated with hierarchy of deference in which elders and parents are seen in the highest status and respect (Mascayano et al. 2016). These cultural beliefs are deeply rooted and need to be carefully considered when working with Latinx individuals in mental health settings.

In addition to cultural beliefs, myths, and systemic challenges that impact the treatment gap for the Latinx community in the US, larger issues such as health disparities influence mental health treatment for this cultural group. Lack of health insurance, transportation, culturally appropriate services contribute to the lack of mental health treatment for Latinx individuals. For example, physiognomy, (e.g., skin color, indigenous features) may be a factor in differential treatment for Latinx individuals, which may discourage many from seeking treatment. For these reasons, researchers and counselors have called for increased culturally appropriate mental healthcare in the US (Jimenez et al. 2013).

Latinx individuals need mental health support but are not receiving it when compared to help seeking majority members (APA 2017). This, in addition to the major challenge of health disparities that are ever present, makes a resounding call to look more closely at obstacles for the Latinx community. Much of the current research on this topic includes several racial/ethnic groups for analysis and rarely focuses specifically on particular racial/ethnic cultural groups. The purpose of this study was to provide a closer look at the Latinx population by asking Latinx Americans to describe culturally embedded beliefs that inhibit help seeking for a mental health concern, in particular the beliefs that prohibit coping with a mental illness. This research also explored the characteristics that are desirable in a mental health professional among Latinx individuals. Hearing these perspectives will assist in providing mental health treatment in culturally competent ways, thus increasing the likelihood that this population will get the mental health treatment they deserve.

Literature Review

Health Disparities and Minority Mental Health

While attitudes, myths, and individual factors contribute to help seeking and stigma with mental health concerns, societal and systemic issues contribute as well. Shim et al. (2009) explored whether attitudes of African American and Latinx individuals impacted health disparities. Contrary to the initial hypothesis, African American and Latinx individuals had more positive attitudes than Caucasian participants in their sample, suggesting that we cannot assume that attitudes impact disparities. Comparable results related to disparities were found by Dornelas et al. 2014.

Attitudes about seeking medical help are an important factor that have received relatively little attention in the research literature compared to other variables (e.g., perceived risk, self-efficacy, and social support). Dornelas et al. (2014) explored differences in racial/ethnic subgroups in terms of attitudes toward seeking medical help (Caucasian, African Americans, and Latinx) to see if there might be attitudinal differences that constitute barriers to help seeking. African American and Latinx groups had more favorable, pro-help seeking attitudes when compared to Caucasian adults. The study showed no evidence that racial/ethnic health disparities result from negative attitudes as barriers to medical help seeking.

Similarly, Cook et al. (2017) compared trends in racial/ethnic disparities in mental healthcare access in African American, Caucasian, Latinx, and Asian population groups. Significant disparities were found in 2004–2005 as well as 2011–2012 for all minority groups compared to Caucasians. In fact, disparities in mental healthcare access were exacerbated during this time. The authors made a call for interventions, policies, and research to decrease disparities and provide more access to mental health treatment.

Racial/Ethnic Minorities, Stigma, and Help Seeking

Many studies related to minority mental health include a comparison of a number of racial/ethnic group attitudes related to mental health. There is a paucity of peer-reviewed articles that look at racial/ethnic minority groups, in particular. Nadeem et al. (2007) sampled low-income immigrant and non-immigrant Black (African immigrants, Caribbean immigrants, and US born blacks) and Latinx women (immigrant and US born) about barriers to mental health treatment, stigma, and whether they desired or were receiving treatment for a mental health concern. Over 15,000 participants screened for depression participated in the study. Stigma was most common among immigrant women. This finding underscores the impact of stigma on underuse of mental health services in this ethnic minority group.

Collado et al. (2019) looked at stigma among Latinx individuals with depression who were receiving treatment. Using Relational Cultural Theory (RCT, Miller 1976), they studied the efficacy of programming to reduce stigma. They concluded that stigma existed in those who were in treatment. A supportive counseling group had more of a decrease in stigma than those in the behavioral activation group, suggesting that supportive counseling may assist with lowering some of the stigmatizing views in underserved populations. This study used a clinical population, rather than those who may or may not meet diagnostic criteria for depression. Hunt et al. (2013) used a clinical sample (those diagnosed with anxiety) and compared beliefs related to mental illness and treatment between African American, White, Latinx, and Native American participants. Beliefs related to mental illness within Latinx and Native Americans were most distinctive but small in magnitude while beliefs and service use differences were weak and statistically insignificant.

