Working with Interpreters in Mental Health Settings

1. Working with Interpreters in Mental Health Settings Presentation Prepared by Yeshashwork Kibour, Ph.D. Center for Multicultural Human Services March 27, 2008 Duplication of materials may not be done without prior approval of CMHS

2. Outline of Presentation • The need • The population • The tool • Proper Assessment and Assignment • Issues to consider • When it works • Resources (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

3. The Need • Many of immigrants, refugees, and asylum seekers overcome numerous barriers and seek mental health services each year. 46% of Cambodian refugees (Marshall et al, 2006); 12.5% of Ethiopians with mental health issues received services (Fenta et al, 2007). • CMHS provides services to hundreds of newcomers annually who speak at least 15 different languages. • Newcomer populations pose a particular linguistic challenge in that mental health and social service agencies rarely have staff with a linguistic match. • Challenges of alternatives such as the language line for mental health services (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

4. The population • Have suffered traumatic experiences that impact their mood, thinking, and sense of safety. • Overwhelmed with numerous needs such as housing, education, employment, etc. • May define communication differently (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

5. The population cont . . . • Time and Space * • Fate and Personal Responsibility* • Face and Face-Saving* • Nonverbal Communication* • Have been silenced *LeBaron (2003) (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

6. The Tool: Interpretation The interpreter's function is conveying every semantic element (tone and register) and every intention and feeling of the message that the source-language speaker is directing to the target-language listeners. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

7. The Tool cont . . . • Interpretation is rendered in two modes: simultaneous and consecutive. • Whispered interpreting • Liaison interpreting • Language line (via telephone) (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

8. The Tool Cont . . . Simultaneous Interpretation The interpreter renders the message in the target-language as quickly as he or she can formulate it from the source language, while the source-language speaker continuously speaks (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

9. The Tool Cont . . . Consecutive Interpretation The interpreter speaks after the client has finished speaking. The speech is divided into segments, and the interpreter sits or stands beside the client, listening and taking notes as the speaker progresses through the message. When the speaker pauses or finishes speaking, the interpreter then renders the entire message in the target language. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

10. Proper Assessment and Assignment • When unable to communicate above and beyond simple greetings • Able to communicate above simple greetings but not clinical issues or emotional content • Critical Need: Initial assessment; specialist or multidisciplinary assessment; risk assessment; legal issues involved; discharge planning. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

11. Issues to Consider • Stigma • Confidentiality • Technical language • Interpreter attitudes and beliefs • Flexibility • Accuracy of information • Continuity (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

12. Issues to Consider Cont . . . • Trust between clinician and interpreter • Professional partners • Provision of cultural information • Block booking • Assessment and accreditation of interpreters (levels of accreditation) (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

13. When it works: Before (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

14. When it works: Before cont . . . • Identify appropriate language • Explore preference for interpreter gender, dialect, country, ethnicity, etc. • Schedule enough time before and after session to touch base with interpreter • Assess availability of interpreter on an ongoing bases • Assess interpreter’s experience or training in mental health issues (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

15. When it works: Before cont . . . • Prepare the interpreter on the client and the agenda for individual session • Have a brief discussion about terminology that you may be using that session • Discuss what will happen (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

16. When it works: During (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

17. When it works: During • Introductions, codes of ethics and roles explained • Confidentiality • ▲ seating • Keep sentences short and pause • Clinician maintains direction of session • Keep eye contact with client at all times • Communicate directly with client “I” and “you” • Avoid jargon or colloquial language • Body language (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

18. Challenges Facing Multicultural populations Needing Mental Health Services Having a world view that explains psychological / health dysfunction differently Not seeing mental health service providers as a primary resource for help with adjustment issues Not knowing where to go for help in a fragmented system Mental health not a priority –dealing with more immediate survival health issues (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

19. Challenges Cont . . . Unwillingness to discuss traumatic issues No insurance or not knowing how to use it Fear of compromising legal status Language and other cultural barriers Lack of trained bi-cultural professionals and targeted funding (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

