H. Russell Searight, PhD, MPH
With an increasing population of persons with limited English proficiency (LEP), psychologists are likely to need to conduct assessments through a foreign language interpreter at times. The goal of the interpreter-mediated patient encounter should be to approximate a language-congruent clinical encounter. Issues such as the spatial configuration of all participants during the session, guidelines for the interpreter’s verbalizations, and some modification of the psychologist’s interview style will maintain patient rapport while obtaining necessary patient information.
A health psychologist colleague who practices at a hospital a mile from your private practice office just called to ask if you could do a psychological evaluation of Mr. Adan, a 27-year-old man who recently came to the U.S. from Somalia and who does not speak English. Mr. Adan is currently in the emergency department and is described as agitated, suspicious, and confused. He is accompanied by his 19-year-old brother, Mohamed, who indicates that he will serve as Mr. Adan’s interpreter. On your way to the hospital, you wonder if it will be awkward to have the patient’s brother participate in the interview involving personal material. You wonder if this three-way exchange will elicit the information you need to make a decision about Mr. Adan’s immediate disposition. Are you the best choice of available clinicians? But, you do not know of any psychologists of Somali background in the region, so conducting the interview in the patient’s own language is not an option. You wonder about the ethical aspects of this situation. What compromises in your customary policies regarding patient confidentiality, provision of optimal care, and privacy will this situation require? Are there HIPAA regulations that address this situation?
Patients with Limited English Proficiency (LEP)
At present, 20% of the U.S. population speaks a language other than English at home (Zong & Batalova, 2015), and at least 8% of the U.S. population demonstrates LEP. This figure has risen steadily over the past 30 years with the U.S. Census currently listing a total of over 300 languages spoken (U.S Census Bureau, 2015). In the New York City metropolitan area, approximately one third of the population speaks a language other than English at home, with a comparable figure of over 50% for the Los Angeles metropolitan area. Linguistic diversity is common in the center of the country as well, with 29% of the Chicago area and 12% of metropolitan Detroit residents speaking a language other than English at home (U.S. Census Bureau, 2015).
Even if you have never worked with a patient with LEP in a clinical context, there is a strong possibility that at some point in your career, you will require the assistance of a foreign language interpreter. Interpretation, as opposed to translation (which refers to written text), goes well beyond literal language to include the cultural meaning of the patient’s communication.
Title VI of the 1964 U.S. Civil Rights Act included LEP under the guidelines for nondiscrimination and equal access to any programs and/or institutions that receive Federal funding (The Joint Commission, 2015). In 2004, the Office for Civil Rights issued a policy directive indicating that compliance with the 1964 Civil Rights Act required access to qualified interpreters at no cost to the patient (The Joint Commission, 2015), particularly in organized care settings. State laws may be relevant. Psychologists in private practice who are considering accepting such referrals must be aware of the relevant laws and regulations affecting their practice (and responsibilities) with LEP patients. Often a referral to an organized care setting with interpreter services in place is the best option to maximize patient care and effectiveness of service.
More recently, the 2016 Affordable Care Act (ACA) detailed specific guidelines for patients with LEP in healthcare settings. Relevant to the encounter described in the opening, section 1557 of the ACA states that family members, bilingual minors, friends, and untrained staff of the healthcare facility in which the patient is being seen are all prohibited from serving as interpreters (although adult family members are permissible under HIPAA standards). Exceptions are recognized for emergency situations. The healthcare institution is responsible for providing interpreter services. However, third party payers, including Medicaid, do not typically cover charges for interpreter services (Juckett & Unger, 2014).
Private practice psychologists need to consider whether interpreters meet HIPAA business associate contract requirements. At a minimum, a private practice psychologist should have a brief document consenting to the use of the interpreter and with all parties agreeing to confidentiality—and signed by the psychologist, the interpreter, and the patient. This will demonstrate that you addressed the topic, discussed it with all parties, and reached agreement—before you made a professional judgment to move forward with the clinical contact.