DeFreitas et al. (2018) surveyed Latinx and African American college students about mental illness stigma. African American students had more stigma than Latinx students. Finally, Fripp and Carlson (2017) surveyed Latinx and African American participants to explore attitudes, stigma, and help seeking behavior. They found that attitude was a unique predictor of one’s willingness to seek counseling and was influenced by stigma. This quantitative study suggested the need for future research on attitudes, help seeking behaviors, and stigma, specifically suggesting qualitative inquiry could reveal the nuanced perceptions that impact these relationships in racial/ethnic minorities.

Thus, the current research aims to add to the literature base on stigma among Latinx Americans while also extending Fripp and Carlson’s (2017) work by using qualitative methods, particularly sampling Latinx individuals, further examining attitudes towards mental health concerns and help seeking. This will be the only known study that looks at Latinx perceptions only, as others have included comparison groups from other ethnic/racial minority statuses. Authors have made a compelling case for more qualitative studies with Latinx individuals, and this study answers this call (Delgado-Romero et al 2018).

Methods

Theoretical Framework

Critical Race Theory (CRT; Bell 1995) guides this study and provides additional clarity in examining and understanding this phenomenon (Collins and Stockton 2018). CRT theorists posit that one must assess society and then radically change it, considering the ways in which systemic forces impact marginalized communities’ experiences. This disposition counters narratives that blame and focus on a deficit perspective. CRT is particularly relevant to this study because of its focus on Latinx adults, who are often underrepresented in mental health counseling services. Rather than focusing on Latinx attitudes towards mental health from a deficit perspective it is more culturally responsible to seek understanding, considering the ways in which race and racism shape perceptions about mental illness (Bell 1995).

Research Team – Contextualizing Ourselves

The research team included two African American women, one Latinx woman, and two European American women all with previous experience conducting qualitative research. To begin, the researchers discussed differences in identity and perspectives brought to the topic. As a team that had worked together before, the researchers also discussed roles and needs for the project and attempted to create space for all feedback and ideas. The researchers participated in bracketing exercises throughout the research process. Bracketing is a process in which researchers acknowledge and attempt to temporarily set aside past experiences, assumptions, and potential biases that may influence the data and research process (Hays and Singh 2012). Each researcher completed bracketing exercises in a reflexivity journal when conceptualizing the study, during data collection and data analysis, and while writing the results. One of the major themes from the bracketing exercises was the idea that external and internalized messages would impact Latinx who experience stigma and their attitudes towards mental health. As the study progressed, many of the identified findings confirmed these initial thoughts.

Procedures

The lead author’s Institutional Review Board approved the study prior to conducting the research. The researchers used an electronic survey to explore attitudes towards mental health treatment, mental health concerns, and preferences for mental health provider characteristics among a large and national sample. The researchers used a cluster sampling procedure (Creswell and Creswell 2018) via Qualtrics Panel software. A recruitment email with a link to the electronic survey was distributed to the general US population. Self-administered surveys have demonstrated improved response rates and allow for more data collection (McColl et al. 2001). Participants were recruited from the general population and opted to participate for a small amount of compensation (e.g., points towards a gift card, sky mileage) for completing the survey. Several measures were taken to ensure fidelity of self-report responses. First, a soft launch of the survey (n = 50) was done to determine the median duration to complete the survey. The median length for survey completion was determined to be 11 min. Next, the lead author examined the soft launch data to identify any cases where a participant had not answered thoughtfully (e.g., open ended questions including unreadable responses). Three cases were removed where the open-ended text was non-sensical (Ruel et al. 2016).

For the full survey, any participant who completed the survey in less than one-third of the median completion time was automatically terminated. The survey also included a question at the beginning that read, “Thank you for agreeing to take this survey. We care about the quality of our survey data and hope to receive the most accurate opinions, so it is important to us that you thoughtfully provide your best answer to each question in the survey. Do you commit to providing your thoughtful and honest answers to the questions in this survey?” Participants who answered “no” or “I cannot promise either way” were taken to the end of the survey.

