1.9: Considerations for Interpreting- Working in Mental Health Settings

The scope of mental health interpreting work is broad. This necessitates a tailored and specific skill set to provide effective services. Recommendations for interpreters working in mental health include developed competencies in source and target languages, an understanding of settings, mental health professionals, and treatment approaches, along with exploration of one’s own personal history, coping strategies, biases, and ability to work in situations which can be emotionally charged, sensitive, or explore traumatic topics. Interpreters working in mental health must be able to establish effective self-care strategies and should incorporate effective supervision as part of their work.

Even practitioners who do not desire to work primarily in mental health settings may find their career rife with appointments which have mental health components and/or consist of work involving clients who receive mental health services. Sometimes, interpreters will enter the assignment unaware and unprepared for such an eventuality. It is therefore critical that professionals sufficiently prepare themselves with sufficient knowledge of the impact of mental health on their work, to avoid causing harm.

Like other specialty settings, mental health work has unique challenges. When an interpreter enters a mental health assignment assuming that nothing unusual is occurring, they may be missing salient points of the encounter, which can run counter to the overarching value of most helping professions of “do no harm.”

Recommended Qualifications

Some literature has explored the concept of whether interpreters working in mental health should also hold counseling credentialing to truly understand the scope of mental health work, however, the workforce feasibility of this concept is limited (Lee & Cangelosi-Williams, 1983). It is recommended that work in mental health settings be performed by interpreters who hold national certification, are state licensed, and have post certification credentialing in mental health, such as Alabama’s Qualified Mental Health Interpreter certification (Alabama Department of Mental Health, 2003). Areas identified for requisite training include mental health systems, providers, therapeutic approaches, comorbidity, language dysfluency, ethical decision making, practice profession models, clinical supervision, demand-control schema, psychopharmacology, vicarious and secondary trauma stress, self-care, communication assessment (Registry of Interpreters for the Deaf, 2007). Workshops are a starting point for gaining knowledge about mental health but are insufficient to long-term understanding and expertise (Dean, 2023). Interpreters following a practice profession model should seek opportunities for mentoring, supervision, improved decision-making strategies, and practicum/internship related experiences within mental health.

Settings

Settings which are often viewed as traditional mental health settings vary depending on the service spectrum of the facility; in general, mental health settings run the gamut from intense crisis intervention, inpatient services, or outpatient monitoring. Each of these settings comes with consumers with differing levels of acuity of mental illness, facilities with different service packages, treatment approaches, management, expectations as well as providers with different competencies, and goals.

More restrictive settings, such as inpatient psychiatric hospitals, crisis centers, or secure medical facilities, typically work with clients who exhibit more severe or acute symptoms. Treatment, while not an exhaustive listing, can include screening, intake, assessments, medication management, psychoeducation, counseling which focuses on and supports improved social skills, understanding the impact of their mental illness, learning to express needs, increasing resiliency or coping skills, appropriate boundaries, and the correlation of cause and effect which can impact the length of stay within an inpatient facility. Many of these services correlate to the presenting problem, which necessitated the more restrictive level of treatment, and the ongoing assessment of issues of safety for the client or others. Additional services may include connection to care for medical issues, case management, peer support services, and assistance with next steps for transition to a less restrictive setting.

Less restrictive and more community-based programming includes step down programs, group homes, supported living environments, mobile crisis teams, programs of assertive community treatment, or in-home treatment. Community-based outpatient services have an array of potential services from therapy (individual, group, family), case management, rehabilitative day programming, peer support, medication management, et cetera. Often the focus on these programs is supporting the client’s ongoing stability, addressing social behaviors, reactions to stressors and emergent issues, providing and managing medication, psychoeducation, and community resources.

