MENTAL HEALTH INTERPRETING:
UNIQUE CHALLENGES AND PRACTICAL SOLUTIONS
Arianna M. Aguilar
Latino Outreach Consulting of NC, Inc.
Abstract: Mental Health Interpreting is an important subset of study, since the issues encountered intersect with both medical and legal interpreting theory, practice and Code of Ethics. It involves complex and intimate interpersonal communication with individuals who may act, speak or think in unusual ways, and there are laws that may require the interpreter to break confidentiality or intervene. This paper seeks to educate interpreters about these issues and offer practical solutions and best-practices to balance professionalism with quality care and patient safety.
I. IMPORTANCE OF STUDYING MENTAL HEALTH INTERPRETING
Mental Health Interpreting is an important subset of study, since the issues encountered intersect with both medical and legal interpreting theory, practice and Code of Ethics. It involves complex and intimate interpersonal communication with individuals who may act, speak or think in unusual ways, and there are laws that may require the interpreter to break confidentiality or intervene.
Surprisingly enough, mental health interpreting issues have not been properly studied or researched, and is scarcely mentioned in even the most prominent medical publications such as the Diagnostic and Statistical Manual of Mental Disorders, used by clinicians to diagnose mental disorders. Even within the interpreting community, there are no official positions on the role of the interpreter or code of ethics in mental health.
Since mental health encompasses medical, community and legal issues, we can deduce that the interpreter must follow the common precepts of recognized interpreting codes of ethics such as confidentiality, impartiality, faithfulness to message, non-involvement, duty to self-educate, etc.
However, the role of the mental health interpreter cannot be described as a precept of an absolute nature; rather, the situation will dictate the role of the interpreter at any given time, as the situations encountered in mental health do not always lend itself to a position of total non-involvement and invisibility.
Mental health professionals (and interpreters, by default) make ethical and professional decisions based on the following principles, as stated by the American Psychological Association: A) Beneficence and Nonmaleficence B) Fidelity and Responsibility C) Integrity D) Justice E) Respect for People’s Rights and Dignity (Ref 3). Hence, interpreters must shift their focus from strict adherence to an immutable professional code to a principle-based approach that balances professional duties with client welfare.
The main duty of the mental health interpreter remains the faithful conveyance of a message via speech, albeit in a conscientious manner with respect to beneficence and nonmaleficence by helping overcome communication obstacles caused by culture. Indeed, “psychiatrists pay close attention to speech. It is through speech that we understand what is on a person’s mind. You tell a story about your concerns and how they developed, and psychiatrists extract from this a pattern of illness” (Ref 9, p.227). Since diagnosis will take place mainly from self-reported symptoms and descriptions, it is obvious that the use of an unknowledgeable interpreter may distort the clinician’s view of the patient’s mental status, since the words or thoughts that the clinician will hear can be unconsciously or consciously filtered by the interpreter (Ref. 14).
Interpreters must also educate themselves on the emotional toll that mental health interpreting can have on an individual. As most seasoned interpreters know, in most fields (medical/legal/community), one rarely has the opportunity to continuously interpret for the same individual over a long period of time. However, as a mental health interpreter, one may very well follow the individual through the initial period of intake through months or even years of treatment, meet several family members and friends, and have to deal with the very personal and emotional effect of having intimate knowledge of another’s life and emotions. Interpreters do well to learn techniques that clinicians learn to deal with these and other obstacles.
This paper has the objective to help practicing and knowledgeable interpreters build on their expertise and prepare themselves to better interpreter in the mental health field. Therefore, it will not go into an in-depth discussion of interpreting techniques, code of ethics or the role of the interpreter. Rather it will briefly explore the external and internal processes involved in mental health interpreting, as well as mental health laws that are of concern to interpreters.
II. EXTERNAL PROCESSES IN MENTAL HEALTH INTERPRETING
Understanding the external processes in mental health interpreting refers to understanding the institutional framework within which the mental health interpreter works, including a basic knowledge of what constitutes mental health and illness, professionals that the interpreter will work with, and the types of interpreting encounters.
2.1 Definition of Mental Health
The first step in comprehending the external process in mental health interpreting is understanding the very definition of mental health. Mental health is the successful performance of mental functions in terms of thought, mood and behavior. A person with a mental illness has impaired mental functions to the point that it interferes with functioning on a social and developmental level (Ref. 19). A person with a mental illness may have difficulty holding a job, making decisions, keeping friends, or enjoying life. (Ref. 16).
Mental health conditions are extremely common, in that about one in four American adults suffer from a diagnosable mental disorder in a given year, and nearly half have more than one disorder. (Ref. 18). The most common mental health disorders are: mood disorders (major, minor or chronic depression, bipolar disorder); schizophrenia; suicide; anxiety disorders (panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and phobias); eating disorders; ADHD; autism; and Alzheimer’s disease. In fact, a study published by Harvard Medical School’s Ronald Kessler, PhD, demonstrated that 46% of the American population is at risk for developing any one or more of the above disorders within their life time. (Ref. 11).
Despite the prevalence of mental disorders, even the term “mental health” carries with it a long standing stigma. This stigma has been institutionalized by the separation of mental health and physical health. This break in the treatment of the mind and body as separate entities was influenced by the French philosopher Descartes, who purported that the mind was the spiritual region, the concern of organized religion, and the body was the corporeal region, the concern of physicians (Ref. 19).
The acceptance of humans as “organic machines, collections of matter organized so as to be able to perform vital functions, attached to rational souls” divided the practice of medicine into two distinct fields: mental health and physical health (Ref. 8). Therefore, mental health came to be seen as a spiritual problem or “weakness” and the body as machine that could be fixed when it broke down (Ref. 15). The stigmatizing result of these and other beliefs persists into our times, “despite advances in the 20th century that proved the interrelationships between mental and physical health” (Ref. 19).
Even the language used to describe mental health issues continues to divide and stigmatize. “Common parlance continues to use the term “physical” to distinguish some forms of health and illness from “mental” health and illness. People continue to see mental and physical as separate functions when, in fact, mental functions (e.g., memory) are physical as well and are “points on a continuum” and “inseparable.” (Ref. 19).
Although the entities such as the United States Surgeon General propose the utilization of more “neutral and appropriate” designations such as “mental” and “somatic” health, the fact is that the stigmatization continues in almost every culture and language; people still tend to view mental health issues as mainly a personal problem that a client can choose to overcome instead of a medical problem (Ref. 19).
Interpreters must be aware of these issues to carefully choose the language utilized to describe mental health conditions or symptoms. Some terms that were previously widely accepted are now considered to be stigmatizing and unacceptable. Examples: “mental health patient” vs. “client” or “consumer” (the latter two terms widely preferred); “You are depressed” vs. “You have depression” (the latter which does not equate the person with the illness, and hence, is preferred) (Ref. 15).
