Course # 91282 • Using Interpreters in Health and Mental Health Settings


Study Points

  1. Identify demographic trends that speak to the multicultural diversity in the United States.
  2. Explain the legal context of using interpreters.
  3. Identify the merits and limitations of the different perspectives of interpreting.
  4. Assess the advantages and disadvantages of the different interpreter models used in organizations and barriers to using professional interpreters.
  5. Describe the challenges in the interpreting process.
  6. Discuss best practices for building a positive and collaborative relationship between interpreters and practitioners.
  7. Explain ethical issues for practitioners when working with patients not proficient in English and when working with interpreters.
  8. Describe ethical principles for interpreters.

    1 . Of Americans who do not speak English at home, what is the predominant language spoken?
    A) French
    B) Tagalog
    C) Spanish
    D) Chinese

    DEMOGRAPHIC TRENDS IN THE UNITED STATES

    As noted, English language proficiency is a barrier for many racial and ethnic minorities, particularly those who have recently immigrated to the United States. In 2016, it is estimated that more than 30% of undocumented adult immigrants self-identified as being proficient in English (meaning they predominately spoke English at home or rated themselves as speaking English very well) [6]. The most recent data indicate that 40 million residents in the United States speak Spanish (the most common non-English language) at home, a 133.4% increase when compared with 1990 [75]. In 2017, almost half (48.2%) of all United States residents in five major cities (New York, Los Angeles, Houston, Chicago, and Phoenix) spoke a language other than English at home [77]. Between 2010 and 2018, the number of Spanish speakers in the United States increased by 4 million and the number of Chinese speakers increased by 653,000. Languages with the greatest percentage increase were Telugu (an Indian language) (86%), Arabic (42%), and Hindi (42%) [77]. Overall, the U.S. Census estimates that there are 350 languages other than English spoken at homes in the United States [79].

    Click to Review



    2 . Which state has the highest percentage of population who speaks a language other than English?
    A) Texas
    B) Vermont
    C) New York
    D) California

    DEMOGRAPHIC TRENDS IN THE UNITED STATES

    Language varies geographically as well. The states with the greatest percentage of population who speak a language other than English are [77]:

    • California: 44%

    • New Mexico: 33%

    • Texas: 36%

    • New Jersey: 32%

    • New York: 31%

    • Nevada: 31%

    • Florida: 30%

    Click to Review



    3 . What was the goal of Title VI of the Civil Rights Act of 1964?
    A) To promote women's rights
    B) To protect the rights of business owners
    C) To protect the rights of gays and lesbians
    D) To guarantee that federally funded programs do not reinforce discrimination based on national origins and English proficiency

    LEGAL CONTEXT: LANGUAGE ACCESS

    As is clear, discrimination is prohibited based on national origin, and the Act was created in part to ensure that federal funds were not used to support and perpetuate discriminatory activities in government-funded programs [8]. This section has been interpreted to include individuals who cannot be denied federally funded medical, social, educational, mental health, or legal services based on their limited English proficiency [9]. In this situation, discrimination based on language is considered the same as discrimination based on national origin [8].

    Click to Review



    4 . How was Executive Order 13166 revised in 2003?
    A) It added an addendum focusing on immigrant children.
    B) It indicated a type of continuing education that must be offered to health and mental health providers.
    C) It specified that states' programs must not reflect (in the number and intensity of language services offered) the demographics of the state.
    D) It specified the proportion of contact with a specific language group and the proportion of interpreting and language services offered by an organization.

    LEGAL CONTEXT: LANGUAGE ACCESS

    In 2003, this Executive Order was upheld by the Bush administration, but the policy was revised in four areas [8]. The first involves the number of language services offered, which is based on the number of limited-English-proficiency patients served. The second area deals with the frequency of contact with a specific language group. An organization, for example, that has more contact with a patient group speaking a particular language must have more interpreting and language services. The third area deals with the nature of and importance of the service provided. In other words, the more important a service offered, the more language services are needed by that organization. The last area touches on cost and resources of the organization. An organization receiving less federal funds and with a smaller budget is not expected to provide the same level of language services as an organization with a larger budget [8]. As of 2013, organizations that are federally funded must have a clear written policy on language accessibility [11].

