Consider this scenario: You’ve been asked to provide cognitive behavioral therapy for anxiety to an 11-year-old whose mother uses American Sign Language (ASL) to communicate. You can sign the alphabet, but you’re having trouble communicating with the mother about her daughter’s progress in therapy. Can you ask the mother to bring her sister to treatment sessions to act as an interpreter?
Or this case: A woman who recently emigrated from Vietnam and speaks little English seeks your help for depression. You don’t speak Vietnamese and the idea of finding, arranging for and paying an interpreter seems challenging. Should you tell her you’re not able to help?
Such questions are more common than ever as the U.S. population becomes increasingly diverse and more people seek out psychotherapy, neuropsychology assessments and other psychological services. Legally, psychologists have an obligation to provide effective auxiliary aids and services to deaf and hard of hearing patients or their family members. They must also provide free language access services to limited English proficient patients if they receive Medicare, Medicaid or reimbursement from federal health programs. But even psychologists who are not required to provide free interpretation services say their patients reap great benefits from the use of an interpreter.
“A trained interpreter will help with not just the interpretation, but will also help the examiner understand mannerisms, cultural practices, expectations, slang and body language,” says Adriana M. Strutt, PhD, director of BCM Cerebro, a Spanish outpatient neuropsychology service at Baylor College of Medicine. “There is a health disparity in psychology and neuropsychology, and providing interpreter services is only the first step toward providing equitable care.”
How do you find a trained interpreter? Here’s some advice to help sort out your options and responsibilities.
Understand the services available. Today’s health-care providers can choose from several types of interpreter services: on-site, over-the-phone and video remote interpreting. Each modality comes with pros and cons, so practitioners should evaluate them based on their own needs and the needs of their patients, says Maggie Butler, PhD, director of APA’s Office on Disability Issues in Psychology. For example, on-site interpreters can be a wonderful option, but they can also be more expensive for practitioners since they may charge for travel time and parking expenses in addition to interpretation services.
And, depending on the location of the provider and patient, it may not always be feasible to find a qualified interpreter in your area. “What if you have a patient who speaks Farsi in Mississippi?” points out Antonio E. Puente, PhD, a bilingual clinical neuropsychologist and pastpresident of APA. “How many Farsi-speaking interpreters are there in Mississippi?”
In such cases, you may be better off using over-the-phone or video remote interpreting, offered through companies such as LanguageLine Solutionsopens in new window, InDemand Interpretingopens in new window and others. This can be a less expensive option than a face-to-face interpreter, but it can also come with technological challenges. For example, a poor video connection or a weak Wi-Fi signal can be worse than no connection at all. Further, it can be easy to miss nonverbal cues from patients, experts say.
Know your state laws regarding interpreters. Federal regulations and guidance do not require interpreters to be licensed or certified. However, some states do require the use of certified interpreters. Two national organizations in the United States provide formal certification of medical interpreters: the National Board of Certification for Medical Interpretersopens in new window and the Certification Commission for Healthcare Interpretersopens in new window. Whenever possible, clinicians and health systems should seek to use the services of interpreters who are certified by these organizations—but even these interpreters often have limited training in mental health issues, experts advise.
Know where to find an interpreter. Some institutions already have a contract with a language access company such as LanguageLine Solutions or InDemand Interpreting, so practitioners should consider using an interpreter through their organization’s already vetted resource. Freelance interpreters can also be found through the Registry of Interpreters for the Deafopens in new window and the American Translators Association (ATA). To search for an interpreter by language and specialty, go to the ATA directory of interpreters and translatorsopens in new window.
Hire a proven interpreter. Be sure any interpreter you work with has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages, has the training and experience to interpret with skill and accuracy, and adheres to the National Code of Ethics and Standards of Practice of the National Council on Interpreting in Health Care.