Stigma is also reinforced by the media, as in the case of Hollywood and its extreme and unrealistic portrayals of mental health clients. For example, in the movie “Instinct” (1998), Anthony Hopkin’s violent and silent character, a prisoner in a jail for the “insane,” constantly physically attacks and mentally manipulates his doctor, portrayed by Cuba Gooding, Jr. During the entire movie the client has free reign over the facility, is never supervised nor administered treatment in line with a real life scenario, and simply fuels the stigma associated with mental illnesses (Ref. 13).
The effect of the media and the popular mind on the view of mental health issues may not be ignored by the interpreter, as if he/she is immune to be infected by the “ patronizing attitude of moral superiority to the mentally ill” that even many professionals working in the field are known to have (Ref. 7).
The most common stigmas as reported by Rebecca Frey, Ph.D. in the Encyclopedia of Mental Disorders (Ref. 7) are:
TABLE 2.1 MOST STIGMATIZED MENTAL HEALTH CONDITIONS
EXCERPTED FROM ENCYLOPEDIA OF MENTAL DISORDERS
Interpreters must thrust aside such stigmas and remember that mental health clients are simply human, and that their problems arise from the same kind of situations that we all face (Ref. 12). Interpreters must take care to not stigmatize clients by their unconscious tone, internal attitude, body language or reactions, because this can affect clients’ willingness to seek treatment or cause noncompliance, therefore nullifying the usefulness of the interpreter in the process.
2.2 Mental Health Settings
One of the most important ways to overcome an internalized stigma or stereotype is education. Interpreters will feel more comfortable with interpreting in a mental health setting if they understand what kind of settings they may be called to interpret for.
It is helpful for interpreters to have a general idea of the setting itself and what to expect. Interpreters will not have to concern themselves about lying down on couches next to their clients during their therapy sessions, for example, as the popular mind might have them think.
Instead, mental health settings closely resemble medical settings, but with more precautions in place to ensure both client and professionals’ safety, due to the fact that some mental health problems are more severe than others.
Although the settings can vary, most mental health encounters take place in either outpatient or inpatient settings (see Table 2.2).
TABLE 2.2 MENTAL HEALTH SETTINGS
|Local Mental Health Departments (referrals to outside providers, or provision of services)||Emergency room (for medical evaluation, 24 hour observations/holds, referrals to inpatient/outpatient programs)|
|Private psychiatrists (provide medication, diagnosis)||Short term inpatient unit (unit in a Mental Health Department or Hospital, either private or public)|
|Private psychologists or therapists (therapy)||Inpatient hospital (private/public hospital dedicated exclusively to relatively short term (days to weeks) treatment/stabilization for acute mental health and substance abuse issues)|
|Community health clinics (low cost provision of services)||Group home (residential setting for long term care for mental health/substance abuse/developmental issues for adults, children, elderly)|
|Outpatient group therapy (AA, NA, support groups)||Respite care (residential setting for short term care to provide respite to caregivers of individuals with mental health/substance abuse/developmental issues/Alzheimer’s)|
|Outpatient partial day programs (vocational, rehabilitation, drug/alcohol day treatment programs, day treatment programs for developmentally disabled, dementia, Alzheimer’s, etc.)||Court system/jail (interpreter may be called to assist in a forensic evaluation, a competency hearing, an involuntary commitment hearing or routine psychiatric treatment for incarcerated clients)|
An outpatient public mental health facility will usually have a screening procedure prior to the waiting room. There may be security measures such as log books, metal detectors, or secure entrances, or simply a receptionist in a secure window that will offer assistance. Once inside, waiting rooms are usually open and look very much like the waiting room in a hospital, with chairs and reading materials.
Contract interpreters will be required to identify themselves and the client they will be interpreting for. Many times, contract interpreters will be given a client medical record number to identify the client in all communications, since mental health privacy laws require strict confidentiality with regards to client identity (see Section 3.1).
Contract interpreters are usually required to wait in the public waiting room or another designated area to be called in by the clinician. Some interpreters take this opportunity to introduce themselves to the client, build some rapport and assure the client of the confidentiality of the interpreting encounter. However, it is recommended that interpreters not engage in extraneous conversation with the client or sit near the client in the waiting room if not necessary, to avoid client self-disclosure and other issues.
Once called by the clinician, the interpreter will accompany the client to an office, usually through another secure area. If the interpreter is not familiar with the clinician, then she should take the opportunity to introduce herself and brief the clinician on how to utilize the interpreter.
The clinician’s office looks much like an attorney’s office with a desk, chairs, and reference materials. However, the furniture is not usually arranged in a position of power (i.e.: the clinician sitting behind a desk with the clients facing him). Instead, the desk is usually against a wall, with the clinician’s chair enabling him to write when necessary but face the client. All of the furniture tends to have a circular placement, which again, has the intention to foster good communication and mutual cooperation.
The interpreter would do well to follow the same cues and try to position herself so as not to align herself either with the clinician, which may make the client feel as it were two against one, nor with the client, which may foster the client trying to form a close relationship with the interpreter instead of the clinician, by looking and speaking mainly with the interpreter and not the clinician. It is usually possible for the interpreter to place herself between both the clinician and the client, which will reinforce the idea that the interpreter is the vehicle through which the relationship between clinician and client will form.
Private mental health facilities are usually similar to public facilities, with the exception that the security measures are not as strict.
Interpreters should follow the culture of the facility when choosing the clothing that they will wear; some interpreters may find it surprising that many mental health professionals dress more casually than medical personnel. This practice has the intention of being a more relaxing and cooperative atmosphere rather than the authoritative or threatening one that wearing white lab coats or suits might invoke.
Interpreters should also follow all security measures, to assure personal and client safety.
An initial encounter may take place in an emergency room; clients are there either voluntarily or involuntarily. (See Section 2.4 for a discussion of voluntary/involuntary encounters). In either case, if it is determined that the client is in need of mental health services, usually they are transferred to a special bed or room within the hospital for observation. In practice, this means that a security officer will be placed within or outside the room to ensure safety, and a member of the medical staff will stay at all times with the client, annotating observations of clinical manifestations of symptoms such as crying, hearing voices, paranoia, etc. The interpreter (unless also a duly qualified and trained staff member, such as a nurse) should never be the person called upon to observe or accompany the client.
For client safety, the client will not be permitted to leave once placed on a psychiatric hold for observation. The client will also usually be required to be in a hospital gown, and is stripped of all belongings and items that could be utilized to harm herself or others, including hairpins, strings, laces, medications, etc.
