1.10: Working in Behavioral Health- Perspectives from a Deaf Professional and a Designated Hearing Interpreter

In this chapter, co-authors—Deaf Behavior Technician and their designated interpreter—will examine what it looks like to interpret for a Deaf Behavior Technician, their roles and responsibilities, and how interpreters can work alongside them to achieve their goals. In our collaboration, we aim to provide insights into the unique challenges and considerations involved in interpreting for individuals working in behavioral health settings. By sharing our perspectives, we hope to enhance understanding and support for Deaf Behavior Technicians and promote effective communication in this important field.

Behavior Technicians

Behavior Technicians (BTs) are trained professionals who teach individuals how to modify their behaviors, learn new skills, and improve their communication. The two types of Behavior Technicians are Qualified Behavior Technicians (QBTs) and Registered Behavior Technicians (RBTs).

A QBT is an entry-level position that requires workplace training as a qualification to provide therapy to a clinic’s clients. This training typically forms a foundational understanding of mental health, behavioral health, neurodivergence, Applied Behavioral Analysis (ABA), coping skills, maladaptive behaviors, and technical skills like how to record session notes for official documentation purposes. Subsequent required training may include CPR and First Aid, as well as clinic-specific safety training. Once all training is completed the technician will be deemed eligible to carry out individualized treatment plans for the clients of a behavioral health clinic. An RBT, on the other hand, must pass an additional assessment and obtain at least 40 hours of supervised work to obtain a license within 180 days after their initial training.

Other Clinical Staff

Behavior Technicians use ABA to teach clients how to better manage their mental and physical wellbeing by modifying or reducing maladaptive behaviors, learning new skills, and improving their communication through the procedures listed in the detailed treatment plan. ABA is also used to develop short-term and long-term goals, as well as, a detailed individualized treatment plan for each client by a Board-Certified Behavior Analyst (BCBA). BCBAs hold a postgraduate degree in their field and a state license to practice. Clinical Directors hold the same license as a BCBA and oversee the clinic and its staff and can intervene when necessary.

Clinical Work

Preschool–aged clients through adults may be eligible to receive services. When a client is brought into a clinic for assessment, the BCBA works in collaboration with the client, and their guardians if they are a minor or a dependent, to identify the client’s needs. The BCBA also will work in collaboration with the client’s educational team, the courts, medical providers, or other professionals who have been requested to assist in the assessment and treatment process. After collaboration with the aforementioned professionals, the client, and the client’s guardians, the BCBA will identify short-term and long-term goals and develop a treatment plan that outlines measurable outcomes for the client.

Each client’s individualized intervention and treatment plan addresses the behaviors that were identified during assessment as maladaptive or in need of development. BCBAs develop the treatment plan and then review it with the assigned BTs. One or more BTs will be assigned to carry out the treatment plan on a regular basis with the client during structured sessions. The number of service hours the client receives will depend on their specific level of need and their insurance plan. During sessions, BTs are responsible for recording data to closely track the client progress and for insurance purposes. Assigned BTs follow specific protocols and use intentional language and terminology when engaging with the client. The language used and the skill acquisition protocol is largely influenced by the ABA process. BCBAs are responsible for monitoring the client’s ongoing progress through observations, meetings with the BTs, meetings with the client’s family, and through further assessments when necessary. BCBAs are also responsible for updating the other professionals on the client’s team.

The members of the team meet on a weekly basis to discuss any changes that need to be made to the treatment plan. A client’s progress is measured as increases in positive behaviors and decreases in maladaptive behaviors (the behaviors that the client should not continue performing). If the client can improve or reduce their targeted behaviors to a satisfactory level, they may be recommended for dismissal from services.

Considerations for Interpreting in Behavioral Health

Knowledge of Process

It is important for a designated interpreter to understand the clinical work involved in behavioral health settings, particularly when working with a Deaf BT, as it provides crucial context for their role and responsibilities. By understanding the process of assessment, goal-setting, treatment planning, and progress monitoring, interpreters can better support communication between the BT, their team, and clients. This understanding allows interpreters to ensure the goals and interventions outlined in the treatment plan are interpreted effectively. Additionally, interpreters who are familiar with the ABA process and terminology can help bridge any communication gaps that may arise during sessions, promoting a more inclusive and collaborative environment for all involved.

Conduct

When interpreting in behavioral health it is essential that interpreters are familiar with the specific clinical setting in which they will work. For example, each clinic may have variations in their expected professional conduct and safe work procedures. The ASL-English interpreter will often be expected to adhere to the same rules as the BTs in relation to conduct and safety procedures. The interpreter should understand what type of conduct is allowed, or considered inappropriate, for clinical settings and discuss any safety concerns with the Deaf professional prior to the beginning of the session.

In some instances, a client may be known to exhibit aggressive behaviors such as biting, kicking, throwing objects, or hitting. BTs are trained to address their clients’ maladaptive behaviors in very intentional ways to promote the development of coping skills and to minimize harm. Interpreters should consult with the Deaf professional in advance, so they know how to respond to a potentially hazardous situation in a way that maintains the safety of all participants and is minimally intrusive to the treatment process.

