Through the Looking Glass

Interpreting in the Mental Health Setting May, 2018 El Paso, Texas

Click to edit Master title style • Broadly: – What is mental health interpreting – How is it different from other ‘terping? – Who you will work with Click to edit Master subtitle style – How to handle various situations – Taking care of yourself This will not make you an expert!

• Community interpreting vs. mental health interpreting: what’s the difference? • “I Don’t DO mental Health interpreting!” – Are you sure??? Mental health interpreting can happen in unexpected times and places

•Medical settings ● Educational settings •VR/social services

• Interpreter training has been a response to • There are several models of interpreting: historical antecedents – Helper – Machine (or conduit) – Communication facilitator – Ally – Cultural mediator

• Cultural mediation model is growing in acceptance – especially since start of 2000s (c.f. Executive Order 13166) – Driven, in part, by spoken language interpreters

• Reaction to the Conduit Model • Opposition from some because it is “unethical” Equal Access Equal Outcome Thought: – Attempts to put interpretation into a cultural – Charge arises from a world view informedIs itby better the to context “machine model” allow a – “Our job is to give ‘equal access’ to the • For example: “State School” is misleading – misperception information!” especially when talking to “mental health” types! based on • Another concern relates to trainingculturally and loaded professional maturation material to adversely effect – Beginning interpreters untrained/unprepared to consumer handle this level of professional responsibility outcomes?

• Opposition from some because it is “unethical” • Alabama MHI concept is an outgrowth of – Charge arises from a world view informed by the both the Cultural and Ally models with “machine model” important twists – “Our job is to give ‘equal access’ to the – Several key precepts: information!” •The interpreter is part of the treatment team and • Another concern relates to training and impacts the treatment process professional maturation •The interpreter is usually the only one on the team who is aware of the complex interplay of various – Beginning interpreters untrained/unprepared to sequelae of deafness handle this level of professional responsibility •Interpreting is a practice profession rather than para-profession

• Developed from a knowledge-driven viewpoint • Accurate interpretation involves: rather than a skills-driven viewpoint – The structural differences between languages – Early efforts (1995 – 2003) in Missouri – How each language is seen and used by each • “Minimum Competencies” culture – Alabama State Code – 2003 Prior to MHIT • Emphasis on training, application most training in – The “thought worlds” of the parties involved and demonstration • Mandated 40 hours of specialized MH interpreting training – the MHIT Project were of the (Full information at www.mhit.org) “how do you sign

______” variety

“What’s Going On With You?” • Further, accurate interpretation depends • In a psychiatric hospital between night nurse and clear understanding of: patient • In an emergency room between a doctor and a quietly – Context seated patient – Intent of the communicants • In an emergency room between a doctor and a patient – Purpose of the message with his foot facing the wrong way • In the police station between mother and son • Between close friends who haven’t seen each other in a long time

Cheerfully plagiarized from Robyn Dean

Cheerfully Plagiarized from Dean and Pollard

• Clinicians use language to test hypotheses as to what is going on with a consumer – What things (“demands”) might be operating in the following opening of a clinical session: “How have you been doing since the last time we met?” • First we have to understand how mental illness overlays the process

Cheerfully plagiarized from Robyn Dean

• DSM-V Definition: • Major types of mental illness: – A mental disorder is a syndrome characterized by – Psychosis clinically significant disturbance in an individual's •Fundamental mental derangement (as cognition, emotion regulation or behavior that reflects schizophrenia) characterized by defective or lost a dysfunction in the psychological, biological, or contact with reality developmental processes underlying mental functioning. • An expectable or culturally approved response to a Remember: common stressor or loss, such as the death of a loved The signs for disorders I use here may be OK for using one, is not a mental disorder. with professionals but are not effective with consumers

Emphasis mine

• Major types of mental illness: • Major types of mental illness: – Psychotic disorders – Psychotic disorders •Schizophrenia is the most familiar form •Schizophrenia is the most familiar form – It is organic and incurable – Delusions – Most admissions and residents of public mental hospitals – Hallucinations – Chronicity and severity mean costly and difficult to treat – Disorganized thinking/speech – Public policy - homelessness, notorious crimes – Grossly disorganized or abnormal motor behavior

Sensory Modalities • Erroneous beliefs • Auditory that usually involve • Visual a misinterpretation • Olfactory of perceptions or • Gustatory experiences, not • Tactile supported by reality – Bizarre and non- bizarre https://www.youtube.com/watch?v=LWYwckFrksg

“I am Godd.”

“I used to play with Napoleon as a young boy. We built a wagon together.” • Major types of mental illness: “My mother is Elizabeth Taylor. My father is Andrew Coumo.” – Psychosis •Schizophrenia is the most familiar form “The TV tells me what to do and I communicate with the TV by placing notes into the vents in the back of the TV.” – It is organic and incurable – Most admissions and residents of public mental hospitals “I am pregnant with 99 babies. They won’t come out.” – Chronicity and severity mean costly and difficult to treat “I am a CIA baby. The CIA talks to me through my hearing aids and tells me – Public policy - homelessness, notorious crimes what to say.”