    Click to Review



    5 . What is a disadvantage of word-for-word interpreting?
    A) It is prone to a high error rate.
    B) It is a challenge to locate interpreters who specialize in word-for-word interpreting.
    C) It can be difficult to translate idioms, terms, and/or jargon because losing subtle cultural nuances.
    D) Word-for-word interpreting is not used often, and this skill is not being employed by many interpreters.

    AN OVERVIEW OF INTERPRETATION

    In word-for-word interpretation, the interpreter provides a verbatim rendering of the communication into the target language. Word-for-word interpreting can be beneficial when one party is giving factual and technical information to the other party [19]. However, this mode of interpreting can be difficult because words in one language frequently cannot be easily translated into another language without losing subtle cultural nuances [19].

    Click to Review



    6 . Which type of interpreting is like having a voiceover?
    A) Proximate interpreting
    B) Consecutive interpreting
    C) Simultaneous interpreting
    D) None of the above

    AN OVERVIEW OF INTERPRETATION

    When using simultaneous interpretation, the interpreter communicates the targeted language while the speaker has moved on to the next sentence, which requires the interpreter to simultaneously listen to the next sentence while interpreting the last sentence [20]. Simultaneous interpreting is almost like a voiceover, with nearly verbatim interpreting done immediately after the speaker has completed his/her thoughts. This is a complex process because the interpreter must simultaneously actively listen, process, and then interpret into the targeted language with minimal delay [82]. Some argue that this form of interpreting can be distracting [78]. In addition, simultaneous interpreting can be more stressful for interpreters, which can lead to more errors [21]. However, simultaneous interpreting can be useful in a situation in which not all parties require interpretation. In group work, the interpreter can softly interpret the speaker for one individual in the group without disrupting the process [22].

    Click to Review



    7 . If a hospital enlists a telephone interpreting service, what type of interpreting is being done?
    A) Remote interpreting
    B) Proximate interpreting
    C) Culture-relevant interpreting
    D) Process of simultaneous translating

    AN OVERVIEW OF INTERPRETATION

    Interpretation can also be categorized by setting and proximity of the involved parties. If interpretation is done with all persons in the same room or setting, this is called proximate interpreting [23]. However, if it is not conducted in the same setting and/or the interpreter is linked in through some sort of telecommunication system, this is referred to as remote interpreting.

    Click to Review



    8 . What is a limitation of using family members as interpreters?
    A) Client confidentiality is compromised.
    B) They may have a competing agenda in the clinical process.
    C) They may screen out sensitive or embarrassing information.
    D) All of the above

    ORGANIZATIONAL MODELS OF INTERPRETER USE

    However, employing a patient's family member as an interpreter also has its disadvantages and unique challenges regarding boundaries and role confusion. Family members may feel embarrassed or uncomfortable in having to convey potentially intimate and private information [36]. Consequently, they may unconsciously or consciously screen out or summarize information, to the point that they alter the original content or intent [34,36,86,104]. For example, the family member may exaggerate symptoms in order to advocate obtaining a particular procedure or intervention [105]. In a study with 28 caregiving relatives, participants reported selectively interpreting information for the patient based on a personal assessment of the patient's emotional status [88]. This method of interpretation does not promote the patient's confidentiality and privacy, and the interpreter is not bound to uphold confidentiality [35,37]. Family members may decide to limit information provided to the patient due to family loyalties and/or power dynamics [38]. Because family members are so close to the patient's situation, they may include their own views and opinions in the interpretation [39]. If the family member acting as interpreter has his/her own agenda, there may be three competing agendas in the clinical process—the practitioner's, the patient's, and the family member interpreter's—which can be time-consuming and render the communication process more complex [34,105]. Family members or friends are also limited in their knowledge of medical, psychiatric, or other clinical terms compared to professional interpreters.

