Clinical Geriatrics

Introduction

In 2005, On Lok Senior Health Services, a comprehensive long-term care health plan for the frail elderly, took on the challenge of offering in-house mental health services for its senior population.1 The On Lok Lifeways mental health team faced the complex task of providing quality mental healthcare to an extremely diverse population. To illustrate the enormity of this challenge: On Lok serves more than 1100 elderly persons who speak over 30 different languages. Cultural and linguistic diversity render it nearly impossible to offer mental health services to patients in their native languages. Therefore, reliance on interpreters became essential to provide care.

Like other healthcare providers facing these challenges, On Lok teams frequently have had to turn to telephone translation services to meet the diverse linguistic needs of its population. In recent years, telephone translation services have become a more developed field, with guidelines now published for medical telephone interpreting.2,3 However, in the field of mental health, telephone interpreting cannot substitute for face-to-face translation.4 With telephone interpreting, there is too great a risk for interpreter errors and too much potential damage to the therapeutic alliance, with fewer possibilities for correction and repair.

The use of on-site interpreters also presents challenges. The majority of interpreters are not specifically trained to work in mental health settings, just as the majority of psychotherapists are not trained to work with interpreters. The vicissitudes of psychological communication within the therapy framework yield a complex interplay of cognition, emotion, and nonverbal expression. Interpreter errors can be frequent, and misunderstandings often arise. The consequences of miscommunication are profound: the potential for misdiagnosis and ineffective treatment.5-7

The following case illustration demonstrates how common interpreter errors can interfere with treatment. The therapist-interpreter team approach is then discussed as a possible method to minimize errors and promote effective treatment.

Case Presentation

Mrs. B was a 76-year-old monolingual Spanish-speaking, Mexican-American woman. Reportedly, she had suffered from years of spousal abuse by her now deceased alcoholic husband. Mrs. B also had multiple medical problems including congestive heart failure, arthritis, diabetes, difficulty hearing, and mild secondary parkinsonism with muted facial expressions, tremors, stiffness, and soft speech. A widow for 10 years, Mrs. B was the mother of 15 children, had no formal education, and lived with one unmarried son.

Mrs. B had been diagnosed with post-traumatic stress disorder (PTSD) and major depressive disorder, and was treated with antidepressants for over 6 months with very little success. Her symptoms included nightmares, insomnia, anhedonia, and social anxiety. Her primary care physician referred Mrs. B for psychotherapy for symptoms of depression and anxiety.

During her initial assessment, Mrs. B was withdrawn and soft-spoken. She appeared distressed and uncomfortable, her facial expressions sullen and body language tense. A professional interpreter who focused on making factual translations was used during the interview. Mrs. B, with her parkinsonism symptoms and her difficulty hearing, was very hard to understand. Following the best practice guidelines of his profession, the interpreter focused on accuracy, seeking frequent clarification from Mrs. B when he failed to understand her. By asking her to speak up or to slow down, the interpreter inadvertently took control of the pace of the session. Furthermore, he tried to maintain his professional standard of impartiality by showing little emotion.8 Mrs. B responded to questions minimally, became increasingly withdrawn, and appeared intimidated by the clinical setting.

Over the next several sessions, Mrs.