Bilingual therapy: why therapy in your native language matters

About 304 million people were international migrants in 2024, around 3.7% of the world’s population^[4]. You may have seen the figure 281 million: that was the estimate for mid-2020^[5]. If you are one of them, you may work, make friends and even argue in a language you learned later. But when something hurts, the language you talk about it in can matter more than you expect. Here is what research says, and what it doesn’t.

Why feelings land differently in your first language

In a classic study, 32 Turkish–English bilinguals rated a range of words and phrases for pleasantness in Turkish, their first language, and in English. Meanwhile, researchers measured their skin conductance, a sweat response that rises when we are emotionally aroused. People reacted more strongly to taboo words and to childhood reprimands such as “Shame on you!” in Turkish than in English^[1].

A later study with Turkish students found the same pattern. Their skin responses to emotional phrases were weaker in English, “an effect which was most pronounced for childhood reprimands”. There was a twist: when they were lying, English statements caused larger responses, which the authors put down partly to “anxiety about managing speech production in non-native language”. They wrote that this needs to be better understood to inform practices “ranging from bilingual psychotherapy to police interrogation”^[6]. In other words, what it means for therapy was still an open question.

Reviews of this research reach a similar view. In a 2015 review, Caldwell-Harris writes that, compared with a native language, emotional phrases “heard or read in a foreign language elicit weaker skin-conductance responses”^[7]. In a 2012 review of clinical, cognitive, psychophysiological and brain-imaging studies, Pavlenko describes a “first-language (L1) advantage”: emotional processing is more automatic in the first language, and the skin reacts more strongly to emotion-laden words in it. For some people, especially those who learned a language later, she suggests the later language may be “processed semantically but not affectively”^[2]. Put simply: you understand the words, but you may not feel them as much.

It isn’t the same for everyone

This is a tendency, not a rule. Caldwell-Harris notes that second languages “can also come to feel emotional, if they are used frequently and are learned via immersion rather than in the classroom”. She also notes that lab results have not always been consistent^[8]. Pavlenko’s review sets out the limits of the findings so far^[2].

Some people even prefer their second language for feelings. In a study of Mandarin–English bilinguals, people said Mandarin expressions felt stronger, but they “nonetheless preferred to express their emotions in English, citing more relaxed social constraints”. For people with good Mandarin and good English, skin responses were similar in both languages. The exception was endearments such as “I love you”, which caused larger responses in English^[9].

Keep the size of this research in mind. These are mostly small lab studies. They measure a body response to words, not how well therapy goes.

What is the “foreign language effect”?

Psychologists use this name for a finding about decisions. In a 2012 paper, researchers reported that “the framing effect disappears when choices are presented in a foreign tongue”. The framing effect is when the same choice feels different depending on whether it is described as a gain or a loss. A foreign language also “reduces loss aversion”. The authors proposed that “a foreign language provides greater cognitive and emotional distance than a native tongue does”^[10].

A 2014 study found that people using a foreign language make “substantially more utilitarian decisions” in moral dilemmas, which the authors linked to “the reduced emotional response elicited by the foreign language”^[11]. Another study suggested this works “by blunting emotional reactions”, rather than by making people think harder^[12]. Pavlenko sums up: “The converging pattern of findings suggests that foreign (FL) and second language (L2) processing do not engage affect to the same extent as processing in the first language (L1).”^[13]

The effect is real but uneven. A review of 17 studies and 47 experiments found it in both moral choices and risk-taking. In that review, how similar the two languages were made a difference, and how well people spoke the foreign language did not^[14]. A second review found the moral effect depended on how well people said they could read the language, and concluded that “not all bilinguals may experience a Foreign Language Effect”^[15]. On risk-taking, four experiments gave “mixed results”, and two found no effect at all^[16].

What it means for therapy

All of these are decision-making experiments, not therapy studies. So they do not show that therapy in a second language is harmful. One lab study even found that a foreign language “may reduce fear conditioning”, and said this “opens the avenue to the potential use of a foreign language in clinical contexts”^[17].

A fair reading is this. Distance can make it easier to say something painful. But therapy also asks you to feel what you are talking about. Being able to move between languages gives you both.

What research says about therapy in your own language

The strongest evidence comes from a 2006 review of 76 studies of therapy adapted to clients’ culture. Therapy delivered in clients’ own language, when that was not English, was “twice as effective” as therapy delivered in English. Therapy aimed at one cultural group was four times more effective than therapy for mixed groups^[3]. The studies were mostly with minority groups in the US, and the review is now old, so treat the exact size as a guide.

A later review of 99 studies found culturally adapted therapy worked somewhat better on average, though the benefit shrank after accounting for studies that may never have been published. It also found that what clients felt mattered. When clients rated their therapist’s cultural competence, those ratings were strongly linked with how well therapy went (r = 0.38). Therapists’ ratings of themselves were not (r = 0.06)^[18].

Sharing a background is a different thing. Across many studies, people often prefer a therapist of the same race or ethnicity, but matching on that alone brought “almost no benefit to treatment outcomes” on average, and the effects were “highly variable”^[19]. So the evidence points to language, and to feeling understood, rather than to a shared background as such.