Need for Interpreters
Ideally, patients with LEP would be seen by a bilingual psychologist. In some locales, particularly on the East and West coasts, psychologists with fluency in Spanish or East Asian languages are available. Many national bilingual certification programs exist that institutions can use to certify their staff. As a psychologist, if you believe that you are competent in another language, consider whether you can conduct a typical assessment interview in a second language with the same facility as in English. False fluency is a common error occurring when healthcare providers, believing that they can effectively evaluate patients in a second language, over-estimate their knowledge and skills (Flores, 2005). While Federal and State laws and guidelines indicate that qualified medical interpreters must be trained, the amount and content of educational preparation is typically left unspecified.
In Mr. Adan’s case, you will have to make a decision about your options for an interpreter. Under the law, healthcare institutions should have a system in place for providing clinical services for LEP patients. The level of the personnel providing such interpretive support may vary greatly. Psychologists in independent practice should make themselves aware of the options for interpreter services in their community. Larger communities will likely have agencies that provide interpreters for a fee. And, remote interpretation services are also available over the Internet.
. . . consider whether you can conduct a typical assessment interview in a second language with the same facility as in English.
Ethical Challenges with Foreign Language Interpreters
The use of interpreters raises potential conflicts with APA’s Ethical Code. Specifically, interpreters assisting psychologists must demonstrate competence to provide services, in addition to protecting patient confidentiality and avoiding dual relationships (APA, 2017). With the absence of formally trained mental health interpreters and the simultaneous need to provide services to patients with LEP, the clinician must weigh two of the underlying dimensions of the Code’s General Principles, namely non-maleficence (do no harm) and beneficence (protect and promote the patient’s welfare—Principle A). Moreover, since patients do have the right to an interpreter of their choice (and can refuse the one provided), there can also be an ethical tension between respect for people’s rights and dignity (autonomy—Principle E) and the clinician’s commitment to beneficence and non-maleficence.
The ACA directive that family and friends are not appropriate as potential interpreters can be invoked as an institutional “policy.” This stance avoids any implied criticism of the accompanying family member’s linguistic abilities. In emergency contexts in which there is concern about harm to self, others, or psychosis, the assessment will of necessity have to proceed. However, in those hopefully rare instances in which the patient’s family or friend is interpreting, the interview should focus solely on the content needed to address the emergent issue. A more detailed clinical interview should be deferred to a later date when a more appropriate interpreter is available.
In contrast to the American emphasis on individual self-sufficiency and control of personal information, collectivist cultures may de-emphasize autonomy. The ethics codes of mental health professionals reflect such personal privacy and confidentiality. However, the concept of individual personal privacy may be at variance with an interpreter’s worldview emphasizing family or collectively held information (Searight & Gafford, 2005). Because some linguistic communities are small, it is likely that the interpreter knows someone who is also a family member or acquaintance of the patient. Additionally, in some cultures, negative or potential emotionally upsetting health-related information such as a diagnosis of dementia or a new diagnosis of schizophrenia is often not shared directly with the patient but only with adult family members (Searight & Gafford, 2005).
Nonetheless, in the U.S. healthcare system context, the interpreters must understand and accept the U.S. ethical and professional standards. It is your ethical responsibility to insure that the interpreter understands the concept of confidentiality as it applies to an American mental health context and is willing to abide by this standard. After receiving this assurance, the psychologist should repeat the expectation of confidentiality with the patient and interpreter, together.
In most cases, you should hold a meeting with an interpreter prior to the clinical session with the patient present. You should let the interpreter know the length of time you expect the session with the patient will last. Explain the seating arrangement you intend to use. Ask about the interpreter’s experience doing medical interpretation as well as mental health interpretation.
Basic ground rules for working with an interpreter include:
- Speaking in the first person (Psychologist to interpreter: “If Mr. Adan says, ‘I can’t sleep at night,’ say, ‘I can’t sleep at night’ rather than ‘he can’t sleep at night’ ”).