    Click to Review



    9 . When an agency uses an untrained staff member, such as a receptionist, as an interpreter, what type of organizational interpreting model are they employing?
    A) Ad hoc
    B) Proximate
    C) Consecutive
    D) Patchwork approach

    ORGANIZATIONAL MODELS OF INTERPRETER USE

    Using the approximate (ad hoc) interpreting model, staff persons (e.g., receptionist, in-take worker) may also step in as interpreters. The advantage to this approach is that the interpreters are familiar with the agency and setting [90]. However, one of the problems with using staff who happen to be able to speak the patient's language is that it interrupts the workflow [41,90]. Consistently eliciting interpreting assistance from staff persons who are not hired to do so can cause additional stress (because they are not professionally trained) and can trigger anger and resentment over time, affecting staff morale [41,42,43]. In a case study of a community health center that was training and utilizing staff members to do interpreting, these ad-hoc interpreters reported high levels of work pressure [44]. One of the main reasons was because interpreting was not their sole job responsibility; they were also doing their other tasks.

    Click to Review



    10 . Which of the following is NOT a barrier to practitioners using professionally trained interpreters?
    A) Cost
    B) Availability
    C) Practitioners choosing to "get by"
    D) Concern about lack of alignment between the interpreter's philosophy and agency's mission and values

    BARRIERS TO USING PROFESSIONAL INTERPRETERS

    Healthcare professionals' perceptions regarding the value and necessity of professional interpretation affect its utilization. In a qualitative study with 20 resident physicians in two urban hospitals with good interpreter services, researchers explored the physicians' decision-making process when determining whether to use interpreter services [51]. They found that the resident physicians knew they were not optimally using the interpreter services, but they felt that they could "get by" using hand gestures, limited second language skills, and information already communicated in the histories by other healthcare providers. The physicians tended to make interpretation decisions primarily considering the amount of time and effort necessary to obtain an interpreter and the overall perceived value. Most often, they did not feel it was a worthwhile time investment. The study participants reported feeling it was easier to use a family member or their own second language skills (even if limited), as this required minimal time and effort. Despite understanding that patients with limited English proficiency receive less adequate care compared to those who speak English well, underutilizing professional interpreters was considered the norm.

    The theme of "getting by" without interpreter assistance also surfaced in a qualitative study with nurses. Although the nurses in the study expressed frustration with using family members as interpreters, they were not proactive in obtaining professional interpreters. They tended to "make do" with the easiest available option (an ad-hoc interpreter) in order to avoid additional costs and increased workload [52]. Macro or structural barriers were noted, but individual-related factors also impeded practitioners from using interpreters.

    It has become evident that practitioners are underutilizing professionally trained interpreters despite clear benefits to patients and the quality of care. Identifying and addressing barriers to the use of professional interpreters are the first steps in improving care for non-English-proficient patients. Some such barriers include lack of resources, diversity of the patient population, and ambivalence.

    Many agencies' and organizations' budgets do not allow for either professionally trained interpreters on staff or easy access to remote professional interpreter services. In a 2010 survey of physicians, participants cited cost as a leading barrier in the use of interpretation services [50]. Demographics and practice type may also be factors, as 62% of the physicians had small or solo practices. Time constraints have also been noted as a significant barrier to the use of professional interpreters, with the act referred to as a "luxury" or "interruption" [90]. In a 2016 survey study, more than 30% of participants indicated that they resorted to using an ad-hoc interpreter due to the wait time for trained interpreters [111]. Similarly, providers cited the urgency of a situation and/or a busy workload as motivators for ad-hoc interpreter use [112].