Preparing for an assignment includes working knowledge about the type of setting which the interpreter will encounter and what type of services are offered. One example can include talk therapy, henceforth labeled as therapy. An interpreter who is hired to interpret for a therapy session should know if this will occur in a secure medical facility, an inpatient psychiatric facility, a group home, at a community provider facility, or other location as this may drive the type of therapy which occurs and the interpreting and behavioral decisions that the interpreter will be faced with. Therapy in a forensic facility may address themes centered around the client’s crime, legal proceedings, assessments as to competency to stand trial, restoration to competency, the client’s mental illness, et. cetera, which would necessitate that the interpreter have both legal and mental health training and awareness. Therapy in a community-based scenario in which the client sees a therapist once a month (or other regular intervals) will often focus on the therapeutic relationship of trust and exploration of problems within the client’s life such as history, family, current living situation, life stressors, decision-making, and an examination of effective and ineffective responses. The therapist may spend time connecting the client to additional supportive resources within the program and the community. The service provider-to-client relationship may include a more social approach than an inpatient/crisis setting. Additional factors such as the therapeutic approach of the therapist will also influence how the session progresses and decisions of the interpreter.

The interpreter should also be cognizant of safety issues for themselves and aware of expectations regarding interactions with both deaf and hearing clients within the facility. It is common for settings which are more restrictive, such as a forensic facility or inpatient setting, to have regulations regarding the safety of consumers and providers. These can include items which should not, or cannot, be brought into the site such as phones, medications, metal soda cans, food, drink, pens, and/or small items which may be dangerous if swallowed and so forth. Additionally, items which are permitted typically should not be shared with clients. The interpreter will also want to consider appropriate dress. Providers, including interpreters, are encouraged to dress conservatively and the facility may highly discourage or not allow some items of clothing such as open-toed shoes, high heels, dresses/skirts, jewelry, et cetera. Subsequently, the interpreter should be familiar with existing rules and follow the protocol in a manner similar to other staff so as to not create issues for the clients or concerns for their safety, and this consistent expectation is often necessary for successful treatment.

Outpatient settings are typically the least restrictive mental health setting and usually do not impose limitations on consumers other than those that are frequently demonstrated in other social agencies (no weapons, consideration for communicable diseases, or social courtesies, to name a few). However, when boundaries are established at a particular agency, the interpreter would want to be aware of them and abide by them.

As stated previously, some interpreters may avoid settings which are perceived as mental health for a variety of reasons including the complexity of the work, the potential for serious negative outcomes, fear of people with mental illness, a personal history of mental illness in themselves or their family, and/or a personal history of trauma. However, when considering the interpreter’s scope of work and career, mental health work will occur whether it occurs within a traditionally viewed mental health setting or with a person who has a mental health diagnosis. This can occur in any setting including those not traditionally viewed as mental health, such as medical, educational, vocational, community, legal, and others. What may have been contracted as a medical appointment for an injury, may include a consult for depression and medication to address the presenting problem. A medical condition such as extremely high blood sugar levels in a person with diabetes or a severe urinary tract infection, may present as a mental health issue. Hospital emergency departments are commonly a first point of contact for a mental health crisis. A disciplinary issue in a school setting may be addressing psychiatric or behavioral problems. A student may be coping with significant life issues of sexual, physical, or emotional abuse or neglect. They may also be dealing with other life stressors (relationship issues, bullying, self-image, or unplanned pregnancies). Work environments can incorporate stress related to finance or workloads, workplace violence, involvement in employee assistance programs, and so forth. Legal settings can often also be stressful and may include emotionally charged situations such as probating estates, divorce, child custody, child protection, abuse, violence, et cetera. Probate courts also handle involuntary commitments to inpatient facilities. Religious settings may incorporate pastoral counseling, marriage counseling, issues within the family, medical illness including death and dying, assistance with individuals in the community who are struggling with poverty, or homelessness, all of which may turn into a mental health concern.

Regardless of the field of interpreting specialization that an interpreter chooses, mental health will be a component of their work. Learning what mental health work involves and how mental health work is different, can reduce the chances of an interpreter causing harm.

