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Mental Health Settings: Are Sign Language Interpreters at Risk?

Sign Language Interpreter Needing Support

Sign language interpreters are rarely equipped to deal with the trauma sometimes incurred in mental health settings. How can interpreters find support and prioritize self-care for themselves and their colleagues?

Friendlyville is a mid-sized city (population 85,000) in a Midwestern state with a Deaf (ASL) population of about 200.  Janice is one of the few RID-certified sign language interpreters in Friendlyville. She is the child of Deaf parents, and chose to become an interpreter after graduating from an ITP in Bigtown in a different state.  Janice works with a sign language interpreting agency in Friendlyville, and she tends to be called upon for the most challenging assignments.  She travels in a multi-county area, sometimes going as far away as Metrocenter (population 1.3 million), a distance of 120 miles from Friendlyville.

On July 14, Janice was contacted by the Emergency Department of the Friendlyville Community Hospital and asked to interpret for a deaf man.  Janice asked for specifics regarding the individual for whom she would interpret, but the person who called Janice stated that this information was confidential and she would need to sign a HIPAA Compliance form before any PHI could be released to her.  So, Janice arranged for daycare services for her two preschool children and rushed to the hospital.

Upon arrival, she signed the necessary confidentiality forms and was escorted to an examination room where she found Dr. Wilson and a 27-year-old Deaf man she had never met before, James.  Dr. Wilson had a notepad with which she had been attempting to communicate with James, but the attempts at writing back-and-forth had not been successful.  James had exhibited several violent outbursts (screaming and hitting the bed) but had not hurt anyone.

Since Janice had never met James before, she asked Dr. Wilson if she might introduce herself to him. The doctor agreed. As Janice introduced herself, she voiced for Dr. Wilson and tried to identify common “deaf introduction” items, such as James’ school background, where he had grown up, and the name signs of several local Deaf community members.  None of these topics elicited any “connections.”  Janice then informed Dr. Wilson that James was unknown to her.

Dr. Wilson informed Janice that James had been brought to the ER by police officers (who were still outside the door), and that he had been arrested in downtown Friendlyville while making strange noises and pounding his fists against the brick walls of a homeless shelter.  James was dressed appropriately for the weather, but had noticeable body odor and needed a shave.  His hands had some fresh bandages on them, but he was able to sign unimpeded.  No one seemed to know much about him, but he had a driver’s license which was used to identify him.  No outstanding warrants or medical history had been found on a quick records check.

Dr. Wilson began asking questions, and James’ level of agitation seemed to diminish in the presence of the interpreter.  James knew his name, but when asked where he lives, he replied that he has no home, that a flying object (spacecraft?) had brought him to Friendlyville, and that he had been forced to have sexual relations with unfriendly life-forms from another galaxy.  He was a Messenger to Earth and warned of imminent destruction unless all people on Earth agreed to have sex with the inhabitants of “Xylic.”  He also asked Janice and Dr. Wilson if they would like to have sex with him.

James’ signing was rapid and disjointed, and often it was difficult for Janice to voice for him because of his sign speed and the rapid changes of topics in his discourse.  She did her best to provide an exact verbal interpretation of James’ signs and the strange incidents he tended to describe.  James used some signs which Janice had never seen before, and when she asked him to explain he replied, “You’re stupid!  You don’t know my alien sign language.”

At one point in the session, Dr. Wilson received a crisis call and left the room.  As soon as Dr. Wilson departed, James exposed himself to Janice and demanded sex “before the doctor gets back,” adding, “we need to create offspring for the Xylic people.”  Janice handled the situation well – she immediately left the room and asked the police to step in.  She didn’t return to the room herself until Dr. Wilson came back and she was able to tell the doctor what had happened.

Dr. Wilson quickly arranged for James to be admitted to the hospital. Janice accompanied James to a locked treatment unit where paper work was completed and he gave a brief personal history.  He objected strongly to medication, but the doctor insisted that he MUST take it either through pills or through an injection.  James agreed to take the pills because, he said, “I hate needles.”

