An Interactional Handicap:
“Figure of room, occupancy in a field of general space occurs.”
Verbatim translation of a sentence meaning “it has plenty of room” in Shawnee (an American Indian language). Kyle & Woll (1985).
A paradox has been pointed out (Vernon and Brown, 1964) that deafness increases the probability of emotional problems by increasing tension and frustration, yet also gives rise to a barrier to communication that rules out the possibility of psychological assessment and treatment. Although many assessment techniques are inappropriate (Vernon & Andrews, 1990) and false-positive as well as false negative diagnoses are common (Monteiro, 1989) it appears probable, given appropriate assessment instruments and techniques, that deaf people show comparable rates of prevalence as hearing people for many psychological complaints such as anxiety disorders, depression, substance misuse, somatoform disorders, paranoid, schizoid, schizotypal, compulsive and histrionic personality disorders, and schizophrenia (Vernon & Andrews, 1990; Schein & Delk, 1974). Thus, Vernon and Brown’s (1964) initial premise is shown to be false and the paradoxical nature of the observation no longer applies - however, as a powerful means of indicating the central difficulty for a hearing therapist without facility in the appropriate sign-language it remains effective - it points towards communication as the main handicap resulting from deafness which influences access to psychology and other services. Following this, Elliott et al (1987) point out that communication is both expressive and receptive and as such the disability of the client (the deafness) gives rise to a handicap experienced by the client, the therapist or both. I would argue that communication is necessarily an interactional process, even in the presence of considerable time-delay between expression and reception, that it is the functional coincidence of expression and reception, and so that the above handicap is necessarily experienced by both parties.
This distinction may be further illustrated by considering an example of a hearing therapist and a hearing client, the difficulty in this example being that the therapist speaks only English and the client speaks only Japanese. The ‘disability’ if we may call it that, is clearly symmetrical - each is unable to communicate in the language of the other. A therapeutic situation involving an English-speaking therapist and a British Sign Language-using client may be compared in many important respects to this example, and enables us to move away from the idea of overcoming a disability to enabling communication between two parties who use different language-systems. Although BSL is the fourth major language of the United Kingdom (after English, Welsh and Gaelic) there are just three mental health services in this country providing their services in BSL, and very few psychologists, or other mental health professionals, who are able to communicate in BSL at any level, yet alone fluently. Also, the in-service components of most training courses for psychologists, psychiatrists, nurses and so on make access to such courses for potential deaf professionals particularly arduous, if impossible. How then may non-BSL-using professionals and BSL-using clients overcome this barrier to communication, and thus to services which are clearly needed ?
Breaking the Sound Barrier
It is sometimes assumed that a deaf person will be able to understand spoken English if the speaker were to speak slowly enough, speak louder and exaggerate lip movements (Roe & Roe, 1991). More enlightened people may stress the importance of speaking naturally, if a little clearer, in order to maximise the success of the lip-reader, and indeed in this situation many deaf people are able to understand spoken English with almost flawless accuracy. However, many other deaf people are not able to comprehend spoken English by this means - perhaps unsurprising in the absence of continued aural exposure to the grammar, syntax, vocabulary and idiom of the language. Jeffers and Barley (1975) have estimated that approximately 60% of English speech sounds are indiscriminable or invisible without the accompanying sound, consisting one half of the vowels and diphthongs and three-fifths of the consonants. Roe and Roe (1991) calculate from this that a fluent English speaker who loses his or her hearing could only be expected to distinguish 40% of spoken communication, although they do not elaborate whether this refers to spoken communication at a phonemic level, a word level, or a noun-phrase or sentence level. Equally, meaning derived from inflection and stresses is inaccessible to the lipreader. It can be assumed therefore that a prelingually profoundly deaf person without continued aural exposure to the language could not be expected to reach this level of understanding of spoken English. The utility of this approach in a therapeutic situation therefore is highly questionable for most clients. For a client unable to express spoken English, the question is also begged of how to confirm understanding, and of how this approach facilitates communication in the direction of client to therapist. Of course it does not.
In the absence of more appropriate means to bridge this gap in communication, some therapists have resorted to written communication, that is, passing written notes between therapist and client. The fact that this cumbersome method is generally inappropriate for psychological assessment and treatment requires no further elaboration, especially when one considers the reduced exposure to the syntax and so on of English alluded to above.
