All material is copyright Jim Cromwell from the date of posting unless otherwise specified

Run With Your Client, Not After

This article has been published in the British Medical Journal (BMJ 2004;329:1176 [13 November], doi:10.1136/bmj.329.7475.1176). So if you are citing it, please do so accordingly. Well... They seem to have had a GCSE student re-write it, so if you want to quote this superior version instead, that would be your prerogative...

Chris was always climbing the fence. It was tall, a mosaic of chain-link and climbing weeds, about eight feet, and surrounded the euphemistic “garden” on three sides – the fourth being a three-storey red-brick ward. The ward was a home of sorts to a dozen people with learning disabilities and challenging behaviour and, similarly, a half-dozen nurses. Chris’s most prominent behaviour was “absconding from the ward”, a curiously circular reason for his admission and an activity he engaged in quite successfully on a daily basis.

Absconding was more often than not preceded by a few minutes of artfully presented nonchalance, entirely cloaking him from the watchful eyes of the nurses posted strategically about the place looking for, and only seeing, those behaviours listed in the various reports and management guidelines currently in action. The abscond itself was never witnessed. By sheer well polished sleight, Chris would fade imperceptibly from the consciousness of the assembled staff and then appear, as if conjured from ether, running full-tilt away from the fence.

The staff would snap into action. Blood, previously thickening in our veins, would course effervescently around our bodies. A unified flock-consciousness would drive us towards our joint and single purpose: to catch Chris and bring him back to within the confines of the fence.

To catch Chris.

Our prey stood in excess of six feet and, with daily practice, had developed both the athleticism and gait of an ostrich. He could turn in an instant and be suddenly careering in a completely different direction with no evident change in speed. He could slow down and speed up with no suggestion of inertia or momentum. His flight, essentially, was Brownian.

We would fly from the ward like light streaming from an opening door. We had a purpose. We had a plan. Roles were never discussed but somehow we knew to break into smaller units and try to bisect Chris’s unknowable path. We would run at break-neck speed towards him as if locked onto him like missiles. We would run orthogonally to limit the available directions he might take. We would unspokenly gather volunteers to the chase as if in a stampede. We would hide behind trees.

Catching Chris, despite the iniquity of numbers, invariably took upwards of an hour. Pursuers would retire from the chase exhausted, or perplexed. Sometimes entire shifts would change over the duration of the hunt. Ultimately, however, Chris would be apprehended in a frenzy of arms, legs and divots, attracting staff and onlookers like flies around a kill. Only partially subdued he would be guided, in a ruck, back to the ward where more often than not he would be carefully watched for the rest of the day while he returned our gaze repackaged as a scowl.

I don’t know how it happened. Nobody remembers, if they ever knew.

Chris had breached the fence again and was high-tailing it across the grounds. Somebody went to fetch him back. The mood was completely different, completely at odds with the usual galvanizing sense of mutual excitement. Perhaps we no longer cared. Perhaps, somehow, we were inspired. Our solitary staff member didn’t pursue Chris. He didn’t barrel after him like a Pamplona bull. He just ran. Within a few minutes he was shoulder-to-shoulder with Chris and running alongside. And they kept running. They ran for a further ten or so minutes and then returned to the ward. Nobody laid a finger on Chris. Nobody said a word. There was a ten-minute run and then home.

There were no absconds after that. Just runs.

Hearing Staff in Deaf Services

Deaf services often have a considerable number of policies regarding communication. These documents are intended to cover a variety of needs, but the one thing they all have in common is the access to information and discussion for the staff and client groups with their variety of communication modalities, registers and systems.

Often, however, the assumptions held by staff - and the culture and attitude of the institution - fail to yield the equal access to information and discussion which we would like to believe we foster.

The main area in which we fail is the use of interpreters in meetings.

Staff always try hard to make sure enough communication support is provided by interpreters. This of course is great, and we pride ourselves on this and criticise other services for not providing interpreters themselves. However the way in which we use interpreters gives rise to a major problem which is an inconsistency between philosophy and practice:

1 Hearing staff believe that, regardless of their level of BSL competence, the presence of an interpreter allows them to ignore the signing policy - which usually states, in its simplest form, that all staff should sign when a deaf person is present. Rarely does it say that staff may disregard the signing policy in this instance. So despite the presence of an interpreter all staff should aim to sign in the company of a deaf person.

2 Unfortunately, the vast majority of qualified staff are usually hearing. Thus, the discussion is inevitably led by hearing staff. A problem arises when

i) Those hearing staff are not signing and

ii) They are not respecting “interpreter-time” (the delay between the endings of the spoken utterance and the signed translation). In failing to respect interpreter-time, hearing staff respond to each other immediately after the other person has stopped speaking. This means the deaf people present are not able to contribute to the discussion on equal terms with the speaking people. This is why I am making a distinction between access to the information and access to the discussion. Current practice allows deaf people access to the information, but it is impossible for deaf staff to access and contribute to discussions to the same extent as staff who are not signing.