Janice left the hospital after several hours.  She had assisted by interpreting for James’ orientation to the rules of the Mental Health unit of the hospital.  She had also made arrangements to return for James’ therapy sessions and his medication management meetings with staff.  When she left the unit, she saw James sitting alone, watching a news program on television.

After leaving the hospital, several thoughts occurred to Janice:

– Did I do my job effectively and appropriately?

– Did James REALLY need to be locked up in that hospital?

– Did James get the same treatment as the other people on that unit?

– Would a CDI have helped with really comprehending James’ language?

– Does James really belong in that place?

– What will happen to him there?

– What if that had been my dad?

…and so on.

The Follow-Up

“What if that had been my dad…” begins to strike at the core of the issue, even if a sign language interpreter isn’t the child of Deaf parents.  What has been happening inside Janice’s own mind and heart are rarely part of the mental health services delivery continuum.  Social workers, counselors, and psychiatrists have professional support networks available to them where they can receive “supervision” from clinicians and colleagues, and where they discuss problems that are affecting them personally.  But interpreters are sometimes constrained from seeking personal support by obsessive adherence to a Code of Professional Conduct.

Sign language interpreters who have worked in mental health situations can probably empathize with Janice better than anyone else in this scenario.  Janice can’t get help from Dr. Wilson (who is probably too busy to offer the time anyway) or from other interpreters who don’t work in mental health settings. It’s not the same as educational interpreting, and it’s not the same as legal work.  It’s not even the same as medical interpreting.

This is not to say that mental health interpreters should not participate in their personal therapy sessions to better understand their own feelings and reactions to very non-traditional experiences.  Hearing mental health personnel may be accustomed to such things as patients propositioning them, but sign language interpreters are rarely confronted with such events when all alone, and such experiences may leave traumatic scars on a person’s psyche.

How Can Sign Language Interpreters Care For Themselves?

The major concern here is for Janice, and for the trauma she may have experienced through this event.  As shocking as it may be, sign language interpreters are human beings and, as such, they are vulnerable to psychic insult as a result of the work they do.  An interpreter does not usually encounter overt sexual trauma such as this as a regular part of a normal assignment.  In this case, events transpired which were unexpected.  Janice is unlikely to find much consolation from the mental health staff, since they are trained to deal with such events and may experience similar things on a fairly routine basis.  How can interpreters prepare for these realities?

Below you will find a few suggestions for interpreters in such circumstances:

1) Colleagues With Experience.

If an interpreter is fortunate enough to know other interpreters with a great deal of mental health experience, such people can be a valuable resource to tap into.  As with all such connections, of course, strict adherence to confidentiality and professional codes of conduct needs to be observed.  But codes of conduct do not prevent a person from discussing strategies or receiving the assistance and support they need to function as a healthy and happy interpreter and continue to provide a valuable resource to Deaf people and the larger professional communities.

2)  Debrief.

Debriefing with a supervisor or trusted colleague may offer an opportunity to share feelings and hear the perspectives of other professionals.  Care must be taken to preserve the confidentiality of the deaf consumer, as well as the reputation of other professionals in the incident.  Sometimes we have a tendency to take a judgmental position and offer advice in the form of, “You should never have done… .”  Not only is such unsolicited advice unhelpful, it does little to offer alternatives or solutions to the interpreter directly impacted by the incident.

3) Online Support Group.

A confidential online support group might be a possible solution, especially for interpreters who have few “local” resources, or when confidentiality would be compromised by using such resources.  Situations like a widely publicized event or involving well-known Deaf person(s), for example, might be better handled in a more anonymous setting online.  Each situation will dictate the best approach to take.

ITP Encouragement

Typically, Interpreter Training Programs don’t include much coursework on caring for one’s own psychological health (although this may be an area to consider for curriculum enhancement).  Seeking professional counseling from a generic therapist or psychiatrist is sometimes avoided because, “They don’t understand what I do as an interpreter, and I don’t want to waste expensive hours educating them.”  But even though a mental health professional isn’t an expert in Deafness or ASL, they are trained to deal with people who have had negative experiences, and they are usually well-equipped to offer strategies for recovery from such trauma.  ITPs would do well to encourage a commitment to one’s own health as a possible investment in burnout prevention.