Usually, the interpreter is called on when the client is admitted into the emergency room to assist with the initial and periodic evaluations by medical personnel during the client’s stay. The interpreter will never be alone with the client, and should observe all security measures.
If the client is involuntarily committed, usually law enforcement will come to transport a client another area of facility. It is during this phase that interpreters must take the most care. For obvious reasons, clients are not usually informed that they will be transferred to an inpatient health facility and may resist being transported, either verbally, physically, or emotionally. In this case, interpreters should follow the instructions of law enforcement personnel and use common sense to ensure their personal safety by carefully choosing their body placement in relation to the client.
An inpatient treatment facility may be a hospital dedicated to mental health, or may be a secure portion of another institution such as the psychiatric unit of a regional hospital or mental health center. Larger facilities will usually have separate units for children, adults, substance abuse issues and extreme mental health issues.
An inpatient facility very much resembles a hospital floor. However, the entire unit is organized around safety. There are usually cameras on the floor and staff members do periodic checks (usually every 15 minutes) to ensure client safety and assess symptoms.
Inpatient facilities usually have a common living area for reading, watching television, and other quiet activities. There may be a separate room for recreational or group therapies.
In most cases, clients are assessed every day by a psychiatrist and may participate in daily group or individual therapy and activities; these are usually the moments that an interpreter will be called upon to participate in.
Again, the interpreter should inquire about all security measures and strictly follow them to ensure safety.
Interpreters called in to interpret for clients in jail or court should follow the guidelines and security measures for legal interpreters at all times.
2.3 Mental Health personnel
A number of professionals intervene in the treatment of Mental Health. Below is a table describing the most common participants.
TABLE 2.3 DESCRIPTION/FUNCTION OF MENTAL HEALTH PERSONNEL
|Psychiatrist (MD): Medical doctor specializing in the medical and chemical treatment of mental health disorders||Makes official diagnosis, prescribes medication, monitors medication. Works closely with case manager or therapist (if part of treatment plan). Signs off on involuntary commitments, admits/releases patients from inpatient facilities.|
|Psychologist (PhD, PsyD, EdD): A mental health professional who has completed a Doctorate.||Assist clients in understanding and managing symptoms. May also be researchers or specialize in a specific subgroup, such as neuropsychology. May provide therapy.|
|Psychiatric Mental Health Nurse Practitioner (PMHNP): Licensed professional nurse with a master’s degree in nursing.||Assist mental health patients in homes, clinics, may administer or manage medication in cooperation with the psychiatrist.|
|Licensed Professional Counselor (LPC): Master’s degree in professional counseling, accompanied with supervised practical experience, licensed by the State.||Provide individual or group cognitive therapy, devise treatment plans to resolve issues.|
|Licensed Mental Health Counselor (LMHC): Licensed by State to provide services (requirements vary by State).||Assist clients in setting goals and action plans in order to resolve emotional or mental impairment.|
|Licensed Independent Clinical Social worker: Licensed by State to make independent clinical decisions in hospital/medical center.||Makes clinical decisions in hospitals/medical centers, assists doctors and psychiatrists in diagnosis and treatment.|
|Licensed Master Social Workers (LMSW): Master’s degree in Social Work.||Handles caseloads of families, manage client files and handle referrals, advocate, help client arrange for support systems. May also be referred to as “case manager.”|
|Licensed Clinical Social Work (LCSW): Master degree in mental health, with a focus on the clinical aspects, achieved with supervised postgraduate practice. Higher designation than LMSW.||Duties may be similar to that of a Social Worker, but on a larger scale, for example, focusing on the well-being of an entire population.|
(Adapted from: http://www.allpsychologyschools.com/faqs/counseling-licenses)
2.4 Accessing Mental Health Services
There are a variety of ways in which a client accesses mental health services. Generally, there are two methods: voluntary and involuntary.
The two methods are briefly explored below.
TABLE 2.4 METHODS OF ACCESSING MENTAL HEALTH SERVICES
Mental Health clients often weave back and forth between the two modes of accessing care, depending on their circumstances. However, the overwhelming majority of mental health encounters are voluntary and for non-crisis situations. Below are two vignettes that explore what might be a voluntary and involuntary mental health encounter:
A voluntary mental health encounter
Maria is a 36 year old woman who is dealing with the death of her father while taking care of her three young children. Maria is feeling sad all of the time because she is grieving the loss of her father and feels guilty because she wishes she could be a better mother to her children. She is also thinking about leaving her husband because he is always working, and when he is home, likes to drink, and he doesn’t understand how hard it is for her to deal with memories of child abuse that she suffered at the hands of her uncle. She has crying spells, insomnia, and lately has a hard time getting up in the morning and taking care of the house.
One morning, her husband took her to the emergency room because she was shaking, sweating and feeling a pressure in her chest and was worried she was having a heart attack. However, she is evaluated by the emergency department and told “nothing is wrong” and is given a slip of paper that tells her to visit the local Mental Health Department, which she does the next morning. However, she’s not really sure why she was told to go there and relays that to the receptionist.
The receptionist takes her name and asks her to sit in the waiting room. A Licensed Clinical Social Worker takes Maria back and gets background information from her and asks her about her symptoms. The worker writes everything down in an intake chart. After listening to Maria, the worker tells her that she suspects what she had sounds like a panic attack and that she is probably suffering from depression.
Maria is relieved but surprised to learn that her condition isn’t medical or life threatening, and agrees to come back to be evaluated by a psychiatrist to see if medication will help her, and to meet with a psychologist for weekly therapy who can help her talk through her feelings and help reduce her symptoms of guilt, trauma, stress, and bereavement.
An involuntary mental health encounter
Louis is a 25 year old male diagnosed with schizophrenia. He had been doing well, but about two weeks ago, decided to taper off his medications by himself because he doesn’t want to be “addicted” or “drugged up.” Lately, he’s being hearing voices and acting strangely. His girlfriend and mother bring him to the local Mental Health Department. During the intake, Louis denies that he’s off his medication and becomes agitated when the social worker begins asking personal questions. He threatens to walk out of the office and starts accusing his girlfriend and mother of wanting to “control his mind” and says he can hear what they are thinking and that they are trying to kill him and states he won’t take his medication. The worker determines that Louis is a danger to himself and others and lets him calm down in a secure waiting area while she consults with the psychiatrist and Louis’ family. They agree that Louis needs treatment.
The psychiatrist signs off on paperwork to have Louis involuntarily committed to mental health treatment. The social worker goes to the local magistrate, who signs a temporary involuntary commitment order that enables Louis to get the treatment he needs but is refusing. The local police department comes to the Center to safely transport Louis to the emergency room to be medically evaluated and observed for a 24 hour period before being transferred to an inpatient unit or hospital.