Beyond therapy, a review of 33 studies, mostly of patients seeing doctors, found that 76% showed at least one better outcome when patient and doctor shared a language other than English. In 15% there was no difference, and in 9% it was worse^[20]. UK guidance for anxiety says: “Consider providing all interventions in the preferred language of the person with GAD if possible.”^[21]

Language and getting help at all

Language also affects whether people get care. A review of 18 studies from four countries found that in 15 of them, limited skill in the local language was linked with fewer mental health visits. It found no published data on whether language support changes that^[22]. In a large California study from 2001, people who did not speak English had much lower odds of getting mental health care they needed than people who spoke only English, even after other factors were accounted for^[23]. These studies are about people with limited local-language skills. Many people abroad speak the local language well, and still feel more like themselves in their own.

Switching languages in therapy is normal, and useful

Researchers call moving between languages code-switching. In a survey of 182 multilingual therapy clients, clients switched significantly more than their therapists did, and it “typically occurs when the emotional tone is raised”. They used it on purpose when talking about trauma and shame, “creating proximity or distance”: to get closer to a memory, or to keep it at a safer distance. The authors write that switching “allows clients to express themselves more fully to the therapist, adding depth and nuance”^[24].

In a second survey of 109 clients, nearly two thirds made short switches. These were “typically linked to difficulties in translation, expressing emotion, accessing memories or quotation”. Over a third used a second language as their main therapy language, and nearly half of those never switched to their first language in sessions, even though some used it daily in their own heads. Some clients did not always get the chance to talk about their languages with their therapist, and for some that held them back from switching^[25].

Therapists matter here too. In a study of 101 therapists, the 18 who spoke only one language differed significantly from their 83 bilingual or multilingual peers in how attuned they were to bilingual clients^[26]. Another project found therapists were anxious about working with multilingual clients, and that training raised their confidence by an average of 4 points on a 10-point scale^[27]. As two researchers put it back in 2002, “little attention has been given to incorporating the dynamics of a client’s language background in treatment”^[28].

These are surveys of people who chose to take part, so they tell us about experience, not about outcomes. But they point the same way: it helps to have a therapist who welcomes your languages.

What can get lost in translation

Clients in these surveys link switching to trouble translating, expressing emotion and reaching memories^[25]. In everyday terms, that might be a family saying that only makes sense in your language, a joke that falls flat in English, or a childhood memory that happened in another language. Many languages also have words for feelings that don’t translate neatly, such as the Portuguese saudade, a deep longing for someone or something that is absent, or the German Weltschmerz, a weary sadness about the world. If the word that fits is in your first language, it helps to be able to use it.

Can therapy in a second language still work?

Yes. Many people do well in therapy in a language they learned later. A second language can come to feel emotional when you use it often and learned it by living in it^[8], and over a third of clients in one survey used a second language as their main therapy language^[25]. If your therapy is working for you, there is no reason to change it because of this article.

What about interpreters? Therapy through an interpreter can still work. A review of 12 trials of trauma therapy for refugees found “no difference in outcome” between studies that used interpreters and those that did not^[29]. But a study of 825 refugee patients at a clinic in Denmark found less improvement among those treated with an interpreter. That study looked back at records rather than assigning people at random, so the groups may have differed^[30]. An interpreter is far better than no help. Therapy directly in your language simply removes a step.

Signs therapy in your native language might help you

These are common experiences people describe. They are not a test, and they are not drawn from research. If several sound familiar, it may be worth trying therapy in your own language.

• You simplify what you feel because the right words don’t come.
• You translate in your head before you speak, and lose the thread.
• Some memories, especially from childhood, feel hard to describe in another language.
• You feel more like you are explaining yourself than talking.
• Sessions leave you tired from the effort of finding words.
• You have put off therapy because you didn’t want to do it in another language.

For more on the feelings that can come with a move, see our guides to homesickness and migratory grief and culture shock.

How to find a bilingual therapist

Before you book, it helps to ask:

• Which languages do you work in, and how comfortable are you in mine?
• Can I switch between languages during a session?
• Have you worked with people who live abroad?
• Which approach do you use, for example CBT or ACT?
• What does a session cost, and how soon can I start?
• What is your training, and where are you registered?

Here are the main options, side by side. It is a guide to help you choose, not a ranking.

In the US, you can see a Bliss Therapy therapist by video too. Because our therapists are based outside the US, sessions are unlikely to be covered by US health insurance.

On Bliss Therapy

On Bliss Therapy you choose a therapist who speaks your language, by video from wherever you live, with no waitlist. Therapists offer approaches including CBT and ACT. 20 psychologists and counsellors list life abroad, with sessions from €40 (about £33). Between them they speak 18 languages. Browse all our therapists, see our page on therapy for life abroad, or read what to expect in your first therapy session. If you are an employer, see our page on employee assistance programmes.

Our therapists are based outside the UK and the US, so they are unlikely to be on UK registers or covered by US health insurance. Ask any therapist about their training and their registration in the country where they practise.

When to get help

You don’t need to wait until things are bad to talk to someone. Talk to a doctor or a therapist, in whichever language you prefer, if:

• low mood, worry or stress is not easing, or keeps coming back
• it is getting in the way of work, study, sleep, family or friendships
• the things you are trying yourself are not helping
• you are using alcohol or drugs to get through

If you are having thoughts of ending your life or harming yourself, get help now. If you live abroad, save your new country’s emergency and crisis numbers today, before you need them.