Another way in which ITPs may assist is through offering advanced training to working interpreters, allowing them to learn from mental health professionals and other interpreters regarding situations such as those described here.  Better collaboration with professional communities can provide opportunities for all collaborators to learn from one another.

Mental Health Service Ineffective Through Interpreters

The incident described here with James is a classic example of an individual experiencing symptoms of a severe mental illness.  The fact that James is Deaf is really not the fundamental issue; James likely has a major mental illness separate from his Deafness.  This is an important distinction to make.  James was not subjected to anything unusual during the admissions process;  he was “treated” in much the same way as people with mental illnesses who can hear.  As he becomes stabilized on the unit and on his medication, he will probably benefit from interpreting services throughout the day.  But, as we know, it is unlikely that the hospital will provide such services as frequently as he needs them.  Because he will not be included in the daily interactions and communications on the unit (formal and informal), James will probably need to stay longer than most of the hearing patients on that unit.  Within a couple of weeks, however, James will likely be discharged to “somewhere” for community-based services.

Community mental health services cannot usually be delivered effectively through sign language interpreters, but in most communities, interpreter services are the only option. If mental health planners honestly asked interpreters, they would learn that sign language interpreters are wholly incapable of providing the same services to Deaf people as hearing people receive.  First and foremost, clinicians who are fluent in ASL are required to meet the needs of Deaf people with severe and persistent mental health issues.  Ideally, Deaf people who are in recovery from mental illnesses should be the primary service vehicle for other Deaf people.

In The End

As interpreters, we are part of some of the best, and some of the worst, times of Deaf people’s lives and, like it or not, we become part of those occurrences.  The impact that these events has on each of us can be personally and professionally profound.  Although we may tend to act as if we are immune from human feelings and reactions to things like child abuse, major disasters, addictions, marital disharmony, etc., it is vital that we take care of ourselves and our colleagues when asked.  We will not be of much value to our customers, our families, our partners, or ourselves if we ignore the fundamental humanity that makes us who we are and allows us to function as the consummate professionals we all wish to be.  It is hoped that this post will lead to a broader discussion of these issues, and to a solution that each interpreter can feel comfortable engaging.

 

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Improving Healthcare: Specialization for Sign Language Interpreters

Sign Language Interpreters Specialize to Improve Healthcare

Quality interpreting in healthcare is a growing need in our field. Author Richard Laurion makes the case for specialization while discussing current initiatives to grow competency among interpreters working in healthcare settings.

Healthcare affects us at every stage of life; not only are we consumers of the healthcare system from before birth until the end of our lives, but healthcare has become a large part of our national discourse and consumes more of our financial resources every day.  Another increasingly common piece of healthcare is interpreting—caused in part by, recommendations from The Joint Commission (Wilson-Stronks, 2008), rules in the Affordable Care Act (Tietalbaum, 2012) and an increasing number of lawsuits brought by the Deaf Community (12 in Minnesota alone in the last 10 years).  It seems the right time for sign language interpreters to increase our focus on healthcare and ensure our effectiveness in this important area of practice.

A Growing Need

Nathan Ellis, the director of the Deaf Immigrant Center for Education (DICE) in Minneapolis, shared that one in every three encounters at the massive Hennepin County Medical Center involves a spoken or sign language interpreter.   Another indicator of this growth locally is the recent hiring of multiple staff sign language interpreters at the six largest health systems in Minnesota.  There are reports of similar increases in requests for interpreters and expansion of interpreting pools in other large metropolitan communities.

In 2012, the National Interpreter Education Center (NIEC) surveyed sign language interpreters, who identified medical interpreting as one of the most common settings for freelance/contract interpreting services.   It was also rated as the second most common setting where practitioners most urgently need training.  In my work for the Collaborative for the Advancement of Teaching Interpreting Excellence (CATIE) Center and the National Consortium of Interpreter Education Centers (NCIEC), we have found nationally that it is common for freelance interpreters to interpret in clinics without any education, training or supervised experience in healthcare interpreting.  A comparison of two earlier studies found a slight, but growing, interest among sign language interpreters wanting to specialize in medical interpreting (Cokely, 2010).  Considering these increases in the demand for interpreters and the interpreting field’s growing interest along with widely admitted unpreparedness and training needs, how are we preparing ourselves, if at all, to do this life-impacting work?