At the beginning of his stay in the inpatient unit, Louis is agitated and upset that his family “did this to him”, but after 10 days, he is back on his medication, calm, and stabilized. Louis does not remember most of what occurred prior to his hospitalization.
He attends a hearing along with his court appointed attorney, and a judge determines that he must continue to comply with his medication and treatment for a period of 90 days, after which he will re-evaluated. If he doesn’t comply, Louis understands he can again be involuntarily hospitalized.
Louis is released from the inpatient unit. He now has a case manager who makes sure he complies with his medication and therapy treatment and reminds him of his appointments.
2.5 Diagnosis of Mental Illness
As previously discussed, mental illness is extremely common, and fortunately, for the most part, very treatable. In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).
This manual is a compendium of diagnostic criteria and codes for mental illnesses, and is a valuable resource available for purchase by the public for anyone who would like an in-depth knowledge of diagnosis, symptoms and treatments.
The manual is the standard for diagnosis, and uses a five axial approach to diagnose and determine appropriate treatments. The Axis are as follows: Axis I: Clinical Syndromes, Axis II. Developmental Disorders and Personality Disorders, Axis III: Physical Conditions; Axis IV: Severity of Psychosocial Stressors, Axis V: Highest Level of Functioning.
The clinician will first determine an initial diagnosis based on self-reported symptoms during a client oral history. An oral history includes ‘presenting problems, social circumstances, family history, personal history, past psychiatric and medical history, personality issues, any medication used, any substances used or abused and any forensic history.” (Ref. 24)
The clinician then will assess if there are any co-occurring developmental or personality disorders (for example: Paranoid Disorder). After that, the clinician will determine if there is a medical condition that is contributing to the continuance, development or exacerbation of the diagnosis reached in Axis I and II. (For example, the use of corticosteroids in the treatment of a chronic illness could cause mania). During the interview, the clinician would be able to detect conditions and life stressors within the environment of the client that could contribute to the illnesses reported in Axis I and II. Finally, the clinician will determine a base-line for high level of functioning, which will assist the clinician in monitoring improvements or worsening symptoms and effectiveness of treatment.
TABLE 2.5 COMMON CONDITIONS AND DESCRIBED SYMPTOMS
|Anxiety||Mild heart palpitations, dizziness, excessive worry.|
|Bipolar disorder||Symptoms of depression that alternate with extreme euphoria, marked by excessive energy, reduced need for sleep, grandiose ideas, lack of impulse control, easily distracted.|
|Depression||Sadness, emptiness, hopelessness, reduced activity in pleasurable activities, sleep disturbances, low energy, difficulty in concentrating, suicidal thoughts or attempts.|
|Panic disorder||Attacks of fear/anxiety, heart palpitations, shortness of breath, described often as “chest pain” or client thinking he is going to die or is having a heart attack.|
|Psychotic disorder (including schizophrenia)||Delusions, hallucinations, disorganized thinking, behavior or speech.|
Cultural issues related to diagnosis
Mental health issues are universal; however, their manifestations differ from person to person and from culture to culture. Therefore, the American Psychiatric Association warns clinicians:
“Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-IV Classification to evaluate an individual from a different ethnic or cultural group. A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, beliefs, or experience that are particular to the individual’s culture (Ref. 21).”
However, the recent DSM-IV editions also recognize cultural bound syndromes and idioms of distress. Although available to clinicians, not every clinician will be experienced enough in working with a certain culture so as to readily identify these cultural manifestations and descriptions of mental illness. If the interpreter educates himself regarding these issues, then he can be a helpful tool the clinician can utilize to identify and understand these cultural manifestations/idioms and to determine whether the client’s signs and symptoms significantly impair their functioning within their cultural context and norms of acceptable behavior, the hallmark of mental illness.
A caveat; although some culture bound syndromes and idioms of distress are briefly mentioned in commonly used resources such as the World Health Organization (WHO) International Classification of Diseases or the DSM-IV, they have not been adequately researched to provide a framework that permit an interpreter to educate himself or others from a purely academic standpoint; rather, each interpreter, with practice, time, immersion and dialogue with members of the population he interprets for, will formulate his own personal mental database from which to draw from and infer if the descriptions proffered by a particular client are culturally bound, and therefore, should be mentioned in a sidebar to the clinician.
Excerpt from Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of the Surgeon General.
IDIOMS OF DISTRESS
Idioms of distress are ways in which different cultures express, experience, and cope with feelings of distress. One example is somatization, or the expression of distress through physical symptoms. Stomach disturbances, excessive gas, palpitations, and chest pain are common forms of somatization in Puerto Ricans, Mexican Americans and whites. Some Asian groups express more cardiopulmonary and vestibular symptoms, such as dizziness, vertigo, and blurred vision. In Africa and South Asia, somatization sometimes takes the form of burning hands and feet, or the experience of worms in the head or ants crawling under the skin (internal citations omitted).
CULTURE BOUND SYNDROMES
Culture-bound syndromes are clusters of symptoms much more common in some cultures than in others. For example, some Latino patients, especially women from the Caribbean, display ataque de nervios, a condition that includes screaming uncontrollably, attacks of crying, trembling, and verbal or physical aggression. Fainting or seizure-like episodes and suicidal gestures may sometimes accompany these symptoms. A cultural –bound syndrome from Japan is tajin jyufusho, an intense fear that one’s body or bodily functions give offense to others.
TABLE 2.5 IDIOMS OF DISTRESS AND CULTURE BOUND SYNDROMES
Example of the interpretation of an idiom of distress
An example of an idiom of distress is that Spanish speaking clients from Mexico may attribute their symptoms to “aire” which is loosely translated as “wind”, but can be utilized to describe any strange and sudden unknown ailment associated with the “wind” or “spirit” become knocked or dislodged from the body by a sudden fright, trauma or illness. Although it is an apt description of the concern and worry that mental health clients often feel at not knowing what they are suffering from, most clients utilizing the term will not attribute it to psychiatric origins.
An interpreter would not be able to simply translate the phrase “Me dio aire” literally as “I was invaded by wind” because the clinician could then believe that the client was speaking irrationally.
In this case, if the interpreter did not know what the client meant, she should ask the client directly to explain what he meant (after letting the clinician know), and then interpret the response. The client’s own definition or description of the phrase in question can usually clue either the interpreter or clinician as to what he might be referring to in psychological terms.
If the interpreter did know what the term meant, she could briefly preface her interpretation with a brief explanation of the cultural-bound term and their significance. The interpreter should always let both parties know of any such conversations and its relevance to the communication process.