“Orange is the CIA, Green is the army, Black is evil – except for interpreters…”

“Every night someone sneaks into my room and takes apart my clothes and then re-sews them a size smaller.”

• Major types of mental illness: – Psychosis •Schizophrenia is the most familiar form – Positive symptoms: thought insertion and broadcasting, loose association, hallucinations (auditory visual, tactile, olfactory,) delusions, paranoia, – Negative symptoms: flat affect, lack of pleasure and motivation, and social isolation

• Major types of mental illness: • Major types of mental illness: – Bi-polar and related disorders – Bi-polar and related disorders •Manic – Can be accompanied by delusions and •Hypomanic hallucinations •Major depressive – Behavior problems when manic •Mixed – Possible suicide when depressed

• Major types of mental illness: • Major types of mental illness: – Bi-polar and related disorders – Depressive Disorders •Thought to have genetic, biological and environmental causes

• Major types of mental illness: • Major types of mental illness: – Anxiety disorders – Trauma- and Stressor-Related Disorders •Panic Disorder •Post-Traumatic Stress Disorder •Phobias •Generalized •Anxiety Disorder

There are enough phobias out there to give you phobophobia

– Schizoid Personality Disorder: • Major types of mental illness: Individuals with schizoid personalities tend to be introverted, withdrawn, solitary, emotionally cold, and distant. They are often absorbed with their own thoughts – Personality Disorders and feelings and are fearful of closeness and intimacy with others. •Borderline Personality Disorder* is common and – Paranoid Personality Disorder: People with paranoid personality disorder are often untrusting, unforgiving, and tough to treat prone to angry or aggressive outbursts without justification, because they – You absolutely must avoid dual relationships in this perceive others as unfaithful, disloyal, condescending, or deceitful. This type of person may also be jealous, guarded, secretive, and scheming, and may appear to case - You cannot let yourself become a pawn! be emotionally “cold” or excessively serious. – Schizotypal Personality Disorder: These people may have odd or eccentric manners of speaking or dressing. Strange, outlandish, or paranoid beliefs and thoughts are common. They may react inappropriately or not react at all during a conversation, or they may talk to * People with this disorder are prone to unpredictable outbursts of anger, which sometimes manifest in self-injurious behavior. Borderlines are highly sensitive to rejection, and fear of abandonment themselves. They can also display signs of “magical thinking” by saying they can may result in frantic efforts to avoid being left alone, such as suicide threats and attempts. see into the future or read other people’s minds.

– Antisocial Personality Disorder: – Narcissistic Personality Disorder: People with antisocial personality disorder characteristically act out their People with narcissistic personality have an exaggerated sense of self- conflicts and ignore normal rules of social behavior. These individuals are importance, are absorbed by fantasies of unlimited success, and seek constant impulsive, irresponsible, and callous. These people are at high risk for substance attention. Prone to extreme mood swings between self-admiration and insecurity, abuse, especially alcoholism, since it helps them to relieve tension, irritability, these people tend to exploit interpersonal relationships. and boredom. – Histrionic Personality Disorder: – Borderline Personality Disorder: Individuals with this personality disorder exhibit a pervasive pattern of excessive People with borderline personality disorder are unstable in several areas, emotionality and attempt to get attention in unusual ways, such as bizarre including interpersonal relationships, behavior, mood, and self-image. Abrupt and appearance or speech. With rapidly shifting, shallow emotions, histrionics can be extreme mood changes, stormy interpersonal relationships, an unstable and extremely theatrical, and constantly need to be the center of attention. fluctuating self-image, unpredictable and self-destructive actions characterize the person with borderline personality disorder. These individuals generally have great difficulty with their own sense of identity.

– Avoidant Personality Disorder: People with avoidant personalities are often hypersensitive to rejection and are • Major types of mental illness: unwilling to become involved with others unless they are sure of being liked. Excessive social discomfort, timidity, fear of criticism, avoidance of social or work – Somatic Disorders activities that involve interpersonal contact are characteristic of the avoidant personality. •Illness Anxiety Disorder – Dependent Personality Disorder: People with dependent personality disorder may exhibit a pattern of dependent and submissive behavior, relying on others to make decisions for them. They require excessive reassurance and advice, and are easily hurt by criticism or disapproval. They have a strong fear of rejection. – Obsessive-Compulsive Personality: Individuals with compulsive personalities are excessively conscientious and have high levels of aspiration, but they also strive for perfection. Never satisfied with their achievements, people with compulsive personality disorder take on more and more responsibilities. They are reliable, dependable, orderly, and methodical, but their inflexibility often makes them incapable of adapting to changed circumstances.