An Important Starting Point

A key aspect of optimal healthcare is the relationship between doctor and patient.  While the importance of communication in doctor-patient interactions has been well documented (Frey, 2010), the complex work of healthcare interpreters has not.  It was only recently that efforts were made to categorize the body of knowledge sign language interpreters should master before interpreting in medical healthcare settings.  The CATIE Center-led investigation for NCIEC identified the following core competencies:

  • Health Care Systems
  • Multiculturalism and Diversity
  • Self-Care
  • Boundaries
  • Preparation
  • Ethical and Professional Decision Making
  • Language and Interpreting
  • Technology
  • Research
  • Leadership
  • Communication Advocacy
  • Professional Development (www.healthcareinterpreting.org, 2008)

This list of domains and competencies is an excellent resource for beginning our development and focus in healthcare interpreting.  In addition to the list above, there are other strategies interpreters may consider for professional development and building competence.

Reflective Practice

The tendency to go into much of our work with “insufficient skills sets” was discussed by Anna Witter-Merithew in her article, Sign Language Interpreters: Breaking Down Silos Through Reflective Practice.  This concept agrees with what the NCIEC identified and interpreters report themselves (NIEC 2013).  Despite having identified a body of knowledge and skills outlined in the Medical Interpreting Domains and Competencies, individuals are largely taking on these specializations without additional preparation or supervision, perpetuating the professional isolation discussed in Witter-Merithew’s article.  We need to consciously move from this condition of isolation into a process of reflective practice, or as Witter-Merithew described, “examining critical incidents that occur within our work to gain a deeper understanding of what they mean for what we do.” She also provided a concrete list for how to actively reflect on interpreting work and decisions.  As I considered this, it struck me that I had seen concrete applications of reflective practice put into action by my colleagues in healthcare interpreting.

Improving Practice with Colleagues

In Minnesota, we take pride in our innovation and excellence in healthcare, and being home to many healthcare industry leaders.  I see this similar pride shared across the Midwest among sign language interpreters working in healthcare.  Three local groups provide excellent examples for reflective practice and use of case conferencing:

  • Medical Interpreters Consortium (MedIC) of the Twin Cities, consisting of staff interpreters working for five local health systems.  They represent a variety of perspectives from primary, secondary and tertiary care.  The focus of their discussions is on the perspectives they bring as interpreters functioning as employees in major health systems, and the various and complex ways their roles differ from those of contract interpreters. They use case scenarios to illustrate issues working within the system as a staff person and how this needs to be different for contractors not directly employed by the system.
  • Minnesota Hospital Consortium (MHC), a group of community interpreters who contract as part of a unified system established for the sole purpose of providing interpreting services 24 hours a day for urgent and emergency care needs at 21 hospitals and 8 urgent care centers across the Twin Cities metropolitan area.  MHC represents many of the same health systems as MedIC. The interpreters’ role and subsequent group discussions are uniquely focused on issues leading to improvements in their response to urgent and emergency care needs for the facilities, staff and patients.  They introduce specific scenarios to illustrate issues of concern or situations needing attention.  Through their sharing they have identified systematic problems and gaps in communication access.
  • Case Study Mentors, consisting of members in and outside of Minnesota. This is a pilot project sponsored through the CATIE Center that includes staff and contract interpreters from several midwestern communities.  The group’s focus is on using reflective practices and case studies as learning tools when working with healthcare interpreting colleagues.  The mentors meet monthly (via the Internet) with a facilitator, define a case study and then individually meet with their local group of healthcare interpreters to work through the scenario.