Ethical Considerations

Ethical expectations of service providers, such as therapists, in mental health settings can be both similar to, and different from, traditional ethical considerations of interpreters. One example is that of dual roles or of extending professional boundaries in relationships with clients. Interpreters are often faced with challenges of dual roles when working with individuals who are deaf. In mental health settings, this may become a significant consideration for therapeutic success. The interpreter, who in the community often views themselves as a cultural ally to the deaf client, will need to realign themselves with the goal of therapy and with the mental health professional so as not to interfere with the therapy. Some considerations include waiting in the lobby with the deaf client, having conversations with the client in therapy that do not include the therapist, interpreting for the client in settings outside of therapy, and consultation with the therapist. When waiting with the client in the lobby, this can lead to an inadvertently establishing alliance between the interpreter and the deaf client who already possess a shared language and cultural framework. This alliance can interfere with the establishment or maintenance of a therapeutic alliance between the therapist and client and can even create an “us against them” perception. Additionally, the therapist is often comparing the client’s present state against a previously established baseline. When the client, who is more likely to be influenced by the mood of the interpreter rather than the therapist (Brunson & Lawrence, 2002), engages in conversation with the interpreter prior to the session, this may change the client’s presentation, potentially skewing the therapist’s conclusion about the effectiveness of treatment. This also may place the interpreter in a quandary of perceived role-exchange, in which the client shares critical information with the interpreter rather than the therapist.

Ethical intersectionality is a juncture in which various ethical guidelines which govern decision-making exist, and for which multiple factors are considered (Burke, 2019). An example of ethical intersectionality in mental health interpreting may include the topic of confidentiality. While interpreters sometimes state that the traditional understanding of this concept means that information related to the assignment is never discussed with anyone, in many other professions such as medical and mental health, it implies the concept of trust in how the information is handled. Elements of information about the assignment are often discussed with pertinent members of the treatment team; this should always be done with a consideration of necessity and often limits the amount of shared information to that which is considered necessary. The treatment team can include the therapist, the psychiatrist, the case manager, the interpreter, mental health technicians, peer support providers, and others. Information shared outside of the team necessitates a signed and agreed upon release of information. Ethical confidentiality is superseded by laws which address privacy such as HIPAA, FERPA, or 42 CFR Part 2¹. The interpreter should be cognizant of legal parameters and be prepared to consider them with the scope of their work. Exceptions to confidentiality such as mandated reporting are also necessary components of the interpreter’s work. Examples of this includes knowing and understanding the age of majority (the age at which an individual is legally considered an adult) versus the age of consent for healthcare (the age or circumstances in which an individual may legally consent to medical care for themselves) within the state the interpreter works and what information can and/or must be shared with parents or guardian and are there legal obligations which exist when a person is thought to be a danger to themselves or others and how should that reporting occur?

Historically, the interpreting profession has held the concept of neutrality to mean that the interaction should proceed as if both parties utilized the same language and as if the interpreter was not there. Thus, implying that the interpreter should have no sway or influence over the interaction. Mental health settings present unique challenges in this regard. Communication is a primary method of treatment (Pollard & Dean, 2003). Individuals with significant mental illness may use language in ways that are symptomatic of mental disorders (Thacker, 1994; Trumbetta, Bonvillian, Siedlecki & Hasins, 2001). However, if the interpreter is unaware of this, they may restructure the client’s message inadvertently removing pertinent clinical information. This is complicated by the fact that language atypicality and/or dysfluency for individuals who are deaf may also have origins related to language modalities, language deprivation, and/or comorbid neurological sequalae as a result of the etiology of deafness – of which the treatment team may not know to consider (Glickman, Crump, & Hamerdinger; 2020; Crump & Hamerdinger, 2017; Glickman & Crump, 2013; Hamerdinger & Karlin, 2003). Differentiating language which is presented in an unusual fashion from mental illness symptomology and acquired language deficits necessitates that the interpreter work with the therapist to notice and comment on unusual language output and to explore possible causalities which may include examination through a formal communication assessment (Williams & Crump, 2018). This may include pre- and post-sessions with the therapist to bolster effective teamwork. The interpreter should consider incorporation of interpreting techniques which are often underutilized such as third person, narrative or descriptive, or consecutive techniques (Glickman & Crump, 2013). Additionally, acknowledging and accepting that the mere presence of an interpreter converts a dyadic therapy session into a triadic session, will impact the treatment process, and has considerations for transference and countertransference, shifts in alliances, and competing professional demands and goals (Hamerdinger & Crump, 2022; Raval, 1996). If the interpreter and clinician are not able to work effectively as a team, this can negatively affect client’s treatment (Costa & Briggs, 2014; Critchfield, 2002). An approach in which the interpreter and clinician view each other as colleagues and members of a multi-disciplinary team can enhance the efficacy of clinical work (Tribe & Lane, 2009).