However, interpreters should be careful not to assume that the term or description utilized by one person means the same thing for each individual. If there is a doubt, the interpreter should request clarification, or follow the lead of the clinician, who often will ask a follow up question such as, “When you said “this”, what did you mean?”, or “What does this mean to you?”
Also, the interpreter should never assume that he knows what the client is thinking and automatically convert a culture-bound syndrome into a text-book one. For example by interpreting “ataque de nervios” (See Table 2.5) as “panic attack” or “nervous breakdown”. Instead, the interpreter should allow the clinician to make his own determination as to if the described symptoms fits the diagnostic criteria of a certain symptom.
The goal of every interpreter should be to educate the professionals and clinicians as much as possible regarding frequently encountered cultural symptoms and descriptions, so as to foster trust building between the client and professional. If the client feels that the professional, even though he may not speak his language, is knowledgeable and culturally sensitive, it is more likely that the client will be open and be able to communicate with his clinician no matter who the interpreter is. This education should preferably take place outside the encounter with the patient, so as not to hamper the communication process.
In the above example, the interpreter, after explaining briefly during her interpretation of the term “aire”, may have a post-appointment conference with the clinician to further explain the term and its origins, and may offer to bring information that examines it from a clinical perspective.
To this end, interpreters should try to locate information that considers the symptoms and descriptions utilized by populations they will be interpreting for, and can compile a list of resources and glossaries for themselves and the professionals they work with. However, they must never forget that their although their job is to promote good outcomes and diagnosis by accurately interpreting the client’s thoughts, once the clinician overcomes the language/cultural obstacle with the help of the interpreter, the ultimate responsibility of the diagnosis and outcome is of the clinician, and not the interpreter.
2.6 Mental Health treatment
The treatment of mental health illness is twofold: somatic and psychotherapeutic.
Somatic treatment is the treatment of physical and chemical causes of mental illness and may include drug therapy and, rarely, electroconvulsive therapy.
Psychotherapeutic treatment can also be referred to as “talk therapy”, and involves many modes such as behavioral, cognitive, family, group, interpersonal, and psychodynamic. Therapy has the objective to help the client diminish symptoms by: modifying behavior to improve illness outcomes (for example: exercising to improve mood and reduce isolation); correcting faulty or inaccurate beliefs (for example: thinking “Everything is my fault”); improving family and social relations, communication, and functioning; understanding the role of past events in current mental status; and learning coping skills.
A treatment that combines the use of medication and psychotherapy is the most effective approach, since as previously discussed, mental health illness is the convergence of both mind and body functional impairment (Ref. 6).
Example of an interpreting issue related to drug therapy
Interpreters may choose to inform clinicians of any cultural aspects that may affect treatment administration or compliance. For example, most psychiatrists ask their clients: “Are you taking any over-the-counter medications or supplements?” English-speaking clients will usually understand that this would include vitamins, herbs, and any drugs that can be purchased at a drug store. However, some cultures may make a clear distinction between “medical” remedies and “natural remedies”, and therefore fail to report herbs, vitamins, and supplements that can actually have psychotropic properties.
In some Latin American countries, for example, people may use the term “vitamins” to herbal remedies in pill form, such as, that can be purchased at any pharmacy or “botica” (folk-pharmacies, which often illegally import unregulated drugs and herbs or medications that can only be legally prescribed but are sold over the counter, such as antibiotics, anti-psychotics, etc.)
Therefore, the interpreter may choose to interpret the question “Are you taking any over-the-counter medications or supplements”, as “Are you taking any medicine/vitamin/pill that you can buy at the store/pharmacy/natural store/”botica”/etc. without a doctor’s prescription or natural herb/ vitamin/remedy/plant/etc.?”
Example of an interpreting issue related to talk therapy
The bulk of the mental health interpreter’s work will take place during talk therapy. The periodicity and duration of the therapy will vary.
An interpreter must strive to foster or conserve a good relationship between the therapist and client. The interpreter can do this mainly by educating the parties regarding the use of the interpreter prior to the session, such as informing them to look and speak directly to each other, and gently re-steering the conversation during the session if the interpreter is being spoken to directly by either party.
Sometimes the client will speak directly to the interpreter, especially if talking about an uncomfortable or sensitive topic. The interpreter must use common sense and empathy in dealing with this deviation outside the “role of the interpreter.” If the client becomes emotional or begins to talk without interruption about a personally emotion-invoking subject, perhaps it would not be time nor therapeutically indicated to immediately stop the client and inform her about the proper use of the interpreter.
In these cases, it might be prudent for the interpreter to show empathy by listening intently, maintaining eye contact with the client and reacting appropriately (for example, handing the client a tissue). The interpreter may wait until a natural pause, or may gently make a visual or verbal cue for the client to pause. Sometimes the therapist herself will take the lead and ask the client to pause. The interpreter can then interpret the statement, looking directly at the therapist, a lead which the client will usually follow by looking to the therapist for the response.
III. INTERNAL PROCESSES IN MENTAL HEALTH INTERPRETING
It is also important to self-educate on the role of internal processes in mental health interpreting. Here, the term refers to the personal framework within which the interpreter will work, and includes dealing with the emotional toll of working in mental health, understanding client boundaries, and dealing with difficult situations (agitation, aggression, nonsensical language).
3.1 Difficult situations
Interpreters who begin working in mental health are often apprehensive about dealing with difficult clients or situations they may face. The reality is that these fears are often based on erroneous beliefs based on stereotypes and popular portrayals of mental health consumers. As previously stated, interpreters must first dispel misconceptions and fears based on fiction, and must educate themselves regarding the facts.
The facts are that the most common mental illness is anxiety, followed by mood disorders, impulse control problems, and substance disorders. Nearly 80% of these cases are mild to moderate, with the remaining 20% being classified as “serious”. Severity includes the degree of disability as well as suicide attempts (Ref. 11).
Keeping in mind that studies have shown that nearly half of the population is at risk of developing a mental health disorder within their lifetime, interpreters should realize that again, the majority of the problems they will encounter will not be unlike ones they or their love ones have faced. Interpreters can therefore draw on their personal experiences to rationally deal with the fear of working in mental health.
In the case of dealing with individuals with unusual thinking or behaviors, interpreters must be aware of the following, as reported by Kennedy and Charles in On Becoming a Counselor: A Basic Guide for Nonprofessional Counselors and Other Helper (1977, p.208) :
Individuals are unaware that they are behaving in any abnormal way and lack any capacity to observe themselves or to have insight into the nature of their illness. They are often as afraid of us as they are of others, concerned that they will be misunderstood or harmed in some way. We need, therefore, to relate to them in a calm, reassuring, and understanding manner. […] A little bit of humanity goes a long way in expanding our simple human effectiveness with these individuals.