Participants

Of the 212 participants, the majority identified themselves as female (n = 131, 62%; male, n = 81, 38%). Forty-nine participants were between 18–24 years of age, 36 were between the ages 25–29, and 43 participants were between ages 30–34. Twenty participants were between 35–39 years of age, 13 participants were between ages 40–44, 23 participants were between the age of 45–49, and nine people were age 50–54. Seven participants were age 55–59, and 12 p were age 60–75. Regarding marital status, 89 participants were single, 12 lived with an intimate partner, 94 were married, five were separated, 10 were divorced, and two were widowed.

Measures

For the purposes of the current analysis, the research team examined four open-ended questions from the full survey. Respondents typed their open-ended responses directly into the online survey. Part One of the electronic survey consisted of demographic questions to gather respondents’ characteristics (e.g., age, gender, race/ethnicity). Part Two included six formal instruments used as quantitative measures to explore relationship between stigma, attitudes toward mental health treatment, and affect (i.e., the Satisfaction with Life Scale, Diener et al. 1985; the Perceived Devaluation Discrimination Scale, Link 1987; the Perceived Stress Scale, Cohen et al. 1983; the Self-Stigma of Mental Illness Scale, Tucker et al. 2013; Attitudes Toward Mental Health Treatment, Brown et al. 2010; and the Positive and Negative Affect Scale, Watson et al. 1988). Part Three consisted of open-ended questions on stigma, mental illness, seeking support, and desirable counselor qualities. These questions were constructed by the research team.

Analyzing participants’ responses in Part Two of the survey is beyond the scope of this manuscript. Rather, the current qualitative study analyzed participants’ responses to the four open-ended questions in Part Three. Open-ended questions and their responses are known to aid researchers in understanding the associated issues within a topic or focus of inquiry and provide new issues for further exploration (Moser and Kalton 1971; O’Cathain and Thomas 2004; Zull 2016) as they allow participants to share without restraint or influence. The open-ended questions were: (1) How do you think mental illness stigma applies (or doesn't apply) to people you know or people in general? In other words, have you known people who have feared seeking mental health treatment because of stigma? (2) If yes, then what were the fears, hesitations, or possible negative consequences of seeking help for mental health treatment? (3) What qualities or traits would you look for in a counselor, or other type of mental health professional, if you were to seek help for a mental health concern? (4) Aside from a mental health professional (e.g., counselor, psychologist), what other sources of support would you go to if or when you were experiencing a mental health concern?

Data Analysis

Content analysis was used to analyze the data (Hsieh and Shannon 2005). Qualitative content analysis is a framework used for the subjective understanding of the content of text data through a systematic data reduction and data classification process (Elo and Kyngäs 2008). This method necessitates coding and identifying themes or patterns in the data (Hsieh and Shannon 2005). Qualitative content analyses allow researchers to understand social processes with the aim of providing knowledge, insight, and a representation of facts (Zhang and Wildemuth 2009).

According to Patton (1990), content analysis identifies and categorizes the patterns in the data. Content analysis is viewed as useful with large amounts of written text, such as the current sample provided. However, it is important to recognize that content analysis extends beyond merely word-frequency counting (Chambers and Chiang 2012; Finfgeld-Connett 2014; Insch et al. 1997). Hsieh and Shannon (2005) posited that there are three approaches to content analysis including conventional, directed, and summative, and only summative includes word frequency. For the current analysis, the researchers utilized both the summative and conventional approach (Hsieh and Shannon 2005). The summative approach provides numerical counting of specific word use, while conventional allows researchers to identify categories and names for categories or themes in the data and is not based on numerical counting. The researchers used keywords and statements as the unit of analysis. When using the conventional approach, the researchers began data analysis by reading through all of the data to gather a sense of the whole. Next, the researchers read participant responses word by word and created codes based on key thoughts or concepts. This provided an initial analysis. Data were sorted into codes based on how the content was related or connected. The researchers continued sorting and categorizing data to reduce codes and examine relationships between codes. The second author, a qualitative methodologist, completed the initial coding. Feedback among the research team was sought on the emergent codes from the other members and codes were further refined.