Preparing for Mental Health Work

Advanced training and certification of interpreters, both deaf and hearing, in mental health as a specialty is needed (Tribe & Lane, 2009). Increased exposure to mental health work as a specialty is also needed in interpreter preparation programs. Many interpreters enter into mental health work with inadequate training (Dean, Pollard & English, 2004). Interpreters who are prepared to work in most mental health settings have experience, earn certification, and receive advanced training in mental health interpreting.

Preparing for mental health work requires knowledge of mental health settings, professionals who work in the mental field, treatment approaches, terminology, medications, understanding how language can be impacted by cognitive, emotional, behavioral, or social factors, and an ability to respond in a professionally appropriate way that coincides with expectations of mental health work, incorporating use of an effective decision-making model such as the Demand Control Schema (Dean & Pollard, 2005).

It is recommended that interpreters prepare themselves for work in mental health by initially pursuing significant and on-going training, such as Alabama’s Mental Health Interpreter Training Program (MHIT) (Crump, 2012). Interpreters can work towards enhanced practice by considering the following: recognizing that using the same interpreter throughout an on-going mental health assignment can be clinically significant and ultimately lead to better treatment outcomes, establishing a positive working relationship with the therapist, having a better understanding of and alignment with the therapeutic goals, and trust and consistency for the individuals who are deaf (Raval & Tribe, 2014; Hamerdinger & Karlin, 2003; Patel, 2003; Nijad, 2003; Raval, 1996). Understanding language dysfluency and how specific language patterns can be a result of different causalities can be germane to the skill set needed to work in mental health interpreting. Another recommendation is considering the impact of fund of information deficits within the deaf community and how this can be misconstrued by a hearing monolingual therapist. Interpreters should be able to incorporate expanded interpreting techniques, such as third person, consecutive, narrative, or descriptive approaches.

Interpreters should develop effective self-care strategies including exploration of the interpreter’s own psychological or trauma history, strengthening of boundaries, intellectual understanding of mental health, and viewing oneself as part of the mental health process. Self-care should also include clinical supervision with trained individuals who have interpreting and mental health experience. Interpreters should be willing to acknowledge the lack of their own impartiality and that every interpreter enters settings with their own set of baggage, history, personality, and skill sets and subsequently be willing to explore them as they relate to interpreting work (both in terms of language and behavior). It is recommended that interpreters seek out resources including articles, books, trainings, and professionals who specialize in deaf mental health work (Registry of Interpreters for the Deaf, 2007).

Mental health work can be challenging. It can also be some of the most complex, exciting, and rewarding work that interpreters do. The knowledge learned and the skills developed for successful work in mental health are highly applicable to interpreting work in all settings and will allow to the interpreter to develop effective strategies that can reduce stressors and may potentially lead to greater career longevity.

Activities

Activity 1:

Interview an employee of a local mental health agency.

Students should develop a list of questions which explores the job of a professional working at a mental health agency and what types of services are provided at the agency. Suggested questions may include:

• What is your current job?

What does your job entail?

What type of clients does your agency serve?

What services does your agency offer?

What type of caseload do you currently have or held prior?

What does a typical day look like for you?

What types of services do clients that you work with most often need?

What has been the most challenging aspect of your job?

What has been most rewarding about your career?

• How often do you work with interpreters (in any language pair)? What questions did you leave with after the encounter?
• Have you worked with individuals who are deaf? Can you tell me about your experience(s)?

Activity 2:

Guest Speaker

Invite a guest speaker, preferably an individual who is deaf who works within a mental health program in your area to discuss the scope of their work as well as considerations for working with interpreters, or interpreters working with clients who are Deaf. This can include a state director, therapist, case manager, or peer support specialist.

Activity 3:

Video Work

The student should view a video of a deaf person signing in which the deaf person displays moderate language dysfluency (or atypical language) and that includes mental health related issues.

• Have the students interpret the video using different interpreting techniques.
• In the first iteration, the students should interpret using first person, simultaneous methods.
• During the next reiteration, have them provide an interpretation based on form, rather than content, utilizing third person narrative and/or descriptive techniques.
• Discuss the effectiveness of each strategy

Students should work in small groups to discuss the following and report out to the class:

• What does the person’s language look like? How are they using language?
• What challenges would the interpreter face?
• What challenges might the hearing mental health professional face?
• What recommendations would you make regarding successful communication access/strategies?
• What resources would you consider providing to the hearing mental health professional?
• Where and/or to whom would you go to for supervision regarding this assignment?

