Clients with limited English proficiency

About 20% of the U.S. population speaks a language other than English at home. Most of them consider English to be their second language. Some people have such limited English proficiency, that it would be inaccurate to even consider English as their second language. But here’s a logical question: what if these people were to seek out mental health practitioners? Would it be fair to them that very few practitioners are bilingual?

The APA recommends always interacting with a client in their first language, whenever possible. But of course, that’s rarely going to happen because of the diverse nature of the country. There are about 381 different languages spoken in the U.S. The chances that a given practitioner would be knowledgeable of a specific language are pretty slim. So what should a practitioner do if they’re unable to understand a limited English proficiency client? Simple. Get an interpreter.

When choosing an interpreter, it should be someone with a professional background. Children, relatives, friends, and even strangers from the waiting room are often used as interpreters but this comes with many concerns. It’s always better to avoid persons who have a multiple relationship with the client because quite often, this can lead to loss of objectivity. For example, a family member might be less willing to disclose sensitive information like domestic violence or substance abuse. The interpreter could also add or omit parts of what the client intended to pass on.

One of the most important qualities of a professional interpreter is competence. That doesn’t just mean that they have advanced academic credentials, but they should also be able to understand subtleties of interpretation and translation. You can only pick that up through formal training and professional certification. The ATA, CCHI, and NBCMI are all great sources for standardized certification processes and they also have online registries where you can find a certified interpreter near you. But what if you can’t find one? Then you can use a paraprofessional but in the presence of an external evaluator so you can be sure of their competence. And if you can’t find a local evaluator, there are a lot of commercial agencies that provide over-the-phone oral proficiency tests in several languages.

One thing you should always remember is that very few experienced interpreters have worked in a mental health setting before. And out of those who have, about 20% have formal mental health training. In other words, you need an interpreter who doesn’t just translate. They have to be skillful enough to know when to omit, add, substitute, and condense. According to Flores (2005), untrained interpreters omitted/misinterpreted up to 50% of physicians’ questions. This can be a big deal. Practitioners are legally obligated to make sure the interpreter is competent; otherwise a lot of problems can occur. Perhaps the most famous of cases goes back to the 1980s when a hospital was forced to pay a $71 million dollar malpractice settlement just because the misinterpretation of a patient’s symptoms resulted in quadriplegia. It also resulted in a mother losing custody of her daughters to Social Services all because of a staff member’s misinterpretation of an explanation regarding her daughter’s injuries.

Studies have shown that practitioners respond negatively to interpreters’ presence during sessions, showing discomfort and underestimating their help. On the other hand, clients responded positively, being more satisfied in the interpreters’ presence than their absence. That’s why it’s important to always ask for the client’s perception of how the therapeutic progress is going since the practitioner’s can be inaccurate sometimes.

So here’s a logical question: what if it’s absolutely impossible to find an interpreter? Should a practitioner work without one? The APA advocates this only if the practitioner has some proficiency in the client’s first language. The practitioner can try to become competent with some reasonable effort through research, training, consultation or even studying. Keep in mind that psychological services rely predominantly on verbal communication whether it’s for assessment, diagnosis, or treatment. A client’s level of English proficiency will most likely become evident in the first visit. That’s when you should make an informed, ethical decision whether or not to provide services and if it’s not possible, whether to recommend internet/phone counseling with a licensed professional in their first language.

The APA also mentions that it’s important to thoroughly discuss matters like privacy, confidentiality, and privilege with the client. Keep in mind that these concepts might be fairly new to them. You should be able to obtain a written informed consent using a language that is clearly understandable to the client. Have one professionally translated if you must.

Now let’s just say for a moment that your client is somewhat proficient in their second language. Does that mean that the session will go perfectly? Definitely not. According to Price and Cuellar (1981), patient disclosed more in interviews done in their 1st language than those done in their 2nd language. In other words, you might not be getting the whole story. Studies have also shown that interviews done in a 2nd language involve less emotional depth and a weaker emotional connection between the client and the therapist. This is because the client spends more time focusing on how they say things rather than what they’re saying. This is bad because then the verbalization of feelings becomes a mere intellectual task which brings minimal therapeutic relief.

The APA provides guidelines on how monolingual practitioners can deal with limited English proficiency clients with the help of an interpreter. However, it provides no help at all on how to respond if there’s no interpreter available. This puts practitioners in an ethically risky position. Should you provide services because there aren’t any other services available? Should you recommend on-the-phone or internet counseling which has several drawbacks? It’s a tough decision but whatever you choose, always make your decision with integrity and keep in mind your client’s best interests.