Other ways to bridge the gap include using a friend or member of the family to act as interpreter, or for the therapist with a basic understanding of BSL to attempt pidgin signed-English. The use of a friend or family member introduces issues of confidentiality, and the presence of that person is likely to have a detrimental effect on the process of therapy and the therapeutic relationship, while the attempt to engage in signed communication without a critical degree of fluency and confidence can only serve to frustrate the client as difficult material has to be discussed in terms simple enough for the therapist to understand. The therapist may also be perceived as being less skilled, in exactly the same way as deaf people have been misdiagnosed as learning disabled as a result of difficulties communicating with non-signing professionals. Hindley (1993), in his albeit small sample, found that using a qualified interpreter was preferable to attempting pidgin signed-English oneself. Indeed, apart from fluency in BSL oneself, it would be difficult to argue that any other alternative is preferable to using a qualified interpreter.
Use of an Interpreter:
The use of an interpreter in enabling a deaf person to access mental health services gives rise to a number of issues which should be considered when embarking upon such service provision. Roe and Roe (1991) divide these concerns into three groups: those centred on the client, those centred on the therapist, and those centred on the interpreter:
Although the interpreter is usually seen as a facilitator rather than an encumbrance, it is possible that in psychological therapy, when the material discussed is often of a personal, highly charged nature, the client will begin to perceive the interpreter as an intrusion, albeit a necessary one (Stansfield, 1981). Also registered interpreters in this country are obliged not to “give advice or offer personal opinions in relation to topics discussed or people present...” and to interpret “without anything being added or omitted from the meaning” (C.A.C.D.P., 1996). This may be seen as indifference by a client who is unaware of this professional standard. It can be seen that from this position it would be less likely for the client to commit 100% to the process of therapy and to be more guarded. Ironically, as a result of this the interpreter therefore can to a degree become a hindrance to the therapy (although this process may of course be addressed within the therapy itself.) In this way the perceptions that the client has of the interpreter lead to issues within the sessions which would not otherwise have arisen. It is possible also that the interpreter may be seen as allied to the therapist, although further professional standards rule against this consciously occuring. The optimum seating arrangement when using an interpreter is for the client and therapist to sit opposite each other and for the interpreter to sit next to and slightly behind the therapist such that both therapist and interpreter may remain in the client’s field of vision simultaneously. From this arrangement one may imagine a client feeling somewhat outnumbered. Alternatively, the interpreter may be seen by the client as allied with him or her despite the seating arrangements, as it is the interpreter with whom the client appears to be communicating. It is of course necessary for the client to maintain eye-contact with the interpreter when the therapist is speaking, which may serve to compound this effect.
Already it becomes apparent that the client may develop feelings towards the interpreter which may need to be addressed or considered during the therapy. Whether transferential or not, these feelings are especially likely to develop because the interpreter is professionally obliged to give away no personal information or opinions (Menninger, 1958) and it is possible for the therapist to be implicated in these feelings as well. For example, the client may resent the need for an interpreter in order to access appropriate services otherwise freely available to hearing people. Stansfield (1981) suggests that this resentment may lead to mistrust of the interactions between therapist and interpreter - the client would thus be less likely to feel safe or contained enough to explore emotionally charged material. Trust becomes compromised.
Padden and Humphreys (1988) point out that the deaf community is small and very tightly knit, and that interpreters and the members of that community often know each other very well. The deaf community is also characterised by the speed with which news travels within it. It is possible therefore that the client will know the interpreter already (calling into question the appropriateness of using that particular interpreter), but even if this is not the case the client may reasonably feel uncomfortable about disclosing difficult personal material to somebody who may have regular social contact with other members of the deaf community. The ethical position of confidentiality of the interpreter as well as the therapist, then, should be made clear in the initial session (”Interpreters shall treat as confidential any information which may come to them in the course of their work including the fact of their having undertaken a particular assignment” C.A.C.D.P., 1996).
It can be seen how, despite considerable ruling by the professional body for interpreters (the C.A.C.D.P. - Council for the Advancement of Communication with Deaf People), even the most conscientious interpreter cannot help but become more involved in the therapeutic milieu than the clearly defined role of faithfully translating between the two languages.