Resources

Brief Tips and Resources for Providers https://mh.alabama.gov/tips-and-resources-for-providers/

Alabama Department of Mental Health, Office of Deaf Services Article Listing https://mh.alabama.gov/peer-reviewed-articles-written-by-ods-staff/

Deaf Wellness Center, Selected Publications https://www.urmc.rochester.edu/deaf-wellness-center/products/publications.aspx

Center for Atypical Language Interpreting, Northeastern University, Unfolding Scenarios Videos https://cssh.northeastern.edu/cali/unfolding-scenarios-videos/

Center for Atypical Language Interpreting, Northeastern University, Language Sample Video Series https://cssh.northeastern.edu/cali/language-sample-video-series/

Language Deprivation Syndrome, Sanjay Gulati, M.D. https://www.youtube.com/watch?v=8yy_K6VtHJw

Texas Mental Health Deaf Youth Initiative Series

• Roger Williams https://www.youtube.com/watch?v=5sr1Dpr8KQE
• Neil Glickman https://www.youtube.com/watch?v=PZULqFti3KA

Deaf Off Drugs and Alcohol (DODA) Program

• Deaf Recovery – Bobby’s Story Part 1 https://www.youtube.com/watch?v=Dx6YSUCPxmU
• Deaf Recovery – Bobby’s Story Part 2 https://www.youtube.com/watch?v=lAJxSXElfr8
• The Serenity Prayer in ASL https://www.youtube.com/watch?v=es-513lVDuo
• 12 Steps in ASL https://www.youtube.com/watch?v=-ysYVfNKGGg
• 12 Traditions in ASL https://www.youtube.com/watch?v=fB2uZYsBcmQ

Training Materials for Substance Abuse Counselors https://www.mncddeaf.org/?page_id=144

National Association of the Deaf, Mental Health and Deaf https://www.nad.org/resources/health-care-and-mental-health-services/mental-health-services/

Registry of Interpreters for the Deaf Standard Practice Paper, Interpreting in Mental Health https://drive.google.com/file/d/0B3DKvZMflFLdWmFVV2tydVRFTHM/view?resourcekey=0-OydUcyRlK3pR2UO9PZNK0A

References

Alabama Department of Mental Health. (2003). Chapter 580-3-24, Mental health interpreter standards. http://www.alabamaadministrativecode...h/3mhlth24.htm

Brunson, J. G., & Lawrence, P. S. (2002). Impact of sign language interpreter and therapist moods on deaf recipient mood. Professional Psychology: Research and Practice, 33(6), 576.

Burke, T. B. (2019). Identity, ethics, and the deaf community. In I. Leigh & C. O”Brien (Eds.), Deaf identities: Exploring new frontiers (pp.52-71). Oxford University Press. https://doi.org/10.1093/oso/9780190887599.003.0003

Costa, B., & Briggs, S. (2014). Service-users’ experiences of interpreters in psychological therapy: a pilot study. International Journal of Migration, Health and Social Care.

Critchfield, A. B. (2002). Meeting the mental health needs of persons who are deaf. National Association of State Mental health Program Directors and the National Technical Assistance Center for State Mental Health Planning.

Crump, C. & Hamerdinger, S. (2017). Understanding etiology of hearing loss as a contributor to language dysfluency and its impact on assessment and treatment of people who are deaf in mental health settings. Community Mental Health Journal, 53(3). Springer Publishing. http://www.tararogersinterpreter.com/uploads/1/0/3/7/103709790/crump_understanding_etiology_of_hearing_loss_as_a_contributor_to_language_dysfluency.pdf

Crump, C. (2012). Mental health interpreting: Training, standards, and certification. In K. Malcolm and L. Swabey (Eds.). In our hands: Educating healthcare interpreters. Washington, DC: Gallaudet University Press.

Dean, R. (2023). Mental health interpreting: Clinical information and work strategies for a practice profession. Mental Health Interpreter Training.