20. CAUSES OF ILLNESS Imbalance in body Germs Spirit possession Loss of soul Violation of Taboo Intrusion of harmful element Divine Decision Evil Eye HOW TO RESPOND Restore the balance Kill them Exorcize it Ritual to retrieve it Penance Remove it Acceptance Rituals / offerings to turn influence away Causes and Response to Illness (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

21. Sources of Healing (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

22. Psychotherapy • Psychotherapy practice is enormously diverse • The treatment of mental and emotional disorders through the use of psychological techniques designed to encourage communication of conflicts and insight into problems, with the goal being relief of symptoms, changes in behavior leading to improved social and vocational functioning, and personality growth. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

23. Psychotherapy redefined A situation comprising three main elements: • Firstly, a healing agent who is either a professional with officially recognized expertise, or others such as a fellow sufferer or group of fellow sufferers; • Secondly a sufferer who is seeking relief; • Lastly a healing relationship that includes a structured series of contacts between healer and sufferer. Frank and Frank (1991) (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

24. Refugees and Immigrants have often experienced Traumatic life experiences Trauma involves two Conditions: • Usually involves actual or feared death or serious physical or emotional injury. • Meaning that the victim ascribes to the event. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

25. TRAUMATIC EVENTS ARE EXTRAORDINARY, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence or death. They confront human beings with the extremities of helplessness and terror, and evoke the responses of catastrophe. The common denominator of trauma is a feeling of intense fear, helplessness, loss of control, and threat of annihilation. Judith Herman, MD, Trauma and Recovery (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

26. Physical Reactions Nervous energy, jitters, muscle tension Upset stomach Rapid heart rate Dizziness Lack of energy, fatigue Teeth grinding Behavioral Reactions Becoming withdrawn or isolated from others Easily startled Avoiding places or situations Becoming confrontational and aggressive Common Reactions to Trauma (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

27. Behavioral Reactions Cont . . . Change in eating habits Loss or gain in weight Restlessness Increase or decrease in sexual activity Emotional Reactions Fear, inability to feel safe Sadness, grief, depression Guilt Anger, irritability Numbness, lack of feelings Inability to enjoy anything Common Reactions Cont. . . (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

28. Emotional Reactions Cont. . . Loss of trust Loss of self-esteem Feeling helpless Emotional distance from others Intense or extreme feelings Feeling chronically empty Blunted, then extreme, feelings Mental Reactions Changes in the way you think about yourself, the world, and other people Heightened awareness of your surroundings (hypervigilance) Lessened awareness, disconnection from yourself (dissociation) Difficulty concentrating (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

29. Mental Reactions Cont.. Poor attention or memory problems Difficulty making decisions Intrusive images Nightmares. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

30. Path to Healing Confronting the situation head on Act to take care of things independently Learn or develop special skills Call a friend Try to see positive aspects of the situation Flags to watch Chronically distancing oneself from the situation Chronically distancing from oneself Escape through dissociation or forgetting Shaming oneself Coping with Symptoms (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

31. Social Support Psychoherapy Treatment Interpretation Client Social Services Legal Services Medical Treatment (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

32. Mental Health- Stages of Recovery • Stage One: Safety • Stage Two: Remembrance and morning • Stage Three: Reconnection • Stage Four: Commonality A healing relationship (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

33. (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

34. When it works: After • Time to clarify • Time to answer questions • Reframe and advise on ways to correct inappropriate behavior on the part of the interpreter • Processing time (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

35. Resources • www.health.state.mn.us/.../immigrant/inter.html • http://www.mmia.org/ • http://www.cmhs.org • http://www.ncihc.org • http://www.vtpu.org.au/docs/interpreter_guidelines.pdf (c) CMHS 2007 Yeshashwork Kibour, Ph.D.

36. Contact information Yeshashwork Kibour, Ph.D. Center for Multicultural Human Services 701 West Broad Street Falls Church, VA 22046 (703) 533-3302x 316 www.cmhs.org (c) CMHS 2007 Yeshashwork Kibour, Ph.D.