However, there still are safeguards in place to ensure safety , such as secure facilities or policies that require a mental health client to be accompanied at all times while in an outpatient or inpatient facility. Also, any suicidal or homicidal thoughts or gestures are taken as seriously as a suicide or homicide attempt.
Therefore, interpreters should follow to the letter any safety procedures and legal reporting requirements is a client is posing a danger to himself or others (see Section IV). Interpreters should also use common sense to ensure personal safety, and step out of their interpreter role if necessary to protect it.
3.2 Ensuring personal safety
Interpreters can ensure personal safety by following at all times and without exception the security measures implemented by the service provider. An interpreter should never be alone with a client. Interpreters should always be aware of their surroundings and assess the client’s specific aggression risk by observing potential aggressive body language, such as clenched fists.
If necessary, interpreters can take physical measures such as not sitting within arm’s reach of client at risk of aggression, placing themselves near the door, and not allowing a client to be between themselves and the door. Interpreters can avoid being pulled into a physical situation by avoid wearing scarves, long earrings or long hairstyles.
Interpreters should know that anger is a component of mood disturbances, and can surface at anytime. Individuals experiencing a manic bipolar phase, for example, cannot easily deal with limit setting or frustration or may feel powerless and externalize this verbally or physically. In an interpreting setting, this may occur when, for example, the client feels that the therapist is not listening to him or he has been waiting too long to see the doctor.
How can an interpreter deal with this situation? First, follow all prevention measures. Secondly, unless the interpreter is also a trained member of the medical staff, the interpreter should never be alone with the client. Mental health staff members are trained to diffuse deal with aggressive or agitated clients, and interpreters should allow them to do their job and get out of the way if a client does actually become physically aggressive as in extreme cases, physical restraint or seclusion will be utilized to ensure everyone’s safety (Ref. 5).
However, most tense situations can be diffused by practicing the following therapeutic responses:
|Keep one’s emotions under control.||Promotes rational thinking in all parties.|
|Speak in a calm, reassuring manner.||Allays client’s fears of feeling threatened or helpless.|
Allow the client to verbalize anger.
|Will lessen client’s physical tension and often avert a situation. Will validate his feelings.|
|Involve the client in a diverting behavior.||A client who is moved to a more private area can often calm down.|
|Do not touch or invade the client’s personal space.||Moving too closely to the client can make him feel threatened and he may react violently.|
|Do not reprimand the client for feeling angry.||Anger is not a feeling that a client can rationally control. Reprimanding can also encourage childish tantrum-like behavior.|
Adapted from: Davies, Janet; Hanosik, Ellen (1991). Mental Health and psychiatric nursing: a caring approach. p.201)
Example of an interpreter dealing with an angry client
A 42 year old limited-English proficient man walks into a mental health clinic, and requests services. He seems agitated and nervous. In the waiting room, he gets up several times to either use the restroom, get a drink, walk around or simply stand, seemingly trying to calm down. He quickly flips through magazines and tosses them back onto the side tables, and loudly shifts in his chair. He audibly sighs and mutters to himself angrily about the process taking too long. He is clenching his fists and wringing his hands.
The interpreter, who has been called into interpret for the client, is also sitting in the waiting room. She chooses to diffuse the situation by commenting to the client, “It seems like we have been waiting for a long time, right? Let me go see what I can do.”
The interpreter then approaches a staff member and privately comments on the observed signs that the client is becoming agitated. The staff member reacts appropriately by quietly approaching the client with the interpreter in a non-threatening manner, verbally validating his concerns, and diverting the client to another area where he meets with a clinician.
During the client’s conversation with the clinician, the interpreter mimics the understanding and compassionate tone and facial expressions adopted by the clinician, and does not reprimand the client when he expresses himself directly to her by stating things like, “You know, miss, I am very upset with this doctor because…..” Instead, the interpreter demonstrates verbally and visually that she is hearing and comprehending what is being said. The interpreter then interprets the utterances to the clinician, prefacing it by saying, “The client is speaking directly to the interpreter and says he feels upset with you because….”, and then proceeds to continue to interpret in the third person.
The client, after verbally expressing his anger, is able to calm down and obtains services without any further incident.
3.3 Dealing with unusual speech
When a person’s mental functions are sufficiently impaired, a client’s language may no longer make sense. Aphasia refers to a disturbance of language use, where because of a change in brain pathology the patient becomes unable to use words as symbols (Ref. 2).
Extremely disorganized thinking that occurs during psychosis (loss of contact with reality) is immediately apparent because the speech is often nonsensical or illogical. For example, the question: “How are you feeling today?” may elicit the response: “I was okay and these green men in black cars. I was walking. The street and the movies but the lights and they were flying okay.”
Interpreters should never edit or try to logically reconstruct nonsensical speech (or explicit or offensive speech, for that matter), since that could hamper the clinician’s assessment of true mental health status. Instead, if the interpreter understands the distinct words utilized, she should repeat the utterances as verbatim as possible. If the speech is so disjointed, rambling, incoherent or pressured so as to making verbatim interpreting impossible, the interpreter can switch to a descriptive mode such as saying: “He is speaking very rapidly and is saying something about ‘I was okay”…..green men, black cars…..walking…street…movies…lights…flying…okay.”
In severe cases, the words may be completely unrelated to the one that follows, or a client may speak to a hallucination or be delusional (for example: hold an irrational belief that the interpreter is his mother). The interpreter should not dispute these facts or correct the client, since the client lacks the insight to know that he is not making sense and is frustrated that others cannot understand him. The interpreter should instead work with the treatment team by being supportive and clear in her communication with the client. If the client becomes louder or more insistent or is not understanding the interpreter, the interpreter should request a break rather than continuing. During this time, the interpreter can apologize to the client for unable to understand him and acknowledge that this must distress him.
You may find it helpful to tell him what you think he is saying, so that he can tell you if you have understood him more or less. He may be able to say yes or no even if he has difficulty putting together more complicated answers, I find that a psychotic patient is often greatly relieved to realized that someone has understood him, since the world has otherwise become such a lonely, frightening, and confusing place (Ref. 9, p. 227).
There are other speech patterns or observations that an interpreter should describe to the treatment team. For example, a clinician who does not understand a language will not be able to detect stuttering, low affect (a flat or inappropriate tone with reduced range of emotion that is not culturally explained) or rapid speech.
Sometimes clients will simply repeat right back what is being said to them (echolalia) or will make up words, use actual words in unusual ways, or believe they are speaking in tongues or foreign languages. Clients may also speak in clang associations, clumping words together that begin or end with the same sound. Sometimes the interpreter may be able to distinctly notice a pattern; for example, that a client is speaking in nursery rhymes from his country.