Janice [A.] awoke with a start to find a male staff person shaking her bed. Other consumers were routinely wakened by knocks on their door, but Janice, being deaf, could not hear the knocks. Janice was the only deaf patient on the unit at that time, and the unit was not equipped with • Major types of mental illness: flashing•“Trauma alarms or is other often adaptive experienced devices commonly as a result used in ofspecialized – Distress falls under several of headings units communicationfor deaf patients. barriers.” (NASMHPD, 2012) •Normal psychological responses to stressful Embarrassed that the male had walked into her room without notice, while conditions she was in bed and partially unclothed, Janice tried to yell at him to leave. – Very common •Was Janice’s reaction “abnormal”? – Manifests as a combination of depression and anxiety She has little intelligible speech, however, and her utterances were •What about the hearing workers’ reaction (“Dope – Many psychosomatic symptoms interpreted as signals of aggression. The aide grabbed her arm and, as up the psycho before she hurts someone!”) – What is normal? What is stress to deaf people Janice struggled to get away from him, the aide called for help. Unable to vis hearing people? quiet•What Janice, aboutstaff called your for reactions? help and Janice was given an injection of a •Are there some stressors that SHP’s would not drug cocktail– Dealing (Ativan with, Haldol secondaryand Benadryl) trauma to is “calm important her down”. comprehend?

• Major types of mental illness: • Terminology follows DSM-V – Impulse Control Disorders • Classified mild, moderate or severe – Oppositional Defiant Disorder – Conduct Disorder • Causes significant impairment – Health – Home – Work/school

http://www.samhsa.gov/disorders/substance-use

• Alcohol Use Disorder • Stimulant Use Disorder – Prevalence in Deaf Community • Hallucinogen Use Disorder – Levels • Opioid Use Disorder •Moderate: up to 1 drink per day for women and up to 2 drinks per day for men – Abuse of Rx drugs is becoming common •Binge: 5 or more alcoholic drinks on the same • Others occasion on at least 1 day in the past 30 days – Tobacco Use Disorder •Heavy: 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days – Cannabis Use Disorder

• Mental health service can be defined as assistance given to an individual to assist in coping with emotional, behavioral or cognitive problems – Problems can be short-term or long-term

• The most critical component in mental • What does this mean for: health work is the personal relationships – The relationship between the deaf consumer established between the client and the and the clinician? clinician – The relationship between the interpreter and – This relationship is based on effective the deaf consumer? communication – The relationship between the interpreter and •Remember Pollard’s quote earlier: the clinician? – The relationship of the interpreter to the process?

• What does this mean for: – The relationship between the deaf consumer and the clinician? – The relationship between the interpreter and the deaf consumer? – The relationship between the interpreter and the clinician? – The relationship of the interpreter to the process?

Discipline Training Special Orientation

M.D. (Medical Doctor) or Biological Treatment, D.O. (Doctor of Osteopathy) and Three Psychopharmacology. Some Psychiatrist year Psychiatric Residency Psychotherapeutic modalities and orientations.

Ph.D. (Doctor of Philosophy in Psychotherapy: All modalities • Mental health work is confusing enough without Psychologist psychology) or Psy.D. (Doctor of and orientations. Psychological having to sort out who does what Psychology) and one year Internship. Testing.

– Not all people do all things M.A. (Master of Arts) or M.S. (Master of Psychotherapy: Some Masters Level Science) or M.Ed. (Master of modalities and orientations. Psychologist – This is especially true in the public sector Education) Psychological Testing. • In the private sector mental health professionals are more likely to be “generalists” Psychotherapy: Interpersonal, Social Worker M.S.W. (Master of Social Work) family, group, milieu • Knowing what different professionals that you orientation. M.A. (Master of Arts in counseling) or will interact with do will make your job easier Counseling. Vocational and Counselor M.Ed. (Master of Education in Educational Testing. – You will be more prepared for what people will say or counseling)

ask Counseling and Psychotherapy: Psychiatric Nurse M.S.N. (Master of Science in Nursing) Some modalities and Specialist orientations.

• Acute Care (Hospital emergency rooms) – May be a regular community hospital or a special psychiatric hospital Think about – Used for control of suicide or psychosis ✓Context •Psychosis means the person’s thinking is so ✓Intent of the communicants disordered they are not safe ✓Purpose of the interaction – This setting is used to help stabilize the client

• Crisis Services • In-Patient Services – The goals are much like that of the ER, but – This is used when the client is not safe to send hopefully can be done without going to the back home hospital •Increasingly involuntary only and for shorter – Teams are (usually) mobile durations – This shades into legal interpreting •Wards may be locked •Clients will have a variety of needs

• In-Patient Services • In-Patient Services – A time of stabilizing and medication – Stays can vary from relatively short (acute) to monitoring many years (long term) •“Stabilize and get them out” •You will encounter a variety of professionals •There may be activities and psychotherapy – Special case: Forensic inpatient services – Individual and groups •Dependent on courts

My personal view: Interpreted group therapy is a waste of time

• Out-Patient Services • Residential Programs – Day Treatment (or partial hospitalization) – These are usually distinct from hospital settings, though they sometimes function like one •Has many of the same goals of in-patient treatment without the overnight stays – A broad term that covers a number of settings •Case management becomes important – May have a high or low level of supervision – General out-patient services (or Psycho-Social – The interpreter may be called for: • Admission procedures Rehabilitation) • Discipline hearings •Focuses on providing a variety of services needed • Crisis intervention to the client to maintain in the community • “Community” meetings