Millie Stansfield (1987) emphasises this apparent dissolution of professional boundaries when she points out that one of the main vehicles for change is the therapeutic relationship itself. Simply by being present, the interpreter enters into that relationship and impacts heavily upon it, for example at the most basic level of changing a therapeutic dyad into a triad (Hoyt et al, 1981). Thus, any interaction between the therapist and the interpreter becomes a part of the process and dramatically affects the therapeutic relationship(s). The presence of the interpreter may also directly affect the therapist by giving rise to feelings which otherwise would have remained absent. Schlesinger and Meadow (1972) describe the “shock-withdrawal-paralysis” reaction experienced by therapists faced with a deaf client when otherwise established skills and techniques are suddenly unable to be used. Feelings of being deskilled and helpless occur which clearly have an effect on the nature of the relationship. I suggest that this reaction is not alleviated by the presence of an interpreter - indeed that it may be that the therapist fantasises that the interpreter will actually alleviate such feelings but when this is found not to be the case the reaction is only increased. Therapists used to individual therapy and to an environment in which, although they contain both parties, the boundaries and environment are largely controlled by the therapist, will find that the interpreter - with the aim of facilitating optimum communication - will suggest changes to otherwise comfortable and familiar aspects of the process and environment. For example, suggestions may be made regarding the seating arrangements (mentioned above) and the lighting, communication will inevitably be slower than usual as information is translated back and forth - interrupting the usual flow, and ideally the interpreter should take a break after approximately half an hour. The reason for this break is that after this time the error-rate of the interpretation increases to statistical significance (Brasel, 1976), but this can lead to a sense of intrusion felt by the therapist as the hour is broken. All of this may be perceived by the therapist as an ‘expert in deafness’ taking control away and drawing attention to his or her own shortcomings.
Similarly, the therapist’s own degree of understanding of BSL may be a double-edged sword. A therapist with no facility in Sign may wonder, as may the client, about the accuracy with which the interpreter is proceeding. Many English forms take longer than one would expect to portray in BSL, while others are suspiciously short. This and the seemingly constant eye-contact between client and interpreter can serve to isolate the therapist and increase the sense of paralysis. However, a therapist with some understanding of BSL who nonetheless is not fluent enough to competently conduct one-to-one therapy in that language without an interpreter may experience a quite separate difficulty. It is recommended (C.A.C.D.P., 1996) - and indeed polite - to look at the client at all times, even though that person may naturally turn to look at the interpreter. If the therapist is able to understand a proportion of the signed material this can be extremely distracting as attention is drawn away from the spoken interpretation to which attention should be directed. This effect is compounded by the facts that the interpreter should be seated slightly behind the therapist, and so seems a disembodied voice, and that the client will often vocalise variably clear words. It is not easy using an interpreter, and the fantasy of a rescuer from the shock-withdrawal-paralysis is soon shown to be false.
Many of the above concerns may equally be viewed as interpreter-centred, however, there are further issues which may reasonably be aired here. Mention has been made of seeming dissolution of professional boundaries and distortion of the therapeutic relationship. Elliott et al (1987) suggest, indeed assume, that the therapist will meet with the interpreter before meeting with the client to discuss issues such as these - clarifying the role of the interpreter, the expectations of the therapist and developing ways to deal with misunderstandings during the session for example. In particular they recommend such pre-session contact so that a system of covert signals may be set up. On occasion it is necessary for an interpreter to explore a number of translations of a particular concept and it would be up to the therapist to decide whether further exploration of an important concept was merited, or could be moved from. Evans et al suggest a signalling system for this, and during psychometric testing for the description by the interpreter of errors made by the client - and they argue that this leads to increased trust between the therapist and interpreter which serves to reduce a few of the concerns outlined above regarding alliance and isolation. It is recommended (Stansfield, 1987) that the client be informed of these meetings, but not of their content. The effect of this on the client’s perceptions of the role of the interpreter and the trust felt regarding both interpreter and therapist can only be guessed. Roe and Roe’s (1991) comments - that it would be better to address issues of communication and confidentiality, and for the interpreter to step out of role as communication facilitator (if necessary) in front of the client such that otherwise extant mistrust and suspicion may be alleviated - are relevant here. I would further add that it may be more productive, if not healthier, for roles to be collaborative rather than secretive, and to be honestly complex and variable rather than artificially and falsely straightforward. That is, if the interpreter is required to step out of role (for example to comment on non-verbal communication) it is better achieved within the session with an apparent crossing of boundaries, with corresponding increase in trust. I would argue that the boundary around the interpreter’s role is not being crossed in this instance, but being clarified as more complex than could be hoped for. If the interpreter is to be presented to the client as simply facilitator of communication, that person should only be used as such.