In all of these cases, the interpreter must not only interpret the decipherable aspects of the speech, but describe the speech for the clinician.
3.4 Dealing with client boundaries
Boundaries are in place to avoid the formation of inappropriate relationships (social, sexual, emotional, personal, religious, etc.) with clients, especially since mental health clients are very susceptible to exploitation and undue influence.
An interpreter should enforce client boundaries at all times by not offering personal opinions, personally expressing a commitment to confidentiality, and explaining what the interpreter can or cannot do. For example, sometimes clients want their interpreters to be their advocates or friends. Interpreters can gently inform clients about their role and advise the clients to speak to a qualified professional such as the clinician.
Interpreters should also not self-disclose information or share personal experiences, for both safety and boundary considerations. In some cultures, however, clients will expect interpreters to answer basic questions such as country of origin, residence, marriage status, etc. in order to establish a framework of trust. Interpreters should use good judgment in answering these types of questions, keeping in mind the equilibrium between professionalism, safety, and client welfare.
One thing that interpreters often question is the use of physical touch. Obviously, any type of sexual touching (real or perceived) is to be strictly avoided, as well as close physical proximity or touch with someone who is agitated. But in some cultures, a kiss or hug is used to greet instead of a handshake, or it is expected that one comfort someone who is crying by hugging, placing a hand on the person’s shoulder, or patting their hand. In these cases, interpreters should use common sense and professional judgment. A rule of thumb is to follow the lead of the clinician, or by default, the norms that a professional would be expected to follow in the client’s culture.
Interpreters who are members of close-knit minority communities may have an even more difficult time establishing boundaries because they may know or know of a client and it may nearly impossible to avoid all contact with her outside of the clinical setting. It is two edged sword: on one hand, the client may feel more comfortable and connected to the process, on the other hand, it may undermine the confidence the she has in the confidentiality and professionalism of the interpreter. All perceived conflicts of interest must be reported to the clinician, and a decision should be made if the interpreting relationship should continue with clearly specified boundaries, or if another interpreter should be used.
3.5 Dealing with personal emotions
Interpreters are often told to think of themselves as invisible, almost mechanical vehicles for speech. However, it would be naïve to think that a person could listen to a heart-wrenching personal story, observe the narrator’s emotions, tears, and face, and then have to interpret and convey the same emotions and message, and not internalize it or become personally invested on some level.
The reality is that working in the mental health field will certainly cause an invisible emotional wound (Ref. 12 p. 12). Interpreters need to work out their own emotions when dealing with the emotional toll, by talking it out and discovering coping mechanisms. Of course, interpreters cannot disclose privileged information, by for example, coming home and telling their spouse about what happened at work that day. However, interpreters can take advantage of the expertise of supervisors (either interpreters or clinicians) and consult with them regarding difficult cases.
Interpreters must also be aware of their own emotions, which will allow them to identify conflicts of interest or boundary issues. For example, if an interpreter herself was a victim of child abuse, she maybe should not interpret for the victim of a sexual assault, because having an interpreter burst into tears during a session would not be in the best interest of the client.
Interpreters should be on guard to detect feelings of helplessness, frustration, fear, and depression that can arise from dealing with clients, especially when interpreters feel that a clinician isn’t doing a good job. Of course, if the interpreter observes obviously unethical, illegal, or discriminatory behavior on the behalf of a mental health professional, he/she should report it through appropriate means by for example, lodging a complaint with DHHS.
Interpreters should practice food mental health habits such as eating a balanced diet, getting enough sleep and exercise, reducing stress via breathing techniques, journaling, and taking up hobbies. Interpreters can also reduce tension by not thinking about mental illness in terms of problems, but rather in terms of persons who are suffering (Ref. 12, p.24).
However, if an interpreter continuously fails in his attempts to establish and follow appropriate boundaries, confidentiality, or cannot accept the limitations of the interpreter role, then he is probably in the wrong line of work (Ref. 12, p.67).
IV. MENTAL HEALTH LAWS (U.S.)
In the U.S., there are state and federal laws that apply to mental health, as well as licensing boards that deal with professional conduct and ethics for mental health professionals. This paper will briefly mention those of most concern to interpreters.
4.1 Privacy of Individually Identifiable Health Information (Privacy Rule)
The Health Insurance Portability & Accountability Act (HIPPA) governs, among other things, the privacy of any information that could potentially identify an individual’s past, present or future physical or mental health or condition, the provision of services, and the past, present, or future payment for the provision of health care. Protected health information includes identifiers such as name, address, birth date and social security number, and covered entities must protect the information, whether electronic, written, or oral (Ref. 22).
The Office of Civil Rights enforces the HIPPA privacy rule. Non-adherence can incur in civil and criminal penalties of up to $250,000 in fines and imprisonment for up to ten years (Ref. 4)
Due to these strict codes, interpreting agencies are required to sign a “business associate contract” with covered entities prior to being legally allowed access to identifying information. Interpreting agencies should also include a special addendum with their subcontractors or employees regarding HIPPA and implement safeguards (Ref. 22). However, once the above requirements are met, HIPPA does not require a specific individual’s authorization to use or disclose personal health information. This means that a protected entity would sign a business associate contract with an interpreting agency and then could contact the interpreting agency to schedule interpreter. The protected entity would not be required to have a signed consent form from each client in order to schedule an interpreter for their appointment (Ref. 10).
With regards to the actual provision of services, since the client is present during the provision of interpreting service, it can be inferred that the individual does not object to the disclosure of protected health information to the interpreter (45 CFR 164.510(b)(2), and therefore, a signed consent form is not required. However, this does not exempt the interpreter from protecting the information; it simply means that the client is not required by law to sign a written consent form for each encounter with an interpreter (Ref. 10).
Therefore, interpreters must not fax nor e-mail any mental health consumer’s name or personal information, even for scheduling purposes. In fact, most organizations will provide interpreters will a client number to be utilized for billing and scheduling. Interpreters must take the necessary measures to protect any personal information in appointment calendars, even shielding documents from the view of unauthorized individuals.
Interpreters should never discuss any information learned through the provision of services, except with specific written client authorization, or if required by law (for example, if a person threatens to harm himself). An interpreter may discuss in a private area and with an authorized individual an issue that may be of clinical or professional relevance, for example, consulting with a clinician during a post-session conference or consulting with a supervisor regarding suggestions for dealing with specific situations. Even in these cases, the interpreter may only disclose the “minimum necessary” (Ref. 22).
Interpreters should never neither confirm nor deny to an unauthorized individual if a client is or was a recipient of mental health services. This includes answering questions from unauthorized persons.