- Interpreting everything that is said. “Do not leave anything out that I say or the patient says. Also, please do not substitute words if you can avoid it, or summarize what either of us say, or add your own observations. If you want to address me directly, please begin with ‘Interpreter would like to say . . .’ ”
- “If there is something you do not understand, please stop me. Also, if it seems to you that I am not understanding something, please let me know.”
- “If you are not sure about how to interpret something that I say, please let me know and I will try to say it differently. I recognize that some of the terms I or the patient use will not have a direct English equivalent. Please do your best to express the meaning of what is said.”
- “I will want you to sit to the side and slightly behind the patient, so as to strengthen the relationship and contact between the patient and myself.”
Finally, you need to discuss and confirm the interpreter’s understanding and acceptance of confidentiality, as well as avoidance of potentially exploitative dual relationships.
To minimize the likelihood of an interpreter-centered exchange, the common triangle seating configuration between patient, interpreter and psychologist should be avoided. This physical arrangement tends to lead to the interpreter, rather than the clinician and patient, becoming the central focus. One frequently recommended configuration is to have the interpreter sitting slightly behind and to the side of the patient. Some clinicians worry that this arrangement prevents the interpreter from optimally “reading” the patient’s facial expressions, but such a configuration is likely to create a patient-clinician connection (and not an interpreter-client primary exchange).
You should look in the patient’s direction when you speak, and you should speak in first-person language. The exception might be if cultural issues, such as minimizing eye contact with patient of the opposite sex, are important in a given case (Raval & Tribe, 2014). The patient may feel an urge to look at the interpreter; however, if you maintain focus on the patient and use first-person language consistently, both the patient and interpreter will likely follow suit. The goal in the interaction with the patient is to be as patient-centered as possible.
You should ask one question at a time, avoiding compound questions, qualifying phrases, and colloquialisms. When providing the patient with information or summarizing, a sentence-by-sentence style of speaking should be employed. While this style may initially feel awkward, a conversational rhythm will emerge over time: the psychologist speaks, the utterance is interpreted, the patient responds, the response is interpreted, and the cycle continues. It also makes it easier for the interpreters to interpret and easier for the patient to understand (and respond).
It may be necessary to diplomatically remind the interpreter of the pre-session guidelines. In particular, many interpreters have difficulty consistently speaking in the first person (“I feel” versus “He says he is feeling”). Similarly, side conversations between the patient and interpreter may occur. Clues to side conversations would include prolonged exchanges that do not seem to be being interpreted in their entirety, significant emotional expression that seems to be “missed” in the interpreted account, nonverbal expressions such as smiling or suddenly looking sad or angry, or prolonged eye contact between the interpreter and patient. When you suspect these exchanges between interpreter and patient, it is helpful to remind the interpreter of the ground rules (e.g., “Everything that Mr. Adan says is important. Please interpret all that he says.”)
Clinically relevant material may be omitted in the interpreted narrative to avoid embarrassing the patient, their family, or placing a cultural community in an undesirable light. Verbalizations about suicide and/or hallucinations may be distorted or omitted to prevent the patient from appearing disturbed (Searight & Searight, 2009). Clues that censoring may be occurring include non-verbal indications of interpreter distress or embarrassment and/or a persistent pattern of vague or tangential interpreted responses to specific questions. It may be necessary to step out of the consulting room and have a 1-to-1 discussion to avoid embarrassment in front of the patient, as well as maintaining rapport with the interpreter.
A brief meeting with the interpreter after the clinical session is often helpful. This post-session provides another opportunity to learn about relevant cultural issues, as well as clarifying interpreted content about which you are still unclear. The post-session can also be an opportunity to reflect upon and improve your skills. Simply asking the interpreter if there was anything that you can do to make their work go more smoothly can provide useful feedback. For example, despite knowing better, I occasionally slip into asking several questions without pausing for the interpreter.