Findings

This study examined Latinx adults’ beliefs about mental illness stigma, help seeking, and support preferences. Latinx adults in this sample shared their beliefs regarding culturally embedded stigmas towards individuals with mental illness. Emergent and the most robust themes included the belief that those with mental illness are crazy and dangerous, inferior and weak, or that mental illness does not exist/should be ignored. In terms of help seeking, some participants shared that they personally did not know anyone with a mental illness or believed that most people would not seek help for fear of the stigmas. In terms of the traits that participants desired in a mental health clinician, they favored professionals who are understanding, good listeners, caring, and empathetic. In terms of other support sources, participants indicated their family, friends, none, medical doctors, online information, or religious supports. We include the themes below with corresponding frequencies but acknowledge that these themes came from saturation of content rather than simple numbers.

Stigma

Findings indicated four themes regarding stigma perceived by Latinx participants. These included that individuals with mental health concerns are viewed as inferior and weak (n = 57) or crazy and dangerous (n = 42), or that mental illness does not exist/should be ignored (n = 48). Additionally, a smaller theme was a need for education on the issues (n = 11). As well, there were 54 participants who did not respond to the question. Thus, that data were not analyzed.

Inferior and Weak (n = 57)

Most frequently, participants shared that individuals with mental illness are viewed within the Latinx culture as inferior and weak. For example, responses that described mental illness as inferior included, “People are expected to be self-sufficient, so having a mental illness means a person is less capable” and “Yes some people see a person who has a mental illness as inferior.” Additionally, some participants described this inferiority as having a negative value to it, or a personal weakness, as seen in the following exemplar quotes: “Mental/emotional problems are taken as failure on the person's side” and “Some think that you can pull yourself together. Don't be a wimp. You are too weak.”

Crazy and Dangerous (n = 42)

Participants repeatedly used the term “crazy” when sharing the stigma associated with mental illness. For example, responses included: “mentally ill people are crazy” and “a negative view people in my culture might have with people that have mental illness is that they think people with mental illness are crazy people and that we should stay away from them” Crazy, according to dictionary.com is defined as “mentally deranged, especially as manifested in a wild or aggressive way.” This definition of crazy, in terms of being aggressive, can be linked to the other participants who responded that individuals with mental illness are dangerous – “if you have a mental illness something is wrong with you and you are dangerous” or as another participant stated “unpredictable, aggressive, low self-control.” As well, participants also indicated that if viewed as crazy and dangerous, it was also believed that an individual cannot be helped, as exemplified by this response: “People who have a mental illness in general are thought to be all unstable as a group regardless if they are seeking treatment or not.”

Mental Illness Does Not Exist/Should Be Ignored (n = 48)

Participants responded that mental illness is not believed to exist. For example, one participant wrote: “They don't seem to believe in it.” While another participant shared it as a personal belief, “First, "mental illness" does not exist” and repeated this response in each question asked throughout the open-ended questions. Participants then added that it was also something to ignore, as exemplified in the following response:

People think mental illness is something you just need to "get over." They don't understand that your brain is sick in the same way your body gets sick when you have a physical illness. A lot of Hispanics are raised to just "suck it up."

Thus, mental illness stigma included the belief that mental illness it is not real or if it is, it is something that can be overcome or ignored. This belief can be viewed as connected to the prior idea that it demonstrates a moral or personal weakness, in that if you were stronger you could overcome or ignore it.

Lack of Education (n = 11)

A smaller theme that emerged when participants were asked about stigma in the Latinx culture was the lack of education on mental illness. An exemplar quote for this finding is the following, “Mental illness is not taught a lot in schools, so at a young age people do not comprehend what mental illness is and they carry this misunderstanding into adulthood where they are still not properly informed.”

Impact of Stigma on Help Seeking

When participants were asked to discuss how stigma impacts Latinx adults’ help seeking behaviors, some shared that they personally do not know anyone who has a mental illness, for example, “I haven't known people with mental illness.” Other participants added to this thought and stated that while they did not know anyone, they realized that this could mean that mental illness is hidden, as suggested in the following quotes:

“I personally have not, but at the same time we cannot rule out that the people we know are hiding their fears.”