3 On those occasions that deaf staff do contribute, it is equally important for them to respect interpreter time to allow equal access to those who do not sign.

4 Signing policies often state that everyone’s choice of communication modality and system should be respected. However it is extremely difficult for hearing staff who may want to sign to do so. There are a number of reasons for this:

i) In any meeting there will be hearing staff with a range of signing competencies, and so most staff will be in the presence of others whose signing skills far outshine their own. When those (usually senior) staff refuse to sign, the person who wishes to follow policy and sign for themselves is made to feel ridiculous as they are singling themselves out. Also they inevitably wonder whether their beliefs about signing for themselves are correct - after all senior staff with advanced signing qualifications are not doing so.

ii) When other staff members who can sign are not doing so, a person who believes that he or she should be signing for themselves may often think that the other staff members feel the same, but have other reasons to avoid signing themselves. In my experience a hearing staff member signing for him/herself can project their anger that other people are not signing onto the other staff, and this is then experienced as extreme hostility from the signing hearing staff who choose not to sign. This feeling can be enough to stop the person signing for themselves. It is also possible that other staff actually are hostile to the signing hearing staff member, as they are being confronted with their own guilt about not signing, or their own fears that their signing is not very good.

iii) It inevitably feels strange to sign to a hearing person who does not sign and so does not directly understand what is being said. This is especially so for signing hearing staff. This feeling is compounded by being the only one.

iv) Initially it is difficult to sign while listening to one’s own signing being voiced over as this is both distracting and can be perceived as providing immediate feedback about the quality of one’s signing. However, ignoring the voice over is a skill which is quickly learnt.

5 When hearing staff avoid signing in meetings, their signing skills will suffer.

i) In mental health care most deaf staff are Health Care Assistants and work shifts, so the majority of staff in a meeting will be hearing. Meetings are one of the few places where staff could, in principle, observe their peers signing and this would make the different competencies and styles of signing within the staff group more transparent. In this way staff would be able to realistically appraise their own signing skills. When the only staff seen signing are deaf native signers, one’s confidence inevitably vanishes. With our confidence goes our inclination to sign at all, and an environment is established in which it is impossible to gauge one’s own signing competence by comparison with hearing staff.

ii) Equally, it is impossible for staff to receive objective feedback about their signing competence from the rest of the staff group. Such feedback would be both positive and negative, but both forms are constructive and lead to increased signing competence, increased signing confidence, and increased signing. In this way the vicious circle of lack of feedback leading to decreased confidence leading to less signing leading to less feedback can be reversed into a positive cycle of objective appraisal leading to increased competence leading to increased confidence leading to increased visible signing leading to further appraisal.

What can be done about this?

In my opinion this can lead to an anti-sign culture which is both oppressive and disheartening. Seeing others signing can enable everyone to feel confident about their skills, and to realistically appraise their own weak areas.

There will inevitably always be a number of staff who correctly feel they cannot sign in these situations - but interpreters are available to allow those people access to the meetings. At the moment interpreters are used to avoid exposing our signing skills to peer-review, to (consciously or not) oppress the deaf staff and clients, and to pretend that we are enabling equal access when in fact we are not. We should be using interpreters solely to support those staff who do not yet sign, and we should respect interpreter time in order that those staff have equal access to both the information and the discussion.

It is my view that:

  • All staff who can sign, should sign at all times.
  • Staff who cannot sign should be trained appropriately and supported.

Therefore all staff who are not attending, or who are not about to attend, a signing course, should be signing for themselves. If they are not, that person’s line manager should address the issues which prevent him or her from signing. This means that all staff with advanced or confident signing skills should be obliged to sign. All other staff should be encouraged to sign - both directly through line management, and indirectly by the culture and attitude of the unit shifting to enable everyone to feel safe enough to sign.

Interpreters, Psychosis, and Voices

From the Psychology Department Newsletter June 2004.