• Substance Abuse Programs • Therapeutic Models – There will be an array of services – Psychoanalytic •In-patient – “Client – Centered” •Out-patient – Cognitive •Self help (12 step groups) – Behavioral – These are all tough to interpret – Family Therapy •Special “slang” and terminology •Confrontational style – Psychosocial •Emotionally loaded material

Theoretical Role of Role of Role of Goal: Model Clinician Client Interpreter Change • The interpreter’s role and approach will Patterns of vary according to the Cognitive Educator Student Interpreter Thinking – Clinician’s theoretical orientation Observer/ Communication Behavioral Subject Behavior Reinforcer Facilitator – Goal of the session Feeling/ Affective Therapist Patient Varies – Clinician’s experience and comfort with emotion introduction of the interpreter into the Psychosocial Member Member Member Relationships therapeutic alliance Resolution of Psycho- Therapist Patient ??? long-standing • Your goal is to help facilitate recovery analytic conflict

• Alliances: Yours, Mine, Ours • By it’s very nature mental health work requires the interpreter to ally with the therapeutic process! • Generally, where your alliances will form depend – This usually means the clinician partly on the setting – DANGER: If you do not have a sense of alliance – Legal settings for example you may ally with the you can do much harm defense, the prosecution, or the court itself – You have to match the clinician’s affect, – Medical settings usually lend themselves to approach, style, etc. alliance with the Deaf person • AL MHIT teaches to consciously ally with the therapeutic process

• Lack of this alliance makes you vulnerable to: • Interpreters are trained to make deaf people – Mistakes “sound good” • You don’t know the: • People with disordered thinking don’t sound – Context good – Intent of the communicants – If you are “fixing” the communication you – Purpose of the interaction • Susceptible to manipulation may be depriving the clinician of valuable information – Trauma •You need to have options for how you can deal with • From consumers “weird stuff” you see • From process • From your own baggage

• Don’t “fix” dysfluent language – describe what • Interpreting is hard enough without dealing with you see things that hinder communication – This requires that you have enough – World View Differences experience and training to recognize – Dysfluency (and language deprivation) dyfluency vs. “Word Salad” or psychotic – Fund of Information Deficits/ information deprivation communication – Psychosis More about this later • Before you can determine abnormal you have to DO NOT DIAGNOSE! know what normal is Do not use diagnostic words Do describe what you see Do put it into cultural context

• What normally happens between hearing • What changes in this process when we introduce client and hearing clinician? a deaf client and interpreter? – Who trusts who? • “How are you doing?” – Who is uncomfortable and why? – Hearing to hearing response – Deaf to Deaf response – Deaf to hearing* response (without an interpreter)

• It is a mistake to pretend that an • Must know the difference between interpreted session is the The goal needs to normal and abnormal behavior for a same as one-on-one session – bring the outcome of specific population set which is what most hearing the deaf to hearing clinicians do! session to the same –Consider: – Shock Withdrawal Paralysis: as it would be if it • Age • Etiology were hearing to Shift to rote behavior • Gender • Socio – economic status (Brain off mode) hearing (or deaf to deaf for that matter) • Ethnicity • Education Equal access ≠ equal outcome!

• “World view” is how people process and catalog • Interpreters believe the message content information they receive is most important • Factors influencing peoples’ “world view” – “Message (content) must be rendered accurately”

Individual Social – “Words chosen” to fit the context – but what influences that context?

Communication – Explicit vs. implicit messages Environment

• How the consumer is using language is an important window on mental functioning – Often how something was said is as important or more important than what was said • ASL is a process-rich language with many non-manual markers – Hearing people are not aware those markers are there and they can significantly change the meaning of a a signed concept – ASL – fluent clinician are (or should be) aware of those markers

• In mental health, weird stuff in form can be • Specific, disruptive errors in language use that caused by: are atypical of average users of that language •Psychosis – i.e. a pathological cause •Information deprivation • medical/trauma •Dysfluent Language (including deprivation) • psychiatric • A general lack of proficiency that is significant enough to impair communication with someone who is proficient in that language – i.e. a developmental cause apart from medical • Some combination of the two

• There are numerous purely medical causes of dysfluency. • What is a “typical” deaf person? Some also cause deafness Here are a few… – Up until the late 20th century, deafness was largely – TBI, stroke are most common either: – Genetic Factors (Heredity) All of these also • Acquired deafness (Post natal) often post lingual – Likely – Complication of Rh Factor have mental health, have well-developed L1. – Meningitis • Hereditary (i.e. genetic) often had no other neurological – Maternal Rubella, and sometimes life involvement. (See Parker, et.al) – may or may not have well- Congenital Rubella Syndrome (CRS) long medical developed L1. – Prematurity consequences – 70 – 80% will be non-syndromic. – Syphilis Bacterial Infection – Late 20th century forward – Herpes Simplex Virus Infection • Decrease in acquired deafness (but increase in acquired – Cytomegalovirus (CMV) Infection New article by Crump and Hamerdinger trauma-induced hearing loss). http://tinyurl.com/jdblfog – Toxoplasmosis • Increased pre and peri natal syndromes involving deafness.