“I have not known anyone who feared seeking health but then again no one has said anything either. It's possible they stay quiet out of fear.”

Those participants who disclosed that they had a mental illness shared that they feared being found out due to judgement.

“The people I know are generally too embarrassed to admit if they have mental health issues. I myself have been hesitant to seek in-person treatment via on-campus mental health counseling because I was afraid people I know might see me there.”

Thus, the main finding when considering how stigma impacts help seeking behaviors was that, in general, mental health issues are not openly shared, likely due to fear of stigma, and that the participants are not comfortable seeking treatment due to fear of stigma.

Preferred Characteristics of Mental Health Providers

When asked what traits or qualities participants would seek in a mental health professional, Latinx participants in this sample shared qualities such as kindness and warmth. The most frequent descriptors included “Understanding” (n = 38), “Caring” (n = 30), “Listens” (n = 29), and “Empathetic” (n = 22). Other responses that were less frequent included “Professional” (n = 11), “Non-judgmental” (n = 9) and the professional being “discreet” when there were employment issues associated with mental health treatment (n = 9).

Other Sources of Support

Participants responded about other sources of support they may seek when experiencing a mental health concern. The following alternative supports were listed, rather than a mental health professional: family, friends, no one, medical doctor, online, and religious support. Often the above responses included several sources, for example: “Talk to friends/relatives or speaking in the unknown web.” As well, the “no one” category also includes responses such as, “no idea” referring to not knowing who they would seek support from. Table 1 summarizes these findings.

Table 1 Sources of support for a mental health concern and frequency count
Full size table

Discussion

In the current study, researchers explored Latinx individuals’ perceptions of mental illness, beliefs about important traits for mental health professionals, and preferences for help seeking and support. Emergent themes included stigmas toward individuals with mental illness being perceived as inferior and weak, or crazy and dangerous. The following section situates the results of the current study in relation to the existing literature, expanding the findings.

Stigma Towards Individuals with Mental Illness

The findings in the current study provide additional insight on the stigma related to mental illness in Latinx communities and the impact these attitudes may have on help seeking behaviors. Overall, study findings aligned with previous literature that suggests that stigma towards mental health concerns remains a significant issue (Fripp and Carlson 2017; Mascayano et al. 2016; Nadeem et al. 2007; Sibrava et al. 2019). Nadeem et al. (2007) identified stigma as the most significant barrier to help seeking among racial/ethnic minority groups. While the existence of mental illness stigma in US Latinx communities may not be novel to the literature (Fripp and Carlson 2017), these qualitative findings are important as they give voice to what may be known quantitatively.

Inferior and Weak

Participants in the current study indicated that individuals with a mental illness might be perceived as inferior or weak. It is important to note how this perception may particularly impact Latinx men, since the concept of machismo persists (Mascayano et al. 2016). In order to uphold the concept of machismo Latinx men may elect to suppress mental and emotional challenges (Mascayano et al. 2016). It is important to highlight that the majority of participants in the current study identified as female. Thus, it is likely that these expectations for Latinx men to repress their emotions stem from females as well. Since Latinx men have a very influential presence in their families and communities, changing the emotional expectations of Latinx men could be central in shifting the attitudes in the broader community.

Crazy and Dangerous

Participants in the current study stated that people with mental illness would be perceived as crazy and dangerous. Although these terms are not always used simultaneously, they are related and are often grouped together when referencing Latinx individuals experiencing mental health concerns. These negative stereotypes may prevent Latinx adults from seeking help as they do not want to be further oppressed and marginalized. Many Latinx individuals already face negative stereotypes based on their race/ethnicity and an additional label of crazy or dangerous may exasperate existing discriminatory experiences (Sibrava et al. 2019).

Mental Illness Does Not Exist/Should Be Ignored

This finding is important because while stigma is a commonly known barrier to help-seeking, participants in this study went even further to suggest that mental illness does not exist. Thus, while existing research reflects Latinx attitudes about mental illness and barriers to help-seeking (e.g., Nadeem et al. 2007), this finding suggests that more exploration is needed regarding the existence of mental illness. It is unclear how, for example, participants would conceptualize mental illness symptomatology (e.g., hallucinations, anxiety) that cannot always be concealed.