Dean, R. K., & Pollard, R. Q. (2005). Consumers and service effectiveness in interpreting work: A practice profession perspective. In M. Marschark, R. Peterson & E. A. Winston (Eds.) Sign language interpreting and interpreter education (pp. 259-282). Oxford Univeristy Press. https://doi.org/10.1093/acprof/9780195176940.003.0011

Dean, R. K., Pollard, R. Q., & English, M. A. (2004). Observation-supervision in mental health interpreter training. In E. Maroney (Ed.) Still Shining After 25 Years. Proceedings of the Conference of Interpreter Trainers. (pp. 55-75). Washington, DC.

Glickman, N., & Crump, C. (2013). Sign language dysfluency in some deaf persons: Implications for interpreters and clinicians working in mental health settings. In N. Glickman (Ed.), Deaf Mental Health Care (pp. 107–137). Routledge.

Glickman, N., Crump, C., and Hamerdinger, S. (2020). Language deprivation is a game changer for the clinical specialty of deaf mental health. JADARA, 54(1).

Hamerdinger, S. & Crump, C. (2022). Collaboration: Sign language interpreters and clinicians working together in mental health settings. In C. Stone, R. Adam, C. Rathmann, & R. Muller de Quadros (Eds.) Handbook of Sign Language Translation and Interpreting. Routledge.

Hamerdinger, S. & Karlin, B, (2003). Therapy using interpreters: questions on the use of interpreters in therapeutic settings for monolingual therapists. Journal of the American Deafness and Rehabilitation Association, 36(3). https://mh.alabama.gov/deaf-services/

Lee, M. & Cangelosi-Williams, P. (1983). Mental health interpreters: Should they be required to have counseling degrees? a case to be made. Registry of Interpreters for the Deaf 1983 Conference Proceedings.

Nijad, F. (2003). A day in the life of an interpreting service. In H. Raval & R. Tribe (Eds.) Working with Interpreters in Mental Health. (pp. 77-91). Routledge.

Patel, N. (2003). Speaking with the silent: addressing issues of disempowerment when working with refugee people. In H. Raval & R. Tribe (Eds.) Working with Interpreters in Mental Health. (pp. 219-237). Routledge.

Pollard, R. Q. & Dean, R. K., (2003). Interpreting/translating in mental health settings: What clinicians and interpreters need to know. Grand Rounds Presentation, Rochester Psychiatric Center: Rochester, NY.

Raval, H. (1996). A systemic perspective on working with interpreters. Clinical Child Psychology and Psychiatry, 1(1), 29-43.

Raval, H., & Tribe, R. (2014). Introduction. In H. Raval & R. Tribe (Eds.) Working with Interpreters in Mental Health. (pp. 1-22). Routledge.

Registry of Interpreters for the Deaf. (2007). Interpreting In Mental Health Settings: Standard Practice Paper. https://drive.google.com/file/d/0B3DKvZMflFLdWmFVV2tydVRFTHM/view?resourcekey=0-OydUcyRlK3pR2UO9PZNK0A

Thacker, A. (1994). Formal communication disorder: Sign language in deaf people with schizophrenia. British Journal of Psychiatry, 165, 818-823.

Tribe, R., & Lane, P. (2009). Working with interpreters across language and culture in mental health. Journal of Mental Health, 18(3), 233-241.

Trumbetta, S., Bonvillian, J., Siedlecki Jr., T., & Hasins, B. (2001). Language-related symptoms in persons with schizophrenia and how deaf persons may manifest these symptoms. Sign Language Studies, 4(3), 228-253.

Williams, R. & Crump, C. (2018). Communication skills assessment for individuals who are deaf in mental health settings. In N. S. Glickman & W. C. Hall (Eds.), Language Deprivation and Deaf Mental Health (pp. 139-159). Routledge. https://doi.org/10.4324/9781315166728

1 HIPAA: Health Insurance Portability and Accountability Act. A federal law which limits the sharing of protected health information without a patient’s consent.FERPA: The Family Educational Rights and Privacy Act. A federal law that protects the privacy of student’s records in educational settings.42 CFR Part 2: A federal law which restricts the sharing of records of patients receiving services related to substance use disorder treatment without their consent.