Cassandra L. Boness, MA
Clinical work with individuals who are culturally and linguistically different from their therapist is a challenge involving ethical and psychotherapeutic issues. Individuals who have been d/Deaf the vast majority of their life and who use American Sign Language as their primary language are culturally and linguistically different from most psychotherapists. Using qualified mental health interpreters in psychotherapy with d/Deaf patients may facilitate the therapeutic process, support retention in treatment, and improve outcomes. A number of ethical and practical issues must also be addressed before and during the use of interpreters with individual patients.
A colleague contacted you yesterday about the potential referral of a 29-year, college educated deaf man who is experiencing marital difficulties. Your colleague is seeing the man’s wife in individual psychotherapy, and the husband is wondering whether he might also benefit from being seen in psychotherapy. But you have never worked with a deaf patient before. Should you decline the referral? If you agree to see the patient, what additional reading and supervision might be involved? What atypical aspects would there be to the treatment? Will you need to engage the services of an interpreter? If so, what ethical challenges will using an interpreter present?
The first thing to appreciate is that being deaf can be defined physiologically, meaning physical loss of hearing, or culturally, meaning affiliation with a culture based on American Sign Language (ASL). In the case of the former, the term “deaf” is used. In the case of the latter, “Deaf” is more appropriate. It is essential to acknowledge that someone who has been d/Deaf since birth or a very early age is culturally different from yourself. Thus, all of the APA principles and guidelines about working with individuals who are culturally and linguistically different from you will be relevant in your treatment of this patient, if you decide to accept the referral (APA, 2014; APA, 2010).
Cultural & Linguistic Differences
You will need to learn something about “Deaf culture,” and the degree of identification and involvement the patient has with it. Not all deaf individuals are the same, and they vary on a continuum ranging from a hearing orientation (speech and auditory orientation) to Deaf orientation (based on manual communication utilizing American Sign Language). Your patient might be bi-cultural, partially living in both cultures (and, more or less, near the middle of the continuum), such as is often the case with individuals who are Hard-of-Hearing (HoH). The majority of d/Deaf individuals have extensive experience with oppression, neglect, bias, and abuse by professions of all types and the public in general. Neglect and oppression in educational opportunities as well as unemployment or underemployment are common experiences (Boness, 2015). Being treated in social situations as if they are “a problem” or less than worthy of others’ time and attention are also common experiences for d/Deaf individuals. All of this shapes their worldview and sense of self-identity.
American Sign Language (ASL) is a language in the full linguistic sense of the word. ASL has its own complex grammatical structures, vocabulary, sociolinguistic variation, and rules of discourse (Cornes & Napier, 2005). ASL varies from English in its vocabulary, syntax, grammar, and discourse pattern. ASL places verbs at the end of sentences, uses adjectives after the words they modify, and does not have individual words for the, is, are, was, and were. ASL uses the space around the signer’s body to convey linguistic meaning throughout a conversation. If you are not fluent in ASL, it is essential that you accept and knowledge your linguistic and cultural difference from any d/Deaf patient with whom you may work clinically. While some individuals may be skilled at lip-reading, this is not to be viewed as an effective means of communication as only 30% of all speech is visible on the lips (Georgia Tech, n.d.).
Language discrepancy between a therapist and client has been demonstrated to negatively affect various issues related to treatment. Research has shown that this includes client retention (Sue, 1991), accuracy of diagnosis (Bamford, 1991), strength of therapeutic alliance (Halgin & McEntee, 1986), and the type and depth of topics covered in treatment. Ideally, all Deaf clients would be treated by a therapist fluent in ASL. However, few therapists know ASL, and it is rarely practical for a hearing therapist to learn ASL in order to provide treatment to Deaf individuals. Thus, one needs to consider the possibility of utilizing the services of a qualified interpreter. The first issue is to determine the patient’s preferred communication, as accommodating this will likely ensure a better treatment outcome. In general, family and friends, although potentially fluent in ASL, should not be used as this can jeopardize confidentiality and introduce bias into the communication (Leigh, 1999).