Crump, Charlene and Glickman, Neil (2011) "Mental Health Interpreting with Language Dysfluent Deaf Clients," Journal of Interpretation: Vol. 21: Iss. 1, Article 3.

Cause Impact Language Issues Cause Impact Language Issues • Physical difficulties may include hearing, • May include brief intermittent • CMV is a common cause of congenital • These individuals typically have a vision, urogenital, and endocrine periods of language incoherence hearing loss. shorter attention span, impulse disorders (similar to, but with a different • May pass newborn screening but will control issues. • Major, frequently late-occurring origin to incoherence as a develop hearing loss later. Progressive • Low tolerance for delayed neuropsychological sequelae (such as psycholinguistic error) in either • 10% to 15% of affected infants will gratification. developmental delay/mental retardation, expressive or receptive language. Cytomegalovirus likely develop central nervous system • Some significantly different autism, abnormal behavior patterns, • Asymmetrical language in (CMV) damage (i.e., hearing loss, language processing. impulsivity, hyperactivity, rigidity and expressive/receptive sign or in Maternal Infection developmental and intellectual specific learning disabilities). written or read English. Rubella delays, psychomotor difficulties). • May use one modality of sign • Visual problems are possible. language expressively and another • CMV-related learning problems may go modality receptively (may use an unidentified until formal schooling English based signing expressively, begins. but understand ASL receptively). • Trouble transferring information Adapted from Crump, C. J., & Hamerdinger, S. H. (2017). Understanding Etiology of Hearing Loss as a Contributor from working memory to long term to Language Dysfluency and its Impact on Assessment and Treatment of People who are Deaf in Mental Health memory. Settings. Community Mental Health Journal, 1-7.

Cause Impact Language Issues Cause Impact Language Issues • High incidence of physical and cognitive • Expressive and receptive abilities disabilities (e.g., aphasia, developmental may differ. Tend to have superior • Vision difficulties, impulsivity, and low • Expressive skills being superior to delay/mental retardation, learning expressive skills. muscle tone or their limbs may be floppy. receptive skills. disabilities, behavioral/emotional • The younger the illness occurs, the • Poor short-term memory, inconsistent • Exhibit an ability to grasp parts of a problems). greater the risk for delayed memory and knowledge base, poor concept, but not process the whole • Children may suffer severe physical and language. There does seem to be judgment. message. neuropsychological sequelae and have opportunity for “catch up” on • Information-processing disorder, poor • Repeat information back as if it is ability to perceive patterns, poor cause understood, when, in fact, the difficulty in educational programs. discourse, but creates delay. Deaf Fetal Alcohol and effect reasoning. information is not. (bacterial) individuals can also have further Syndrome • Inconsistent ability to link words to Meningitis language delay. Disorder actions, poor generalization ability, and • Difficulties using the context of a (FASD) situation to infer others’ intentions expressive or receptive language and appropriately modify their own disorders. behavior. As a result the child may • Poor spatial awareness, resulting in a behave inappropriately because failure to cross the midline (e.G., they have not perceived, or Reaching for something to the left with accurately interpreted, another’s one's right hand.) Less detailed language meaning. than peers.

• Having a good idea of what types of mental A Subtle Example: Mania illness will impact language use and how is She had cancer of the spinal cord when I was 11-years-old a major tool clinicians use to diagnose. and they had to take out her back, eight inches of her back out to kill the cancerous tumor. So that means she was paralyzed from her breast down for 21 years of her life. She died the age of the year I was born, ‘61. I believe everything has a purpose under heaven…I believe that’s the time that God wrote down she is going to die before she hit her 62nd birthday she was going to die and be my guardian angel at 61 of the year I was born.

This is a general list. There are certain forms which are reported among Deaf people.

A Gross Example: Schizophrenia • Poverty of Speech • Word approximation Well their the before on the clock, that’s the 6,7,8,9,10, 11, • Poverty of content • Circumstantialities 12, 1, 2, 3. They go by those numbers of the clock. And • Pressure of speech • Loss of goal when you do the 25 after that’s the after side of the clock. • Distractible speech • Perseveration We go by the 1,2,3,4 and 5 of the clock and the 5 you go • Echolalia right left to 7 number on the clock is the 5 number. You go • Tangentially • Blocking right left to that number. That’s what the 25 is. If you don’t • Derailment do something they tell you to do and Jesus makes the shot • Stilted speech • Incoherence gun sound and then phone rang not to answer the phone or • Self-reference the door bell. • Illogicality • Paraphasia, phonemic • Clanging • Paraphasis, semantic • Neologisms

• How do interpreters communicate what • Clanging String of signs produced with one handshape they are seeing: • Illogicality Conclusions do not connect in a – What’s “deaf” stuff? logical manner • Sign Perseveration Signs are repeated more than – What’s not deaf stuff? threeFrequency times of a specific gesture in inappropriate contexts, not for • Stereotypy communication but for self- stimulation