With war and significant civil unrest in many countries, some refugees experience traumatic memories and flashbacks many years after leaving their home countries (Bogic, Njoku, & Priebe, 2015). Many interpreters are refugees from the same countries as the new patient. You will need to be alert to secondary traumatization of your interpreter. Debriefing in a post-session meeting should attend to this possibility, particularly if the interpreter exhibits non-verbal signs of distress during the interview. Sighing, breaks in the flow of translation, tearfulness, brief trance-like dissociative states during the interview suggest the possibility of interpreter distress and should be gently inquired about during the post-session. If a clinical referral is needed for the interpreter, obviously, this should be done.
Research on Foreign Language Interpretation
The research literature on interpretation is relatively sparse and most studies focus on medical settings. In comparing professionally trained versus untrained Spanish interpreters in a pediatric emergency department, both groups averaged close to 33 errors per encounter. However, when the proportion of errors of possible clinical significance was examined, trained interpreters exhibited fewer errors (12%) compared with their untrained counterparts (22%). Supporting the importance of formal education, interpreters with fewer than 100 hours of instruction exhibited a much greater number of errors (median = 33) than those with at least 100 hours of instruction (median =12; Flores et al., 2012). Thus, you will need to avoid making quick clinical judgments and ask the same question in varying ways so as to maximize the correct clinical data.
Detailed studies of the accuracy of mental health interpretation have not been reported. Qualitative and descriptive studies suggest that with interpreters, patients’ symptoms may be reported as more or less severe and the medical etiology of cognitive-behavioral-vegetative symptoms is more likely to be overlooked (Flores, 2005). In one of the few studies of interpreter-mediated psychotherapy compared with bilingual therapists, Schulz, Resick, Huber & Griffin (2006) examined the outcome of Cognitive Processing Therapy for patients with PTSD from Afghanistan and the former Yugoslavia. There was substantial benefit for all patients and no difference in global outcomes between interpreter-mediated and bilingual psychotherapy conditions.
Conducting assessment and psychotherapy through an interpreter challenges the psychologist’s interviewing and observational skills. While there are minimal comparative data comparing the duration of mental health encounters with and without interpreters, medical research suggests that interpreted sessions are up to 50% longer (Flores, 2005). While this article has focused upon the linguistic aspects of psychological practice, cultural factors add another layer of complexity.
Depending on their country of origin and time spent in the U.S., the patient, and possibly the interpreter, may not be familiar with psychology as a profession (Searight & Gafford, 2006) and expect the mental health encounter be comparable to a medical office visit. This expectation of a biomedical focus may also be related to cultural influences on symptoms. Conditions such as PTSD and Major Depressive Disorder are often experienced somatically by patients from some Asian and Western African countries (Ma-Kellams, 2014).
Stigma may also be an issue influencing both the patient and interpreter. In many non-Western countries, mental illness is equated with severe conditions such as active psychosis, acutely suicidal behavior, or frank mania (Searight & Gafford, 2006). The combination of a knowledgeable and interpersonally sensitive interpreter and a psychologist who is genuinely interested in improving their cross-cultural competency will greatly benefit the growing number of patients with LEP.
H. Russell Searight, PhD, MPH, is a licensed psychologist and Professor of Psychology at Lake Superior State University in Sault Sainte Marie, Michigan. Prior to his current position, he was Clinical Associate Professor of Community and Family Medicine at Saint Louis University School of Medicine as well as Director of Behavioral Medicine at an affiliated Family Medicine Residency in St. Louis, Missouri. His professional interests include psychological practice in the primary healthcare setting, ethical dilemmas in medicine and public health, and cross-cultural issues in end-of-life care.
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The Joint Commission (2015). Overcoming the challenges of providing care to LEP patients. https://www.jointcommission.org/issues/article.aspx?Article=07L7HYJFF9ixfyUPFpD2. Accessed on June 14, 2017
U.S. Census Bureau (2015). Census bureau reports at least 350 languages spoken in U.S. homes. http://www.census.gov/newsroom/press-releases/2015/cb-15-185.html. Accessed June 8, 2017
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