The D/deaf can be viewed as a cultural and linguistic minority. As such, we must view clinical and ethical issues through a multicultural lens, consistent with Principle E of the APA Ethics Code (Respect for People’s Rights and Dignity; APA, 2010). This view requires one to consider issues such as competency. This issue, and others, have been addressed at length in a previous publication (see Boness, 2015). Therefore, the focus of the current article is on the use of interpreters in clinical work with D/deaf clients.
Qualified Mental Health Interpreters
Qualified interpreters are a useful tool for facilitating a sense of belonging for the client and increasing client trust in the psychologist and therapeutic process. The use of interpreters can also reduce the sense of interpersonal isolation by allowing clients to more accurately express complex feelings and concepts in his or her own language. It also serves to start bridging the cultural gap by introducing a third party that can inform psychologists regarding Deaf culture and culturally informed behaviors (Paone & Malott, 2008). This guards against the risk of misdiagnosis, for example.
Previous research has demonstrated that the presence of interpreters increases d/Deaf client willingness to return to therapy (Hillier, Loshak, Rahman, & Marks, 1994). The APA Ethics Code also supports cooperation with other professionals (Standard 3.09) when indicated and professionally appropriate for the purposes of serving clients effectively and appropriately (APA, 2010). Further, the Americans with Disabilities Act (ADA) requires some businesses to provide interpreters for people who are d/Deaf or Hard-of-Hearing (APA Practice Organization, 2012), while Section 504 of the Rehabilitation Act of 1973 forbids organizations from excluding or denying individuals with disabilities an equal opportunity to participate in, and have access to, program benefits and services (U.S. Department of Health, 2006). It is clear that providing qualified interpreters is not only an important ethical consideration, but also a legal consideration. Although a useful and often necessary tool, bringing an interpreter into treatment presents unique ethical and treatment issues.
Qualified interpreters are a useful tool for facilitating a sense of belonging for the client and increasing client trust in the psychologist and therapeutic process.
It is best practice for providers to only use qualified and licensed/certified interpreters. The ADA sets the standard for the qualifications as an interpreter as follows: “A qualified interpreter means someone who is able to interpret effectively, accurately, and impartially, both receptively . . . and expressively . . . using any necessary specialized vocabulary” (U.S. Department of Justice, 2014). The major overall national certifying body in the U.S. is the Registry of Interpreters for the Deaf (RID). An additional certifying body, the Certification Commission for Healthcare Interpreters, is responsible for credentialing healthcare interpreters. Some states have their own interpreter assessment programs that operate independently of the national certifying bodies. There are also a number of states that require specific, advanced training to work in mental health settings (e.g., Alabama). It may be easier for you to contract with an interpreting agency than try to identify individual interpreters on an as-needed basis.
Mental health interpreting is becoming an established subspecialty in the interpreting field (Dean & Pollard, 2005). Qualified interpreters who work in mental health settings are bound by their own set of standards of practice and code of ethics which touch on issues such as confidentiality, impartiality, and discretion (Stewart, Schein & Cartwright, 1998; see NCIHC, 2004 and NCIHC, 2005). Although the code of ethics for interpreters includes confidentiality, it would be wise for the psychologist to ensure that the interpreter understands Health Insurance Portability and Accountability Act (HIPAA) compliance. Interpreters are not HIPAA providers but are Business Associates; therefore, a Business Associate Agreement (BAA) must be completed prior to their engagement in patient care. The RID Code of Ethics (RID, 2005) states interpreters “refrain from providing counsel, advice, or personal opinions” (p.3). Interpreters should be familiar with common terms and concepts used in therapy, and they should be comfortable with conveying this information to the client in a neutral way without inserting their own biases. Correct comprehension of the concepts heard or seen in a mental health context is essential to translating them correctly (Dean & Pollard, 2005).