    Click to Review



    11 . What competencies should a professional interpreter have?
    A) Interviewing, high accuracy rate in diagnosing, and ability to collaborate
    B) Proficiency in Word processing, cultural competency, and ability to conduct interviews
    C) Familiarity with the field in which they are interpreting, interviewing, and cultural backgrounds
    D) Familiarity with different interpreting methods, good language skills, and ability to use software programs

    OVERVIEW OF CHALLENGES AND UNIQUE DYNAMICS INVOLVED IN USING INTERPRETERS

    However, even if not certified, there are basic competencies that all interpreters should possess. Professionally trained interpreters should be skilled and competent in six main areas: the field in which they are interpreting, communication and interpersonal skills, content interpretation, interviewing, cultural background(s), and the expectations of the employing organization. Interpreters who limit their practice to a specific content area should have knowledge of specific technical terms and how to facilitate the flow of communication [115].

    Click to Review



    12 . A parent reports spanking and hitting her child with a belt multiple times during the day in order to teach the boy a lesson. The interpreter tells the social worker that the family has spanked the child on a few occasions, a few slight spanks on the child's bottom. What type of interpreting error is this?
    A) Addition
    B) Minimizing
    C) Delayed diagnosis
    D) Error in not confronting the family

    OVERVIEW OF CHALLENGES AND UNIQUE DYNAMICS INVOLVED IN USING INTERPRETERS

    Studies indicate that untrained interpreters have inaccuracies 23% to 52% of the time [35]. In a study conducted by Flores, even trained interpreters, in this case Spanish interpreters in a pediatric emergency department, made an average of 31 errors per clinical encounter [58]. An estimated 63% of these errors subsequently affected diagnosis and treatment. The error rates are highest when dealing with untrained interpreters compared to full-time hospital interpreters (77% vs. 53%) [59]. In a 2018 study, some providers relayed feeling that interpreters were not attentive listeners or skipped words [116]. For example, an open-ended question might be translated to a closed-ended question [114]. According to Luk, there are three common errors made during the interpreting process: omission, addition, and inaccuracy [19]. With omission of or minimizing information, content is purposely or inadvertently deleted or skipped. In some cases, this is unconscious, but in others, it is intentional in order to save time, minimize perceived embarrassment, or eliminate information that is perceived to be irrelevant or unimportant. In a 2017 study examining transcripts of interpreted health consultations, 25% of healthcare providers' affective utterances (i.e., words that give emotional expression) and 21.5% of all instrumental utterances (i.e., explicit, directive, or factual information) were actually interpreted [117]. Another study found that about 20% of patients' emotional and informational cues were interpreted [118]. Interpreters may minimize issues such as child abuse, family violence, or sexual dysfunction because they want to "protect" the patient, but this can result in delays in diagnosis, missed services, and improper care [60].

    Click to Review



    13 . Which of the following is NOT a term used interchangeably with vicarious traumatization?
    A) Existential fatigue
    B) Compassion fatigue
    C) Secondary victimization
    D) Secondary traumatization

    OVERVIEW OF CHALLENGES AND UNIQUE DYNAMICS INVOLVED IN USING INTERPRETERS

    Because some interpreters work with patients who have experienced trauma, victimization, and/or abuse, it is possible that interpreters may experience secondary traumatization, secondary victimization, vicarious traumatization, or compassion fatigue. These terms all refer to the psychologic trauma experienced by those in close contact with trauma victims [61]. Secondary traumatic stress is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" [61]. Secondary trauma can affect practitioners' beliefs about the world, others, and self, including concepts of safety, trust, control, and intimacy [62]. It has been argued that trauma caused by another person (e.g., abuse) may be more difficult for practitioners to deal with because it brings up the issue of human evilness. This may affect existing beliefs and ideals more than trauma caused by natural events (e.g., natural disasters) [62]. Seven psychologic areas are negatively affected by trauma or secondary trauma [63]:

    • Frame of reference: one's perspective for understanding the world and one's experiences

    • Trust: the need to depend on others and their ability to care

    • Esteem: the need to be validated by others

    • Safety: the need to feel secure

    • Independence: the need to feel in control of one's life and choices

    • Power: the need to exert control over others

    • Intimacy: the need to feel connected to others

    Click to Review



    14 . Secondary trauma can affect interpreters'
    A) code of ethics.
    B) sense of safety.
    C) boundaries with family members.
    D) All of the above