Each of these groups has found it effective to use case studies and conferencing as a means for reflective practice.  Each group has formed around a sole focus and perspective for their discussions.  They use strategies for neutralizing the content and “sorting out the important details and a reason for bringing it into discussion,” as suggested in Kendra Keller’s Street Leverage post, Case Discussion: Sign Language Interpreters Contain Their Inner “What the…!!!?  They have identified how to challenge each other and respectfully examine the decisions they choose. These sign language interpreters choose to further their competence and practice in medical healthcare through reflective discussion.

Engaging Deaf Experts

One doesn’t need a formal group to do this reflective work with colleagues.  In Minnesota, we are also fortunate to have Deaf Community Health Workers (CHW). The certified CHWs, which are also found in other communities such as the Hmong and Somali, are trained to function as cultural bridges to the complex healthcare and government systems patients encounter.  Several Deaf CHWs have made themselves available to interpreters to discuss difficult cases, complex medical treatments and linguistic choices as they pertain to healthcare.

Another ally is the Association of Medical Professionals with Hearing Loss (AMPHL).  This past spring the AMPHL conference made a special effort to host a professional development track for sign language interpreters.  I was able to attend and found Deaf medical professionals excited and eager to work with me as an interpreter specializing in healthcare.

Supporting Quality Care

The demand for skilled healthcare interpreters is growing.  Those of us working regularly as healthcare interpreters are keenly aware, despite the lack of in-depth documentation in the field, of the depth of knowledge and skills required to do this work well.

As mentioned, my colleagues are continuing to develop themselves and build their specialization as healthcare interpreters.  As a field, healthcare interpreting should continue along the path toward specialization.  We should even consider further defining specialization in medical healthcare, mental healthcare, and addiction and recovery.

More Work Ahead

Yet, unlike legal and educational interpreting, there is no certification or credential for healthcare interpreting among sign language interpreters. I have introduced a motion for the 2013 RID conference next month requesting that RID investigate the need for a specialty certificate in healthcare interpreting.  This effort will only help to advance the important conversations we need about how we build interpreting practices in healthcare that are reflective and based on the delivery of quality care and practice.

For example, there has been a dramatic increase in healthcare as an area of specialized practice for spoken language interpreting.  In the past few years, two national organizations for the medical certification of spoken language interpreters have emerged.  Texas has developed such an interest in this certification that the state is currently working on a statewide medical certification for all interpreting language pairs—signed and spoken.  Yet, as an organization, RID has not yet made this commitment.  A small step has begun with the creation of the first members section for interpreters in healthcare, but as a field we are still struggling to focus on the work sign language interpreters do in healthcare and on providing the support, research, and training this important work requires.

Specialized Practice

In healthcare settings, we are often the only professionals who have not completed a standardized, accredited program recognized by the healthcare field.  As we continue to develop and to take our place as greater and active members of the healthcare team, we will need to consider what our model of practice might look like.  What behaviors must we demonstrate that indicate to the nurses, technicians and doctors that we are their colleagues, not friends or the patient’s family members? As professional colleagues, what are our obligations to these medical team members? How are we focusing on supporting the best health outcomes for the patient?

Systematically discussing questions like those above are only part of the bigger picture of developing standards of practice and quality care.  I believe the time has come to build a specialized practice of interpreters in healthcare.  We need to advocate that healthcare interpreters, Deaf or hearing, should have the education and supervised work experience to support full access to effective communication in healthcare settings for Deaf and DeafBlind people.  Communication is an important part of the doctor – patient relationship (Frey, 2012), when needed sign language interpreters should be an important part too.

 

References:

Cokely, D., & Winston, B. (2010). Interpreter practitioner needs assessment, trend analysis final report.

Frey, J., (2010, March). Relationships count for doctors and patients alike. Annals of Family, 8(2), 98–99.

National Interpreter Education Center. (2013). Interpreter practitioner, national needs assessment 2012, final report. 

Teitelbaum, J., Cartwright-Smith, L., & Rosenbaum, S. (2012). Translating rights into access: Language access and the affordable care act.  American Journal of Law & Medicine 348.

Wilson-Stronks, A., Lee, K. K., Cordero, C. L., Kopp, A. L., & Galvez, E. (2008). One size does not fit all: Meeting the health care needs of diverse populations. Oakbrook Terrace, IL: The Joint Commission.