Participants in the study also noted that mental illness should be minimized and ignored. This finding is multi-layered as it suggests an individual’s inclination to suppress symptoms, as well as family and friend’s tendency to minimize their loved ones’ experiences. If mental illness is ignored, then Latinx individuals may opt out of counseling, or discontinue treatment prematurely, and symptomatology may worsen. Further, family and friends may discourage others’ help seeking by questioning the validity of their concerns. This practice is also found in other historically marginalized racial/ethnic populations and may help explain the stark help-seeking disparities among underrepresented communities (APA 2017; Avent Harris and Wong 2018).

Preferred Traits of Therapists

It is important to consider the preferred traits Latinx individuals articulated in a therapist, especially given the mistrust that exists towards mental health professionals (Jimenez et al. 2013). An increased awareness of preferred counselor traits may make counseling more attractive to Latinx communities. While many previous research studies have focused on how therapists’ demographics (e.g., race, ethnicity, gender) impacts help seeking behaviors and attitudes (e.g., Fripp and Carlson 2017), these findings suggest important information related to interpersonal attributes of the preferred therapist.

Participants endorsed the following characteristics: kind, understanding, empathic, compassionate, and non-judgmental. These traits reflect the cultural values of compadrazgo (Mascayano et al. 2016) and challenge counselors to be intentional in creating a working relationship that is simultaneously professional and relational. As Latinx individuals may face increased stressors given the tense political climate, racism, and oppression (Sibrava et al. 2019) therapists and counselors who are non-judgmental and empathetic are vitally important. Moreover, this finding validates seminal work from Luborsky et al. (1975) that found that the relationship between counselor and client is the most significant factor in the therapeutic relationship.

There are clinical theories that align with these desired characteristics. Principles from Relational-Cultural Theory (RCT, e.g., connection, mutuality) could be applied (Miller 1976). RCT provides a framework for building a therapeutic relationship through establishing trust, counselor vulnerability, and mutual empathy and empowerment (Miller 1976). While previous research studies have focused on what prohibits racial/ethnic populations from seeking counseling (e.g., Fripp and Carlson 2017) this finding provides a foundation to begin identifying how to attract underrepresented populations. Overall, the sources of support that were endorsed by participants in the current sample are consistent with other literature (Campbell and Long 2014; Mascayano et al. 2016) that discusses the more informal supports that many ethnic minorities use, when compared to formal supports.

Implications for Practice, Training, and Advocacy

The findings from this study have important implications that will help to improve mental health service utilization within the Latinx community. Mental health professionals, community stakeholders, and others engaged with Latinx adults can adopt an array of strategies discussed below to decrease barriers to mental health services.

As can be gleaned from the study findings, mental illness stigma is pervasive within the Latinx community. Such stigma may lead Latinx individuals to overlook mental health symptomology due the misunderstanding and under-recognition of signs of mental illness. One solution to combat such stigma is addressing mental health literacy within the broader Latinx community. Mental health literacy represents one’s knowledge and beliefs regarding mental illness that assists in the recognition, prevention, and management of mental health-related concerns (Crowe et al 2018; Jorm 2012). Mental healthcare providers can educate Latinx clients and families on specific symptoms that may signify mental distress or certain mental health disorders. For example, providers can explore client symptoms and explicitly discuss symptomology such as isolation or changes in energy level, sleep, mood, or appetite which may constitute depression. Accordingly, Latinx individuals may be better able to appropriately describe their symptoms and move away from using the proverbial term “crazy” to describe mental illness.

Educating the Latinx community is crucial in the fight against stigma. In order to effectively engage with the community and transmit the appropriate information, it is necessary to acknowledge the value of quality educational materials created in the language(s) that are more accessible to the population (e.g., Spanish, Portuguese, etc.). Some materials can also be tailored to specific sub-groups of the Latinx community in support of their specific cultural and linguistic needs. More importantly, hiring qualified bilingual professionals, interpreters, and translators is ideal to serve Latinx individuals and families (Swazo 2013).

