Pragmatic Case Studies in Psychotherapy

Language Use as Both Bridge and Barrier in Bilingual Therapy: A Single Case Study Analysis of the Chinese International College Student, “Mary”

2026-09-10T17:42:49+00:00

Psychologists often encounter clients from varied language and cultural backgrounds, which can pose challenges to the process of helping. The case of "Mary," an unmarried, 24-year-old Chinese international student in the U.S., embodies these dynamics and offers insights into how culture and language shape, and are shaped by, the therapy alliance, process, and outcome in bilingual therapy. Mary was seen in individual therapy that combined a multicultural, relational psychodynamic, humanistic, client-centered, and solution-focused approach by one of the authors (Y.X.) for 10 sessions (over a 14-week period, with four cancellations); and the therapy was supervised by the other author (J.N.F.). Mary’s presenting problems included challenges in adjusting to her new environment, including a decline in self-confidence and difficulties in her social life, which led to significant anxiety in her daily life.

To enhance understanding of the course of therapy, we employed an adapted version of the Critical Incidents Technique (CIT) to analyze significant moments in Mary’s 10 sessions. We focus on the role of language use in bilingual therapy, exploring its functionality as both (a) a buffer against the intense impact of emotional and traumatic experiences, and (b) as a bridge that can foster deeper psychological engagement. We highlight the mechanisms by which the therapist, with supervision, attempted to provide Mary with a meaningful and helpful psychotherapeutic experience. The core theme in our analysis of the case includes the ways that Mary uses her primary (Mandarin) and secondary (English) languages to avoid, and then access, hurtful and traumatic experiences.

Reflections on Bilingual Therapy, Defense, and Emotional Access in the Case of “Mary”

2026-09-10T18:04:47+00:00

Fuertes and Xu (2026) present a case study examining the psychological roles of language in bilingual psychotherapy through their work with “Mary,” a Chinese international graduate student navigating anxiety, shame, and acculturative strain. In this commentary, I focus on two main areas: (1) clinical decision-making and mechanisms of change through treatment, and (2) the broader theoretical, training, and service delivery implications that arise from the work. In both areas, language is emphasized as a tool for affective regulation and psychological defense. I also highlight the timing of linguistic challenges in building the therapeutic relationship and the role of the supervisor in providing a supportive and reflective holding environment, and examine the complexities in interpreting outcome data, particularly when changes in symptoms do not clearly match signs of psychological growth. Institutional factors, such as the limitations of short-term university counseling and the need for supervision that responds to cultural and language differences, are also discussed. Overall, the case serves as an insightful way to understand bilingual psychotherapy not merely as treatment across two languages, but as a process that takes place through multiple emotional, relational, and language domains.

A Response to “Reflections on Bilingual Therapy, Defense, and Emotional Access in the Case of ‘Mary’”

2026-09-10T18:10:58+00:00

This article responds to Dr. Marcela Almeida’s (2026) commentary regarding our case study of the bilingual psychodynamic treatment of "Mary," a Chinese international student (Fuertes & Xu 2026). This response addresses key clinical and systemic themes, beginning with an elaboration on context-dependent and language-dependent memory literature to support the integration of native language (L1) in bilingual therapy. Re-examining the relational dynamics of the therapeutic dyad, this response clarifies that the therapist's approach was a deliberate clinical stance rooted in shared demographic empathy and maternal/big-sister countertransference, rather than a defensive peer performance. Furthermore, Mary’s consecutive session cancellations are conceptualized as active, existential communications regarding her readiness to cross linguistic and emotional thresholds, rather than standard therapeutic ruptures. This response also discusses how the subsequent shift from English to Mandarin was facilitated through deliberate, supervised "planted" interventions that tested the elasticity of the client’s defenses to allow an organic affective awakening. Finally, the response highlights the limitations of standard English-normed symptom scales within university counseling center models and echoes the call to formalize bilingual psychotherapy as a distinct, rigorous specialty competency supported by linguistically matched, culturally responsive supervision.