An interpreter should never approach a client outside the provision of services, as this may lead to the inadvertent disclosure of personal information. For example, an interpreter may be known in the community as working in mental health and therefore, greeting a client outside the clinical setting will alert others to the fact that he/she may be a mental health consumer. In small minority communities clients may self-initiate contact if, for example, they see the interpreter in the grocery store. In this case, the interpreter may choose to acknowledge the contact by returning the greeting, but should limit the contact to as brief as possible. A client may self-disclose that he/she is a mental health consumer, but the interpreter should still maintain the privacy of their health information by declining to discuss it.
4.2 Breaking confidentiality
There are certain circumstances, as required by federal, tribal, state or local laws, in which an interpreter is required to break confidentiality or intervene. Interpreters should inquire in their jurisdiction as to the required exemptions to confidentiality.
The main exemptions to confidentiality of concern to the interpreter are:
The client threatens to harm himself or others.
A walk-in client in the waiting room expresses to the interpreter that he wants to kill himself. The interpreter alerts the staff.
Unreported cases of child abuse
A 10 year old client who is in foster care approaches an interpreter in a grocery store because she remembers her from a mental health encounter. The child informs the interpreter that she is being sexually abused by a foster parent. The interpreter alerts the Mental Health Department, who alerts Child Protective Services.
To provide emergency medical services
A walk-in client faints in the waiting room of a mental health clinic. The interpreter knows the identity of the client and assists the staff to procure emergency medical services.
Court order or subpoena (very rarely)
A judge orders a forensic evaluation of a limited-English speaking defendant. The mental health interpreter utilized during the evaluation is voir dired on the stand.
There are still many mental health interpreting issues that remain to be explored and concreted, both by the medical and interpreting community.
However, the role of the interpreter in mental health cannot be disputed; it is an all encompassing and crucial one, since he holds the key to unlocking the door on the mental status of the client he is interpreting for.
In the absence of comprehensive education resources and official opinions, the mental health interpreter must educate himself on the external and internal processes of mental health interpreting in order to foster quality of care and proper diagnosis, all while balancing professionalism, safety, and consumer welfare.
1. Allpsychologyschools.com.(2009).“What are the Different Types of Counseling Licenses?” Retrieved from: http://www.allpsychologyschools.com/faqs/counseling-licenses
- American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders DSM-IV, 4th Edition. Washington, DC: Author. p. 15.
- American Psychological Association. (2003). Ethical Principles of Psychologists and Code of Conduct. Washington, DC: Author.
Retrieved from: http://www.apa.org/ethics/code2002.pdf
- American Medical Association. (2009) “HIPPA Violations and Enforcement.” Health Insurance Portability Accountability. Retrieved from: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/hipaa-violations-enforcement.shtml
- Davies, Janet; Hanosik, Ellen. (1991) Mental health and psychiatric nursing: a caring approach. Boston: Jones and Bartlett Publishers. pp. 200-201.
- Doebbeling, Caroline, M.D. (2007). “Treatment of Mental Illness”. Merck Manual Home Edition. Retrieved from: http://www.merck.com/mmhe/sec07/ch098/ch098d.html
- Frey, Rebecca, Ph.D. (2009) “Stigma”. Encyclopedia of Mental Disorders. Retrieved from: http://www.minddisorders.com/Py-Z/Stigma.html
- Garber, Daniel. (1998, 2003). Descartes, René. In E. Craig (Ed.), Routledge Encyclopedia of Philosophy. London: Routledge. Retrieved August 29, 2009, from http://www.rep.routledge.com/article/DA026SECT12
- Hicks, James, M.D. (2005). Fifty Signs of Mental Illness: A Guide to Understanding Mental Health. Yale University Press Health & Wellness. pp. 227-230.
- HIPPA Bulletin. (2005) “Is an individual’s authorization required to use or disclose PHI to an interpreter?” HIPPA Bulletin, Article No. 78. Retrieved from: http://www.hipaabulletin.com/articles/78
- Hitti, Miranda. (2005). “Mental Illness Common in the U.S.” WebMD News Archive. WebMD Health News. Retrieved from:
- Hitti, Miranda. (2005). “Mental Illness Common in the U.S.” WebMD News Archive. WebMD Health News. Retrieved from:
- Kennedy, Eugene, and Charles, Sara, M.D. (1977). On Becoming a Counselor: A Basic Guide for Nonprofessional Counselors and Other Helpers. New York: Seabury Press. 1977. pp. 12, 24, 67, 208, 209.
- Lee, Robert. (2009). Introductory Psychology Syllabus. Black Hawk College. Moline, IL. Retrieved from: http://facweb.bhc.edu/EastCampus/leeb/acadweb/intropsysyllabus.htm
- Marcos, L.R. (1979). “Effects of interpreters on the evaluation of psychopathology in non-English speaking patients.” Am J Psychiatry. 1979 Feb; 136(2): 171-4.
- Mayo Clinic. (2009). “Mental health: Overcoming the stigma of mental illness.” Mayo Foundation for Medical Education and Research (MFMER) website. Retrieved from: http://www.mayoclinic.com/health/mental-health/MH00076
- Medline Plus. (2009). “Mental Health”. Medline Plus Trusted Health Information for You. U.S. National Library of Medicine and National Institutes of Health. Retrieved from: http://www.nlm.nih.gov/medlineplus/mentalhealth.html
- Morrison, James, MD. (1995). DSM-IV Made Easy: The Clinician’s Guide to Diagnosis. Guildor Publishing. pp.92, 139, 191, 197.
- National Institute of Mental Health. (2008). The Numbers Count: Mental Disorders in America. Last reviewed: August 10, 2009. Retrieved from: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml
- Office of Surgeon General. (1997) “Chapter 1: Introduction and Themes: The Roots of Stigma.” Mental Health: A Report of the Surgeon General. Substance Abuse and Mental Health Service Administration Center from Mental Health Services.
Retrieved from: http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html#roots_stigma
- Reamer, Frederic. (2003). Boundary issues in social work: managing dual relationships. Social work; Jan 2003; Vol. 48; Issue 1.
- U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, pp. 10, 11, 26, 31, 32.
- U.S. Department of Health and Human Services. (2009) “Summary of the HIPPA Privacy Rule.” Understanding HIPPA Privacy. Retrieved from: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
- Vandenbos, Gary R. (2006). The APA Dictionary of Psychology, 1st ed. American Psychological Association. Author.
- Warwickshire County Council. (2009). “How A Mental Health Diagnosis is Made.” Mental Health. Retrieved from: http://www.warwickshire.gov.uk/web/corporate/pages.nsf/Links/25E2F9CB3A098B6C8025749500596880