It’s also important for practitioners to find someone who has experience or training in interpreting for a psychologist or neuropsychologist, says Strutt. “Patients can cry, become upset or unsure of what is happening as a result of cognitive issues, so we always take time to meet with the interpreter before the testing session begins to gauge their level of knowledge around psychological issues, as well as their comfort level with handling emotional reactions,” she says. To get a sense for an interpreter’s skill in this area, find out about their previous experiences and ask directly during screening interviews, Strutt recommends.
Be mindful of patient privacy protections. Keep in mind that the interpreter is a third party who will have access to the patient’s private, confidential information. This has patient privacy protection implications under both state and federal law. In most states, for example, you will need to obtain the patient’s consent prior to bringing the interpreter into a therapy session or testing assessment. In addition, psychologists who are subject to HIPAA will have to sign a business associate agreement (BAA) with the interpreter, unless the interpreter works for the practice, for example, as a bilingual employee, a contract interpreter on staff or a volunteer, or is a patient’s family member, friend or another person identified by the patient as his or her interpreter. The BAA is a written contract that specifies the interpreter’s responsibilities to appropriately safeguard the patient’s confidential information.
Discuss the ground rules. It’s also important to go over your expectations with an interpreter, emphasizing the importance of translating only what the provider says—and all of what the patient shares. In particular, interpreters need to be primed not to smooth over incoherence or discontinuity in speech, or to assist patients with better understanding cognitive tasks when it comes to assessments.
“The most important thing, regardless of whether it’s sign language or a different spoken language, is to make sure interpreters understand that by helping clients who may be cognitively impaired, they may be increasing the possibility of a misdiagnosis and negatively impacting the course of treatment,” Strutt says.
Psychologists should frequently debrief with interpreters after patient sessions to ensure they agree on what the patient said–verbally and nonverbally.
Know your limits. Even if you have some background in ASL or the language your patient speaks, don’t assume you will be fine without a qualified interpreter. “Practitioners must complete a formal program to demonstrate they have mastered the language,” Butler says. One of the most popular programs is a 40-hour course entitled Bridging the Gapopens in new window. “Simply taking a class or two in a given language isn’t going to cut it, and you’ll end up working outside your scope of practice.”
Don’t rely on family. While using a patient’s family member or close friend to help interpret can often be an appealing—and less expensive—option, it comes with many downsides, Puente says. “Not only are they not certified or trained as an interpreter, but using a family member also introduces all kinds of biases,” he says. It can also push the boundaries of confidentiality and cause the patient to not share as much as they should with the therapist—because of the family member’s presence.
Using nonprofessionals may also be against the law in some cases: Several states, including California and New York, have forbidden the use of children as interpreters in health care.
Take the time to debrief. After each therapy or testing session, compare notes with the interpreter. Some things can get lost in translation, so working together to go over test scoring or discussing details of a story a patient shared can ensure everyone is on the same page.
“Often the interpreter is writing things down in the patient’s native language and will leave out nuances or small chunks of information when they relay it back to me in the session,” Strutt says. These small details can make a significant difference when you are assessing a patient’s cognitive ability or progress in therapy, she notes.
Also keep in mind that interpreters may have experienced traumatic events similar to those reported by patients and may have their emotions triggered when hearing patients’ experiences. Debriefing with the psychologist afterward can help, and it also allows the psychologist to ensure the interpreter has a support system available.
Get patient feedback. Clinicians can become so dependent on an interpreter that they may not be gauging the nuances that are being communicated, says Danielle Previ, PhD, a deaf clinical psychologist who provides neuropsychological assessments at Baltimore’s Kennedy Krieger Institute. That’s why it’s important to make sure your patient fully understands what’s being communicated during their sessions by frequently asking them for feedback on the interpreter through written evaluations in their native language.
It’s also important to realize that patients may not know that they have the right to complain about an interpreter, who may inadvertently cross boundaries by chatting too personally or using an inappropriate signing style, for example.
“Providing them with a survey to complete asking about the therapy process and specifically their experience will help identify if adjustments are needed for interpreting services,” Butler says.