Interpreters should be aware of other maladaptive behaviors that may occur during the session and how they should respond in each instance. For example, if a child with Autism is known to frequently elope (fleeing or escaping an area), the interpreter and the Deaf professional may discuss where the interpreter should position themself in the room to not block the BT’s response. The interpreter should also know, for example, not to chase after or attempt to grab the client.

Interpreters should also consider the environment of the clinic, dress code, and how they pack their belongings. A bustling clinic with primarily children for clients will provide very different demands than an in-home session with a teenage client. It may be appropriate to bring a work bag, coffee, and purse to one setting but not the other. The dress code for the behavioral health clinical setting is typically business casual, but interpreters are encouraged to wear clothing that is non-restrictive, not distracting, or inappropriate for the setting. BTs may be very active during the session especially when working with younger clients who may want to run, climb, or sit on the floor during their session. The interpreter should be flexible and may need to think outside of the box at times to continue providing services effectively in this environment.

BTs may attend sessions in the clinic, as well as in the client’s personal home. Interpreters should be prepared to work appropriately in either setting and should always wait for the arrival of the Deaf professional before entering the personal home of a client. Additionally, interpreters should refrain from passing any personal judgments on the client’s home or family members who may be present.

As with a number of settings, interpreters should be prepared to encounter ethical conflicts, personal bias, unusual interpreting dynamics, and sensitive content matter. These may be present in the form of interpersonal, paralinguistic, intrapersonal, and environmental demands (Dean & Pollard, 2013). When possible, the interpreter should consult with the Deaf professional prior to the session to determine what BT’s goals for the session are, as well as how they would prefer the interpreter to participate in the session, any communication needs or requests they have, and what safety procedures will be followed in the event of an emergency. The Demand-Control Schema (Dean & Pollard, 2013) is highly recommended for interpreters to use in their decision–making process. Before working in behavioral health, interpreters should feel confident in their ability to respond appropriately to conflict, identify several control options for a single demand, and make appropriate decisions that will not disturb, or negatively influence the clinical process, or reflect poorly on the Deaf professional.

Insight from a Deaf Behavior Technician

Successes with Interpreters

As a Deaf person, I have had the opportunity to work with various interpreters in my professional career, but there were two that stood out to me due to their professionalism and reliability. I consistently requested these interpreters because they were punctual, thorough, and maintained a high level of professionalism both towards my clients and me.

Challenges with Interpreters

Conversely, I have faced occasional challenges when using interpreters. In one instance a substitute interpreter was assigned to a session and stepped out of her role conducting a verbal disagreement with a client’s brother. This interaction derailed my session with the client and continued to escalate. I decided we both should leave the session early. The next morning, I had a meeting with my supervisor and the clinical director where I requested that substitute interpreter not be assigned to me again in the future.

After the situation I noticed that the client’s brother communicated with me less than before, and it felt a bit awkward. Fortunately, the incident did not directly impact my client or my relationship with my employer. Any substitute interpreter who accepts a clinical assignment should have a strong understanding of the setting, the technician’s preferences, and know to not act on a personal bias. In this situation, instead of reacting the way the interpreter did, the interpreter should have let me, the technician, know what was happening and I could have figured it out.

Coordination of Interpreting Services

It is incredibly difficult to coordinate interpreting services for my workplace. There have been multiple incidents of poor communication where I was given the runaround by the entity coordinating interpreting services on my behalf. This entity did not ask me for my preferences.

Luckily, thus far, I have only experienced poor communication with one interpreting agency, as they were not transparent about which interpreters were assigned. I was assigned many different interpreters and often did not have an interpreter available when I needed one. I would have preferred consistency. Likewise, the agency did not ask me for my preferences.

As a Deaf professional, I had to learn about the interpreting process, and make interpreter requests to specifically include: no personal bias, good clear communication, some knowledge of ABA and the behavioral health field prior to the session. I also make it clear; an interpreter must be okay working in private locations such as the client’s home. Coming to learn these specifics, forced me out of my comfort zone to address a variety of situations, trying to coordinate interpreter services. I had to pause or postpone a session due to lack of an interpreter and frankly the interpreter coordination process was frustrating. I had even considered giving up on getting an interpreter and forcing myself to use oral communication – definitely not my preference. As I learned more about the interpreting process, I have developed several recommendations for the interpreting agency: ask the professional what they need; be transparent about the agency scheduling process so the professional is not left in the dark; and have more dialogue together to make coordination smooth and successful.

Throughout these experiences, I have learned the importance of advocating for my accommodation rights while also ensuring those rights did not interfere with my clients’ treatment. My interpreters have played a crucial role in helping me navigate these situations, teaching me how to self-advocate and effectively communicate my needs to my employer.

Overall, working with interpreters has been an invaluable learning experience, helping me to understand the importance of clear communication and collaboration in providing the best care for my clients. Interpreters help my work by recording notes for substitute interpreters for smooth transitions and checking in often to adjust the interpreting process.