When engaging interpreter services, it is important that the interpreter has previous experience in a psychotherapy setting, and, in some states, is appropriately licensed or certified. Not all qualified interpreters have mental health experience, so it is necessary for a psychologist to also consider the interpreter’s mental health language competence and comfort with session content (see Standard 2.05 described above; Searight & Searight, 2009). You should meet with and interview a potential interpreter prior to the first time you have them actually join you in a session with a patient to assess their understanding of mental health concepts and clarify ethical expectations about their handling of information gained during psychotherapy. It is good practice to have an interpreter sign a contract stating they received training in ethics from the psychologist, have discussed expectations, obligations and responsibilities of both parties, and agree to uphold the confidentiality of client(s). As noted above, a BAA should be signed.
Interpreters should be familiar with common terms and concepts used in therapy, and they should be comfortable with conveying this information to the client in a neutral way without inserting their own biases.
However, psychologists are required by Standard 2.05 (Delegation of Work to Others) to take reasonable steps to “. . . (1) avoid delegating work to persons who have a multiple relationship with those being served that would likely lead to exploitation or loss of objectivity [e.g., a family member or friend]; (2) authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training, or experience . . . ; and (3) see that such persons perform these services competently” (APA, 2010). Therefore, psychologists are responsible for ensuring that interpreters are competent and trained in the importance of the APA’s ethical standards, including confidentiality, the potential for harm in multiple relationships, and informed consent (Campbell, Vasquez, Behkne, & Kinscherff, 2010).
Although it is vital for psychologists to take responsibility in ensuring mental health language competence and comfort with session content when working with qualified interpreters, it is also important for psychologists to understand the inherent judgment that qualified interpreters must use to do their job ethically (i.e., according to their Code of Ethics) and effectively. Dean and Pollard (2005) believe that when this is taken in a literal context, it is erroneous and detrimental because translations often do not directly correspond to the precise words said. Translations can and often do require information to be added or deleted (i.e., linguistic alterations), and translations are based on the interpreter’s judgment of what consumers mean instead of the words they choose (Dean & Pollard, 2005). This is another reason it is important that you meet with a potential interpreter prior to using them so you can make clear that psychotherapy requires staying as close to the exact words and descriptions used by the patient as humanly possible, even when the content is possibly embarrassing, painful, or graphic.
Psychologists need to be mindful of the possible ambiguity in a d/Deaf client’s response if the comment or question, or the interpretation of it, is too literal (resulting in misunderstanding), too leading (which may shape the client’s response), or incorrectly interpreted (Cornes & Napier, 2005; Paone & Malott, 2008). According to Paone & Malott (2008), psychologists should be cognizant of the fact that interpreters may ignore information they do not understand or believe may embarrass the client (or themselves), may reduce information to decrease translation execution time in favor of translating more important information, which may result in a loss of impact, may use additions, elaborations or phrase changing when they believe the information given by the therapist was incomplete or unclear. Likewise, they may even substitute, condense, or alter material perceived as too challenging for clients to understand because of language difficulty, the amount of information, or possible emotional impact. This is true for both English to ASL translation (from therapist to client), and vice versa. Quality assurance in this regard might seem impossible given that the psychologist does not know the client’s language and therefore cannot readily recognize the linguistic alterations. This is another reason for meeting with potential interpreters prior to using them, as a better relationship and a trusting one will help build confidence and a common goal of communication accuracy.
Since the Deaf community is small in size, and qualified interpreters are scarce, it is important for psychologists to recognize that qualified interpreters are likely to be known to clients in other contexts. This may raise “dual relationship” issues between the interpreter and the patient, which the psychologist also needs to address in the initial meeting with the interpreter in order to raise the issue and set expectations. The psychologist and interpreter should discuss the possibility of conflict and other contacts and relationships which might make it inappropriate for the interpreter to assist with a given patient. Prior relationships and possible future ones may result in heightened anxieties and concerns among clients related to self-disclosure and confidentiality (Steinberg, 1991). The d/Deaf patient will typically orient towards the interpreter because they share the same language, which is a clinical challenge to be sensitively overcome with both the patient and the interpreter in order to build an effective therapeutic relationship. Moreover, when the interpreter is known to the client ahead of time, it often creates an additional problem in building the therapeutic alliance. One needs to carefully consider other possible options for obtaining interpretative services if the patient already knows the proposed interpreter. The potential or actual dual relationship aspect with a given patient and interpreter pairing should be openly addressed and explored with the patient in the first session, along with informed consent. The use of a qualified interpreter (even one that is less skilled) should be preferred over using family members or other ad hoc interpreters (Leigh, 1999). The use of family members can jeopardize the clinician’s ability to diagnose and treat the client, especially if the family member edits the messages conveyed and questions asked or edits the patient’s answers (or, even, answers the questions him or herself rather than letting the patient do so). The presence of a family member may prevent the patient from describing or revealing events that the family views as “private” or “secret.” Further, using family members as interpreters directly compromises the client’s confidentiality, making it a serious ethical challenge.