In terms of psychometric testing, I feel an argument may be made at least for meeting with the interpreter beforehand - and likely for some time - in order to agree on appropriate translation of material and psychologist response. This should be carried out in some detail and may require an exchange of knowledge in that the interpreter will require a basic understanding of psychometric testing, and the psychologist will need to be somewhat versed in deaf issues, language and culture. The interpreter must understand the standardised administration (although it will inevitably be departed from as part of the stipulation is often that instructions are verbally presented), and the psychologist will need to understand if certain items are unhelpful by virtue of being culturally irrelevant, or because the very act of asking the question in BSL gives the answer away. For example the question “how are a ball and a wheel alike?” could not be used as the Signed administration would trace circular figures in the air, divulging the answer (Stansfield, 1981).
The cultural validity of standardised tests, or structured interviews, highlights another way in which the interpreter works apparently outside of straightforward linguistic translation. A good interpreter will communicate not just the spoken words of the therapist, but also the non-verbal and affective content as well. Many concepts do not translate smoothly from one culture to another, and the question is raised therefore of the degree to which the interpreter re-frames the spoken communication to fit most appropriately into the other culture. Gaviria et al (1984) - in a Peruvian study - outline four ways in which culture impacts on the validity of an instrument or technique standardised on a different cultural group and their observations and categorisations are relevant to Deaf and hearing cultures: Semantic validity demands that words in the original and translated versions carry the same meaning; technical validity requires that the very substance of the translated instrument carry the same meaning and familiarity, and yield similar expectations, as the original - the interpreter in Hindley’s (1993) study considered for example a face-to-face interview to be foreign to deaf children; criterion validity requires that items, questions or comments refer to similar normative concepts between the two cultures, and conceptual validity demands more directly that questions asked actually relate to concepts within that culture. If we (reasonably) assume a knowledge of, and familiarity with, Deaf culture from the interpreter, it is clear that all of these concerns are areas in which that person may be of help.
As alluded to above, it is equally desirable for the interpreter to be versed in mental health issues, the process of therapy and so on. Monteiro (1989) sees this as a requirement in that so much of therapy occurs outwith the spoken utterance, the interpreter needs to be aware not only of where the translation from therapist to client is going (ie translating culturally as well as literally) but also of where the translation is coming from - the therapeutic rationale behind the utterance. An interpreter I have worked with, for example, suggested ways in which she may interpret therapeutic silence. Monteiro suggests that an interpreter without such an understanding may even act to the detriment of the therapy.
Such a background is clearly advisable, but, although not arguments against this practice, certain considerations should be borne in mind. To refer back to comments made above, an interpreter with a grounding in mental health issues may be perceived by the therapist as even more threatening and intrusive. Also, an interpreter with such an understanding may find it quite difficult to work with a therapist who acts in a way which conflicts with the way in which the interpreter would act in the other role; and therapeutic approaches or techniques may be perceived erroneously by the interpreter and worked into the translation, conflicting with the approach then actually taken by the therapist.
A number of issues have been highlighted above, concerning potential reactions to the therapeutic triad of the client, the therapist and the interpreter. Certain of these issues can only be addressed with opinion, either from the literature or myself, while others remain simply highlighted. However, the aim here is not to provide answers to these concerns (since there are probably none which are irrefutable) - rather it is to provide a compendium of concerns which challenge the fantasy that using an interpreter will overcome all of the issues raised when a non-BSL-using therapist and a BSL-using deaf person work together in therapy. Some of these concerns are conspicuous in their absence in the verbatim translation of a Shawnee phrase at the head of this text.
Overall, however, it should be noted that apart from the therapist being fluent in BSL, the preferred means of conducting therapy with a signing deaf person is through an interpreter versed in issues of mental health.
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