Insight from a Hearing Interpreter

Prior to interpreting for a session, it is important that interpreters understand the BT’s goals for the session. This will help the interpreter make appropriate judgements when assessing how to navigate setting-specific hurdles, like incorporating significant partial-speech or other auditory information in an effective way, or how to deliver information when the Deaf BT cannot look away from their client for a prolonged period. Interpreters must be aware of the clinic’s policies, safety regulations, and expectations for professionals who participate in treatment sessions. Without any doubt, the interpreter’s conduct and implicit biases influence the session. It is imperative the interpreter’s demeanor should align with the needs of the BT and their client and should always contact the professional running the session to understand their session goals before interpreting.

Interpreters working in behavioral health settings must prepare for the possibility they could be interpreting sensitive topics or any number of traumatic experiences. There may be clients of all ages who are engaging in maladaptive behaviors, experiencing mental illness, have disabilities, with sessions in clinical and private locations. Interpreters are encouraged to observe or take training before interpreting in a behavioral health session for the first time. While interpreting in behavioral health, especially if the interpreter does not have much experience in this setting, it is recommended that the interpreter enact more conservative controls (Dean & Pollard, 2013), especially during assessments or when the client is using atypical language. Have a safety plan and check your own bias at the door.

Obviously, interpreters working in behavioral health should have all required licenses to interpret in their state. Interpreters should also understand common mental and behavioral health practices before working in the field and realize the roles and qualifications of the professionals in the clinical space before interpreting.

Ethics

Significant ethical considerations for interpreters in the behavioral health field revolve around the interpreter’s qualifications and decision-making ability. It is recommended that interpreters working in behavioral health are familiar with the Demand Control Schema (Dean & Pollard, 2013) and can extrapolate multiple control options when presented with behavioral health related demands.

Interpreters should be aware of cultural perspectives on mental health, therapy, counseling, treatment, and healthcare. These perspectives may influence how the BT is able to interact with their client and the client’s family. Being able to identify areas of personal bias and withhold making personal judgements is key for an interpreter. For example, clients may participate in religious practices, cultures, and traditions, or may hold opinions that differ from the interpreter. Such personal judgements or disagreements cannot influence the interpreting situation. And as always, an interpreter should refrain from distorting the message by omitting or adding any information.

Tips From a Deaf Behavior Technician

Depending on the client’s wariness of strangers, it is preferred to both the Deaf BT and the client to have the same interpreter for all the sessions.

Interpreters always must remain professional with the client and ignore maladaptive behaviors.

Establish clear communication expectations with the Deaf professional, which includes discussing preferred communication styles, vocabulary, and any specific accommodations needed.

Encourage open communication, and provide feedback with the Deaf professional. This helps address any misunderstandings or issues promptly and fosters a collaborative working relationship.

Engage in professional development to enhance an understanding of behavioral health topics, communication techniques, and ethical considerations in the field.

Insight From a Deaf Behavior Technician: Interpreting Students

As a Deaf professional, I believe interpreter students can benefit from understanding the importance of collaboration and cultural competence. It is crucial for interpreters to approach their work as a partnership, actively seeking input and feedback from Deaf individuals to ensure accurate and respectful communication. This collaborative approach not only enhances the quality of interpretation, but also fosters mutual respect and understanding between interpreters and Deaf professionals. Students can prioritize cultural competence by immersing themselves in Deaf culture, learning about communication norms and preferences, and recognizing the diverse experiences within the Deaf community. By embracing cultural competence, interpreters can build trust, bridge communication gaps, and effectively advocate for the linguistic and cultural rights of Deaf individuals.

Interpreter students should also cultivate a sense of professionalism, reliability, and a commitment to continuous learning. Professionalism involves maintaining punctuality, confidentiality, and ethical integrity in all aspects of interpretating work. This type of professionalism and reliability forms a level of trust between interpreters and Deaf professionals and their clients. It then fosters a positive working relationship and helps with effective communication.

Interpreter students should embrace a growth mindset, actively seeking opportunities for training, mentorship, and self-improvement to enhance their interpreting skills and to adapt to diverse communication settings and contexts. Through ongoing learning and growth, interpreter students can contribute to the advancement of the interpreting profession and positively impact the experiences of Deaf individuals in various professional and social environments.

Activity

Watch the videos in the reference list and visualize that you are the interpreter assigned to these sessions. Think about where the participants are placed in the room. Think about where you would position yourself as the interpreter. What challenges do you think you may face in this environment? What strengths do you personally bring to this environment?

Resources for Further Learning

A Life-Changing Therapy for Children with Autism at The Children’s Center

https://m.youtube.com/watch?v=pSGVb60-BSw

How To Stop a Tantrum by A Board Certified Behavior Analyst

https://youtu.be/y9gOQSEnCUc?si=TvT-pjqhkFX71p7X

An RBT Day in the Life with RethinkBH

https://youtu.be/WJ8YFzTXukc?si=JuHHgLlK1CRMmF-7

ABA Autism Training – The Discrete Trial https://youtu.be/BacBU-yTzE8?si=LDuC9kPZynRaJ693

References

Dean, R., & Pollard, R. (2013). The demand control schema: Interpreting as a practice profession. CreateSpace Independent Publishing Platform.