Adapted from Crump

• Topic Derailment Changing topics in mid-discourse • Clanging • Illogicality • Topic/Thematic Inappropriate insertion of signs • Sign Perseveration Perseveration related to a theme • Stereotypy A series of unrelated sign or gestures • Topic Derailment • Incoherence that can’t be identified. Grammar • Topic/Thematic andAspects syntax of signare deficient are missing or Perseveration • Visuo-Spatial incorrect (handshape, movement, • Incoherence Anomalies location). Grammar and syntax • Visuo-Spatial are intact Misuse of signing space or using a Anomalies • Paraphasia non-linguistic element in place of • Paraphasia sign Adapted from Crump Adapted from Crump

• We can’t approach behavioral health the • The biggest barrier to this paradigm shift way we have approach interpreting was the “I’m just the interpreter” historically mentality. The reality is that no one ever – A different paradigm was “just” the interpreter. – Your presence fundamentally changes the interaction

• Interpreted interactions are ≠ • I must change the words you have chosen. direct interactions • I will need to add and delete information during my • You are “there” translations. • You presence creates a • I must form my own judgments about what each consumer different thing than would means before choosing from among many possible have been there without an translations. interpreter • You, the consumers, are responding to my translation • Your choices will influence choices, not the original comments, which leads and the course of the interaction influences both of you and the resulting dialogue. • My very presence and my needs will influence the flow of the interaction and your relationship.

• Interpreters are often trained in a • Interpreters are historically “Instead of deontological fashion and may lack the dichotic – everything is black identifying a singular skill of analyzing actions in light of and white! personality type, outcome, i.e. reflective thinking – Inflexible or indecisive these results point to – Tendency to want to evaluate work as a • Old Code of Ethics was written an interesting trend toward extreme product of "paint by numbers“ for dichotic (i.e. deontological) traits.“ “Is it ‘right’?” thinking From:: Brenda C. Seal Psychological Testing of Sign Language Interpreters, – Supervision (mentoring) is often from the J. Deaf Stud. Deaf Educ. 2004 9: 39- same “right or wrong” framework 52

• Baseball analogy: Runners on first and third… Ethical and Effective Decisions – What do you do? What Too Liberal Too Conservative factors do you have to consider? Conservative Therefore Liberal Therefore •If you are defense? (Teleological) (Deontological) ineffective ineffective •If you are offense? and/or and/or – Is there one “right” answer? unethical unethical •There are effective and ineffective choices

From Pollard and Dean

• Code of Professional Conduct encourages • Making decisions requires a framework more flexible thinking – MHIT uses Pollard and Dean’s Demand Control Schema – Interpreters adhere to standards of confidential communication. • The challenges we face in our work are the – Interpreters possess the professional skills and demands knowledge required for the specific interpreting • The techniques we talk situation. about will give you – Interpreters conduct themselves in a manner appropriate to the specific interpreting situation.

How do you make those decisions? http://demandcontrolschema.com/book/

• Content = What was said • Interpreters trained to attend to content – eats shoots and leaves (“accuracy” űber alles) • Clinicians are trained to attend to form • Form = How it was said (and to content, of course) – Eats, shoots, and leaves – Eats shoots and leaves – Eats – shoots - and leaves

• Psychosis • Language structure and usage – Delusions & hallucinations – consistency, age and context appropriate • Bizarre v. non bizarre • Think about cultural differences; • Orientation i.e. high v. low content of discourse – "word salad" • Suicidal or Homicidal Ideation – "weird" • Client history/precipitating factors • Sign Formation – Motor v. psycholinguistic errors – "weird" • Responding to internal stimuli

• Discourse Be sure you do • Language is an important diagnostic tool in – circumstantial or tangential not let clinicians assessing an individual’s mental status • Affect mistake high • We must know how to describe to hearing content for clinicians with a different worldview what our • Speed of Signing circumstantiality – flight of ideas experience and expertise tells us – pressured or psychomotor retardation • Important Resource: • If retarded, consider why (Remember – don’t diagnose!) https://www.northeastern.edu/cali/

• Video clips: • How would you “interpret” each? – One consumer is psychotic • What does the therapist need to know? – One consumer is not, but there is something going on! • As you watch think about: – How would you “interpret” each? – What does the therapist need to know?

• Me sad – finish • A significant source of dysfluency is • What things do you need to consider language deprivation before you render an interpretation? – Two groups of deaf people likely to not have • Med check significant language deprivation issues •Those who became deaf after starting school • Suicide assessment •Those born in an ASL- fluent family • Check in

• A significant source of dysfluency is • Affects many deaf consumers – even well language deprivation educated ones Thought: – Many “born deaf individuals” Hearing – Schild calls this information deprivation – more accurate will experience some level of clinicians have FOI deficit language deprivation, ranging no schema for • Result of or language from insignificant to alingual – Suboptimal Education Difference? – Some of the patterns labeled deprivation – Lack of exposure to incidental “psycholinguistic errors” are without learning attributable to deprivation pathology – Poor reading skills – May be “PsychologicallyLanguage and Learning Unsophisticated” Challenged