Considering the importance of dignidad y respeto, familismo, and machismo, increasing the mental health literacy of all of those involved with Latinx individuals and families is imperative. Mental health providers can consider offering workshops, seminars, or collaborating with faith-based communities to offer trainings to increase mental health literacy within the Latinx community. As an example, a program evaluation conducted by Lee and Tokmic (2019) indicated that Mental Health First Aid (MHFA) programs help to increase mental health literacy within the broader Latinx community. After completion of a MHFA program designed to reduce stigma and enhance the mental health literacy of community-based workers (i.e., teachers, nurses, counselors, small business owners, police officers) employed in immigrant communities, researchers identified that participants reported more positive attitudes toward people with mental health concerns and held less-extreme views of (e.g., perceptions of dangerousness, weakness) and social distance from people with mental illnesses.

Those working with the Latinx community may devote resources to their overall cultural competence development and understanding of specific cultural and linguistic needs of this population. Having representation of the population’s race, ethnicity, culture, and language among the available mental health professionals and agencies serving the Latinx community is pertinent. In fact, such representation may contribute to the elimination of mental health disparities in services to the Latinx community (Miranda et al. 2008).

Latinx Americans in the current study noted a preference for mental health providers who are caring and who listen to their concerns. Although these may seem like characteristics that should always embody a professional counselor, researchers have suggested that Latinx individuals face discrimination, stereotypes, and communication barriers when seeking mental and behavioral healthcare services (Butler 2014). These incidents perpetuate fears and reluctance to seek professional mental healthcare services; thus, the concept of compadrazgo is vital with working with Latinx clients. Care providers should be open to going a step further to cultivate these therapeutic relationships.

Finally, mental health counselors can reference the Multicultural and Social Justice Counseling Competencies (MSJCCs) developmental domain related to counseling relationships which proposes that counselors should utilize culturally competent communication skills that allow them to effectively determine clients' needs and build trust and respect in the counseling relationship (Ratts et al. 2016). Counselors can also consider welcoming family members into sessions to help with communication, provide explanation of mental health concerns, and share a role in treatment. Additionally, counselors should consider the importance of adopting advocacy roles when working with Latinx clients. Counselors can advocate with and on behalf of clients to assist with finding ways to pay for mental health services and connect clients with available resources (Crumb et al. 2019), especially if unfamiliar with the healthcare system.

Limitations and Future Directions

As with all research, the current study is not without limitations. Perhaps the largest is that participants were not stratified according to countries of origin. Clearly not all Latinx Americans are the same in attitudes and preferred characteristics. Nadeem et al. (2007) split participants into subgroups and may serve as one example for future researchers. Similarly, the current study did split the sample by other demographics (e.g., age, gender, sexual orientation, SES), so the researchers were unable to look at themes according to these types of smaller subgroups. The survey was online, and written in English, so this type of design narrowed the type of person who could participate in the study. Future research may be strengthened by having both an English and Spanish version of a survey. A Qualtrics panel was used to recruit, and participants received a small stipend for participation. Other methods (e.g., individual interviews, focus groups, paper and pencil) may yield different findings. As well, self-reported data are subject to social desirability. Sixty-two percent of the sample were female, which may also skew results.

This study did not differentiate between those who did and did not have a mental health diagnosis. It may be impactful to explore the perceptions of Latinx individuals who have been diagnosed with a mental health illness and explore their experiences with the system and their support system. Future research might also continue the line of inquiry of Latinx attitudes, preferences, and behaviors so as not to continue the trend of pairing this ethnic group with another group (e.g., African Americans compared to Latinx). Finally, future research can also explore health and mental health disparities among Latinx individuals, and how stigma and disparities intersect.

Conclusion

This qualitative study sampled 212 Latinx Americans in order to explore their beliefs about mental illness stigma, help seeking, and preferred traits and characteristics of mental health professionals. Resulting themes included mental illness equating to being crazy and dangerous, inferior and weak, or that mental illness does not exist or should be ignored. Clinical and research implications focused on providing psychoeducation about mental illness and anti-stigma efforts. Clearly, there is much still to do in order to combat the hesitations and fears towards seeking treatment for mental health concerns among Latinx populations.