    OVERVIEW OF CHALLENGES AND UNIQUE DYNAMICS INVOLVED IN USING INTERPRETERS

    Because some interpreters work with patients who have experienced trauma, victimization, and/or abuse, it is possible that interpreters may experience secondary traumatization, secondary victimization, vicarious traumatization, or compassion fatigue. These terms all refer to the psychologic trauma experienced by those in close contact with trauma victims [61]. Secondary traumatic stress is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" [61]. Secondary trauma can affect practitioners' beliefs about the world, others, and self, including concepts of safety, trust, control, and intimacy [62]. It has been argued that trauma caused by another person (e.g., abuse) may be more difficult for practitioners to deal with because it brings up the issue of human evilness. This may affect existing beliefs and ideals more than trauma caused by natural events (e.g., natural disasters) [62]. Seven psychologic areas are negatively affected by trauma or secondary trauma [63]:

    • Frame of reference: one's perspective for understanding the world and one's experiences

    • Trust: the need to depend on others and their ability to care

    • Esteem: the need to be validated by others

    • Safety: the need to feel secure

    • Independence: the need to feel in control of one's life and choices

    • Power: the need to exert control over others

    • Intimacy: the need to feel connected to others

    Click to Review



    15 . When using an interpreter, seating arrangements should be taken into account because
    A) it conveys power relationships, it can affect eye contact, and it influences the model of interpreting an organization uses.
    B) it communicates which party is the center of focus, it conveys power relationships, and it affects how rapport is developed.
    C) it affects vicarious traumatization, it communicates which party is the center of focus, and it can impede maintaining eye contact.
    D) None of the above, as seating arrangements do not affect the clinical encounter.

    BEST PRACTICE GUIDELINES FOR PRACTITIONERS WORKING WITH INTERPRETERS

    Consider seating arrangements prior to the session. Seating arrangements can implicitly convey power and position between the practitioner and interpreter and affect the ability to establish rapport [68]. Should the interpreter be seated a bit off to the side? Or should the patient and interpreter sit side-by-side facing the practitioner? The practitioner and the interpreter should determine which arrangement is most conducive for the clinical encounter; there are no definitive rules. If the interpreter sits beside but slightly behind the patient, he or she may not catch all of the nonverbal cues. However, this type of arrangement conveys the message that the practitioner-patient relationship is the center of focus [9,124]. A triangular seating arrangement, whereby every party can maintain eye contact, may be necessary and is most recommended [124]. With this approach, the practitioner and patient can look at each other directly and the interpreter is then perceived as being objective and neutral [39,68]. In a 2015 study, the interpreters conveyed the importance of the sitting position in order to promote eye contact to facilitate trust with the patient and the practitioner [84]. Triangular seating implies that the patient is the focal point and conveys equality of all parties [9,125].

    Click to Review



    16 . What may be a disadvantage to using first person when interpreting?
    A) It renders more errors.
    B) It can increase interpreter burnout.
    C) It may be emotionally distressing for the patient.
    D) It becomes confusing to determine to whom the interpreter is referring.

    BEST PRACTICE GUIDELINES FOR PRACTITIONERS WORKING WITH INTERPRETERS

    Before beginning a session, the interpreter must decide whether to use first or third person. Some argue for the use of first person, because this allows for more accurate (literal) translation of words and emotions being conveyed [37]. However, others have differed. Using first person may be distressing for some patients if it is too personal [57]. In some languages, verb conjugation depends on the gender of the subject of the sentence, which can be confused in interpretation [78]. Consequently, it is crucial that the practitioner and interpreter discuss the merits and limitations of using first or third person prior to meeting with the patient.