A further ethical consideration in working with qualified interpreters is informed consent. The Ethics Code (Standard 10.01, Informed Consent to Therapy) requires psychologists to obtain informed consent, as mentioned in Standard 3.10 (Informed Consent). The Ethics Code encourages informing patients as early as feasible about the nature of therapy, fees, involvement of third parties including the interpreter, and the limits of confidentiality. The patient should be provided sufficient opportunity to ask questions and receive answers. Informed consent is a shared decision-making process in which the professional communicates sufficient information to the consumer so that she or he may make an informed consent about participation in the professional relationship (Barnett, Wise, Johnson-Greene, & Bucky, 2007, p. 179).
This process is complicated when using a qualified interpreter for many of the same reasons previously mentioned. The process of obtaining informed consent should be discussed with the interpreter prior to engaging in the process with a patient. The two of you need to understand and work through any linguistic differences that might limit the client’s ability to make consent truly informed (Barnett & Goncher, 2008; Pollard, 2002). It would also be ethically responsible to consider how the underlying concepts of informed consent can be influenced by cultural factors. Barnett and Goncher (2008) give the example of autonomy, or the right to self-determination (as emphasized in General Principle E: Respect for people’s Rights and Dignity). Conceptualizations of autonomy may vary by culture. For example, a Deaf client may feel more comfortable including significant members from the Deaf community in his or her decision making process. If desired by the patient, such preferences should be respected during the informed consent process (Barnett & Goncher, 2008).
A final factor to consider when deciding to work with an interpreter is related to who pays for the interpreting services provided. The short answer is “whoever is providing the psychological services”—either the clinic or the private practitioner. According to a 2011 ADA Update (US Department of Justice, 2011), it is the business’s responsibility to provide a sign language, oral interpreter, or video remote interpreting service “unless doing so would result in an undue burden.” “Undue burden” in this case is determined by a business’s overall resources. The APA Practice Organization (2012) takes the position that, in most cases, a psychologist should attain and pay for the cost of an interpreter for a d/Deaf patient, because proving “undue burden” would be a significant challenge. The APA also notes that the cost of paying for such interpreter services is outweighed by the risk of an ADA complaint being filed against the psychologist. Further, Gutman and Pollard (1999) have taken the stance that it is “virtually always illegal” to deny a request for an interpreter or to ask the consumer to pay for the cost.
Although bringing a qualified interpreter into treatment can seem like quite an undertaking, at least ethically speaking, the importance of using interpreters in serving the d/Deaf and Hard-of-Hearing communities has been well-documented and the ability to work skillfully with qualified interpreters has been considered a core competency of working with the d/Deaf (Glickman & Harvey, 2008). Psychologists should strive to consider the plethora of relevant ethical issues, particularly those discussed in the current paper, prior to beginning treatment with a Deaf client, and should consider additional matters, such as legal factors, relevant to bringing a qualified interpreter into treatment. A discussion of all relevant considerations for working with qualified interpreters is beyond the scope of this paper. Those interested in specific competencies, knowledge, skills, and attitudes and values should refer to Dean and Pollard (2005), Cornes and Napier (2005), Paone and Malott (2008), and Boness (2015).
Cassandra L. Boness received her MA in clinical psychology from the University of Missouri where she is currently a PhD candidate. Her chief research interest concerns the etiology and diagnosis of alcohol use disorder. Her clinical interests include psychotherapy with the d/Deaf and Hard-of-Hearing communities, Dialectical Behavior Therapy, and ethics.
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