• You need to be able to assess how • Designed to do a full communication skills of the participants are evaluation of the deaf playing out in the setting client’s history, – Is the person having difficulty with English or with background, etc. language skills in general? – Is there a communication system in place? – Assists in assessing the • Do not mistake “home signs” for no language! consumer’s preferred mode – Is the consumer dysfluent or do the linguistic errors of communication indicate something else – Make recommendations • MHIT teaches Communication Skills Assessment such as adaptive equipment Tool and use of a certified sign language interpreter

•Assessors will look for the following issues in • Is it going smooth? If not, think about assessment: possible reasons – Etiology of hearing loss, age of onset, & severity – You have to describe what you see – Family communication styles – Language fluency – ASL, English, home signs? • When faced with linguistic challenges you – Understanding of terms and concepts in mental health have options – Additional disabilities/ co-morbidity – Other factors that may influence how we provide communication and environmental access to care

Meaning Number Number • Remember the choices you have: Per Sign of Signs of Users – Frozen Frozen

– Formal Formal – Consultative – Casual Consultative – Intimate Casual

Intimate

Example per Roger Williams

• You have choices as to how you will • You have choices as to how you will present the information present the information – First person First person, (from the point – First person The narrative strategy: of view of Jill would be): The consumer is telling the story – Third person Jack and I went up a hill to – Third person of “Jack and Jill.” – Narrative fetch a pail of water. He fell – Narrative down and broke his crown Glossing: and I went tumbling after. – Descriptive – Descriptive JACK JILL THEY-TWO MOVE Third person. UP HILL.WHY? GRAB Jack and Jill went up the hill to BUCKET WATER. JACK FALL fetch a pail of water. Jack fell ROCK HEAD HIT HURT down and broke his crown and FINISH. JILL FALL ROLL- Jill came tumbling after DOWN. Jack and Jill examples by Charlene Crump Jack and Jill examples by Charlene Crump

• You have choices as to how you will • You have choices as to how you will present the information present the information In the descriptive strategy: – First person The consumer is telling the story – First person Background information: – Third person of “Jack and Jill.” However, his – Third person The roots of the story, or poem, of expression is more stoic than I Jack and Jill are in France. Jack and – Narrative am used to seeing. Every time he – Narrative Jill are said to be King Louis XVI - signs Jill’s name he adds (as in a Jack -who was beheaded (lost his – Descriptive side comment) “kill son, kill – Descriptive crown) followed by his Queen Marie mother.” His left hand is fidgety, Antoinette - Jill - (who came not producing language, but tumbling after). moving in a short quick movement.

Jack and Jill examples by Charlene Crump Jack and Jill examples by Charlene Crump

First person Third person Narrative Descriptive • You have choices as to how you will present the information – Simultaneous Content Form – Lagged • The choice often comes down to the intent of the – Consecutive communicants, or what is the purpose of this interaction – Diagnostic decisions: more form – Therapeutic alliance: more content

• Mental Status Exams • General Psychological Assessment • Medical Evaluations Highly Specialized Assignments • Forensic Psychiatry

• Mental Status Exams are a crucial element • A systemic collection of data-based in the clinical interview observation of a patient’s behavior (APA • These exams help clinicians get a practice guidelines); “snapshot” of their clients in the here and • An attempt to objectively describe the now behaviors, thoughts, feelings, and • May often determine whether consumer perceptions of a patient; and gets treatment or not • It is the objective portion of the psychiatric interview

• Evaluates • Appearance and behavior, attitude – Appearance/behavior. attitude, perception, – Posture orientation, judgement, cognition, abstraction, and – Gestures insight – Grooming • Administration – Dress – Quickly and repetitively – Facial expression – In theory: objective – Speech – Attention – Mood – Affect

• “My name? Well, I’d tell you my name • “My name? I thought you’d never ask. You doctors except for the weather, which is humid. are always asking so many useless questions, you Hot weather really bothers me, makes me forget the most important ones. I had a doctor once back in 1982 – or was it 1983? – I think he want to paint my car blue. I got fired last was a family practitioner , or maybe he was an week. Chocolate is my favorite flavor of internist. No, definitely an internist. Anyway, he pudding. Centrally planned economies will treated me for thirteen years without ever once always fail because no one can regulate addressing me by name. I think he didn’t know my the temperature in that room you’re going name. Maybe I was just Patient Number 7155 or something. But now that you asked, my name is to admit me to.” Bob.”

• “My name? Why it’s Bob, as in Bob Dole. Did you • Perception know Dole is from Kansas? Kansas – what a state! – Hallucinations Did you know Kansas produces more wheat than – Delusions most countries in the world? Wheat is important. In – Illusion fact, without wheat, there would be no Wheaties. – Other Wheaties makes me regular. I hate being constipated, don’t you? I think constipation is the root of most evils in the world. I’ll bet you Hitler was constipated. That’s because he was a vegetarian. What other questions do you have?”