    Click to Review



    17 . What is a potential dynamic of a shared common community tie between the patient and interpreter?
    A) The practitioner will not feel left out.
    B) The patient may form a deep connection with the interpreter.
    C) The patient may feel threatened that any information discussed will not be kept confidential.
    D) Both B and C

    BEST PRACTICE GUIDELINES FOR PRACTITIONERS WORKING WITH INTERPRETERS

    When possible, the gender of the patient and the interpreter should be matched. There are often cultural norms regarding gender roles, and some patients will feel uncomfortable disclosing embarrassing or sensitive information to an interpreter of the opposite sex [41]. It is also important to take into account any spiritual, sociopolitical, and regional nuances between the ethnicity of the patient and the interpreter [85]. Careful consideration to whether it is prudent to have an interpreter from the same community as the patient is necessary. A shared community experience could promote rapport, or it could make the patient feel that his/her confidentiality and privacy are compromised. However, it is important not to assume that a same or similar racial/ethnic background equates to shared cultural experiences [85].

    Click to Review



    18 . When interpreters work with children and their families, what additional skills are needed?
    A) Knowledge of child development, perspectives about the role of interpreters for children, and play therapy
    B) Knowledge of the impact of cultural norms on children and families, child development, and verbal and nonverbal cues of children
    C) Skills in play therapy, understanding of how having four parties involved in the clinical encounter affects the dynamics, and cultural norms about the role of children and families
    D) Understanding children's moral development, parental disciplining techniques, and an understanding of how having four parties involved in the clinical encounter affects the dynamics

    BEST PRACTICE GUIDELINES FOR PRACTITIONERS WORKING WITH INTERPRETERS

    It is important to recognize that every subpopulation has different needs, and interpreters working with children require a different set of competencies. Skills necessary for interpreters working with children and their families include [60]:

    • Knowledge of child development

    • Understanding of verbal and nonverbal cues of children

    • Knowledge of the impact of cultural values and belief systems on families and children's roles

    • Ability to navigate the complex dynamics of having four parties involved—the practitioner, interpreter, family member, and child

    Click to Review



    19 . What is the main difference between first-order and second-order autonomy?
    A) First-order autonomy is beneficence, while second-order autonomy involves confidentiality.
    B) First-order autonomy emphasizes individualism, while second-order autonomy focuses on the collective.
    C) First-order autonomy is what practitioners and interpreters should always strive towards and dismiss second-order autonomy.
    D) First-order autonomy always involves the family, while second-order autonomy takes into account what the provider thinks is best for the patient.

    ETHICAL ISSUES

    Autonomy, individualism, and self-determination are highly important in Western societies, especially in the United States. But autonomy may be organized into two categories: first-order and second-order [72]. First-order autonomy refers to self-determination and autonomy in decision making, and this is the concept valued in Western medicine. Second-order autonomy is prevalent in collectivistic societies in which decision making is group-oriented. In these cultures, another decision maker is accorded authority and respect, and it may be necessary to involve this designated decision maker in the process. He or she may also need interpreting services. Four parties are then involved, which obviously has a higher risk of complicating the communication process, and enough time should be allotted for everyone involved. If being used, a copy of the consent form should be given to the interpreter so he/she can familiarize him/herself with it before the clinical encounter.

    Click to Review



    20 . Ethically, interpreters are required to
    A) maintain confidentiality.
    B) maintain impartiality and objectivity.
    C) promote the patient's welfare and dignity.
    D) All of the above

    ETHICAL ISSUES

    Interpreters are bound to a code of professional conduct and ethical principles as well. Similar to the codes of ethics that practitioners operate under, interpreters have a responsibility to maintain confidentiality, accuracy (in order to promote beneficence), and impartiality and objectivity. They are also required to promote the patient's welfare and dignity [74]. A sense of self-awareness is extremely crucial when it comes to professional conduct and ethics. Interpreters should be continually cognizant of their role and the limitations of the process of interpreting [67]. The National Council on Interpreting in Health Care Code of Ethics may be accessed online at https://www.ncihc.org/ethics-and-standards-of-practice.

    Click to Review