• Orientation • Judgement – Time – Personal – Place – Social – Person

• Cognition • Abstraction – Memory, short term – Similarities – Immediate recall – Absurdities – Reversals – Proverb interpretation – Concentration – Calculation

• Formal equivalence – Source-oriented – Designed to reveal as much as possible of the form and content of the original message • Dynamic equivalence – Concerned with receptor response – The closest natural equivalent to the source- language message

• Can occur in a variety of MH settings • The goal is to determine: – Medical doctor’s office – Diagnosis – Chemical dependency facility – Disposition (level of care) – Psychotherapy intake – Follow up – Emergency interventions – Psychiatric emergency department – Cooperation/engagement – A medical hospital emergency room – Further assessment (data) needed

• Setting matters • Who is likely to do an evaluation? – General hospital ER or How does “Big 3” – Social worker private practice play out here? – Psychiatric nurse clinic? ✓Context •Treat ‘em or street ‘em ✓Intent of the – Psychologist (aka GOMER) Communicants – Psychiatrist – Demands and controls ✓Purpose of the – Students, trainees, interns, residents will be different in a interaction private practice – Emergency room physician psychiatry clinic!

• Mental Status Exam • Baseline • Sometimes disease or physical disorders can mimic • Chief complaint • Co-morbidity mental illness • DSM diagnosis • Psychopharmacology – Example: hypothyroidism often has the same type of symptomology as major depression • Psychosis • Self-harm Imminent • For example, Pendred Syndrome • Delusion • Maladaptive/adaptive • As mentioned earlier, syndromes that can have • Hallucination • Agitation deafness as one of the symptoms can also have • Mood disorder • Rule out psychiatric or psychological symptoms as well – Blunted affect • Differential diagnosis • Personality disorder

• Management of mental Discussing side • Anti-depressants (also for OCD) illness often requires – Luvox, Prozac, Zoloft, Paxil, Wellbutrin effects is medication • Anti-anxiety – Many symptoms of mental challenging with – benzodiazepines , beta blockers, non-narcotics illness are the result of chemical imbalances language and • Mood-stabilizers • Psychotropic medications information – Lithium, Depakote, Tegretol are very helpful, but can deprived • Anti-psychotics have dangerous side – Zyprexa, Risperdal, Seroquel effects consumers – This is not a place to make mistakes!

• Essential concepts to convey • Essential concepts to convey – Symptoms – Side effects •How do you communicate degree? •How do you explain comparative statistics or – Mechanism effect percentages expressed in .01%? – Fun thought experiment: Explain comparative probability •How does the medication work? of dying in a car crash with dying in a plane crash How do you explain this to you “Language and Learning – Dosage and usage issues Challenged" deaf consumer? – Compliance Zoloft is an SSRI. It blocks the brains utilization of Serotonin

Simply identifying the • Concerns about medications (myths) medications can be challenging. – Becoming addicted “Take the blue pill” won’t cut it. – Being viewed as weak Medication appearance varies – Frustration at “exploratory” process by dosage, route, and, in the case of generics, manufacturer – Rest of life question

Dr: I am going to put you on Klonopin. It’s important to know that Benzodiazepines have been associated with a 54% increased risk of heart failure in seniors

• These are special situations when the courts are • Can be a very valuable tool for the clinical and attempting to determine competency to stand trial or interpreting process assess the validity of an insanity plea • Qualifications and credentials – Insanity pleas are not common • Training for CDIs – Incompetent to stand trial more frequent • Is the purpose assessment or treatment? • NCST can lead to a life sentence for petty crime • The client’s potential freedom (and sometimes his life) is dependent on the accuracy of the assessment • You should be both mental health and legal qualified • There is NO room for mistakes here

• Does the clinician need to understand the • It’s all about TEAMWORK language skills and deficits of the consumer? • What if the interpreter and CDI disagree? • What is happening in the interpreting process? Who is leading the process? • Is the form of the question being changed in a way that is clinically significant? • What linguistic information is shared with the clinician? Is the clinician part of the • With whom does the CDI ally? team? • Very little research on this important topic

• Throughout the day, we have discussed MH • Interpreting is tough – interpreting as a series of demands, for Mental Health interpreting is tougher which we have presented clusters of – Secondary Trauma stress is a huge issue controls – If you haven’t had training in Secondary • You also have demands on your own Trauma – get it! mental and physical well-being

• Insufficient Recovery Time • Beating STS requires having clear strategy: – Self-awareness • Isolation and Systemic Fragmentation – Plan of care • Lack of Systemic Resources – Balance of work, play, and rest • Unresolved Personal Trauma – Connection with other people • Inside your profession • Outside your profession

Perry, Bruce (2003). The cost of caring: secondary traumatic stress and the impact of working with high-risk children and families. From http://www.childtrauma.org/ctamaterials/ SecTrma2_03_v2.pdf. Accessed February 24, 2006

• Avoid bad situations • Reference resources • Know your limits and your buttons Common – www.mhit.org has a lot of resources scattered – Don’t take on assignments you Sense through out the site are not comfortable with ain’t that • Be trained and be current in common! – www.interpretereducation.org/specialization/ techniques healthcare/ • Have healthy outlets • Additional training – This isn’t your therapy session! – You are no good to the clients if you are falling apart yourself!

contact me at

Alabama Mental Health Interpreter Training Project Montgomery, Alabama Full details at www.mhit.org Contact: [email protected]

or at [email protected]