Using an Interpreter

It is almost entirely true to say that in psychology if you can’t talk to your client you can’t do your job. It is certainly entirely false to say that with an interpreter (of any language) you can get on with your job ‘as normal’. The immediate impact of a third party is probably obvious – dynamically, temporally (with spoken language interpreting, being sequential), and transferentially (particularly with BSL interpreters where the client’s emotional relationship is often more powerfully with the interpreter than the clinician). Alongside these more immediately apparent difficulties lies a more pervasive problem of accurate communication, understanding, and - for want of a better term – empathy. While the relation between language and thought is a complex one, it is nevertheless fairly clear that expressed language in any modality is an encoded version of the concepts intended by the person speaking. Just as the vocabularies of two languages never perfectly correspond, so the vocabulary of one’s own language only approximates the “vocabulary” – the concepts – of our thoughts. When I talk to you I am encoding my thoughts, ideas, beliefs into English. This is a process of translation / interpretation which necessarily loses information. When you read my English you attempt to decode the meaning using the phrasebook of your pre-existing understanding, beliefs and expectations. This again is a process of interpretation. Between my ideas and your understanding of them (even supposing I am making sense, possibly a moot point) there is already considerable potential for miscommunication, and we share a common language. It is likely we share a common “culture” too – that of western psychiatry and medicine (like it or not). When working with a client who speaks a different language from you, the interpretation between those languages is variably, and sometimes considerably, prone to information loss or distortion just from a lack of vocabulary equivalence. In addition, you and the client will likely come from different cultures – ‘culture’ meaning in this case not just sociological and anthropological differences but cognitive and conceptual ones. A Chinese person explaining parenting to you in terms of “guan” is presenting a concept alien to Western Europe and not a part of western psychological parenting work. The biggest pitfall of using an interpreter is assuming that you do not only understand what the other person is saying, but also what they mean. This pitfall is not confined to interpreting situations.

Interpreters can work in a variety of different ways, the simplest model of which being a notional continuum of verbatim translation to interpretive meaning - or from a word-for-word level through noun-phrase, sentence, paragraph levels to whole document/speech/session levels. The lack of lexical correspondence between two languages renders verbatim interpretation a nonsense, and the other end of the continuum leads to practical difficulties. However the model is useful when considering what you want the interpreter to do.


Conducting a psychological assessment of a psychotic client using an interpreter is arduous. The only time it does not feel that way is if you are not aware of the complications that the interpretation is bringing to the assessment. Interpreters constantly tread a line between ‘telling you what the person said’ and extracting meaning from the utterance and presenting that – and you don’t know which they are doing! Quite often the absence or distortion of meaning is the clinically relevant feature, but it is the task of the interpreter to understand and, quite professionally, they may clarify and clarify with the client until meaning is found in the language when potentially there was none there to start with. With no clear word-for-word translation possible, how can one interpret word salad, for example? Conversely, if the client appears to make no sense how can thought disorder be distinguished from communication difficulties or difficulties of interpretation? Without an interpreter there are still, of course, two interpreting processes going on…


Nascent employees of the Deaf Directorate almost always learn within a matter of days that prelingually and profoundly deaf people with psychotic disorders hear voices. In a service that, upon recruitment, immediately deskills us, fascinating titbits such as this are survival aids. This assertion is rarely questioned, and much has been written about the neuronal activity of deaf hallucinating psychotic people, the phenomenology of deaf psychotic voices, and so on. Perhaps obviously to those outside of this field, the assertion makes no sense. Clinically I have rarely if ever managed to have a (one to one) conversation with a deaf person said to hear voices where the deaf person has been able to describe the pitch, timbre, vocabulary, volume, or location of the voice. Even if there were some way of demonstrating (with a magical functional MRI) that the person really was experiencing an English-speaking female voice of rather low volume, telegraphic prosody, commenting on her clothes from behind her - volume, prosody, the gender of the voice and auditory location are not things that a prelingually profound deaf person could reliably report upon.

Could it be that asking specific questions about such symptoms gives the client (deaf or hearing) a lens through which to evaluate quite probably chaotic and confusing internal experiences? Why do we trust the report of a prelingually profoundly deaf person on the nature of their psychotic experiences when that same client, at the same time, is not able to reliably report upon where they think they are or who they are talking to? Psychotic experiences may well be (who knows?) the cognitive equivalent of dropping all the pages of your thoughts in a puddle and reassembling them, soggy, in the wrong order. The process of encoding those experiences must be even more prone to misrepresentation than non-psychotic mental phenomena. In the context of a clinical interview, deliberately or otherwise asking questions which are even only slightly leading (“Do you sometimes hear a voice that seems to come from nowhere?”) is equivalent to showing a Rorschach blot and asking “Do you see a bat?”

The ABC model of voices suggests the voice is an activating event triggering beliefs about it. Quite possibly the voice is delusional as well. But what’s the difference?

Mental Health Act Language

Often mental health services, particularly inpatient teams, use the language of the mental health act when discussing patients, not just the detained ones. I think this is unhelpful because a) it is misleading, but b) because it reflects a mindset that detention and the restriction of patients’ liberties is the norm, when in fact it is the exception. Even if the majority of patients are detained, we should still maintain the attitude that detention is the departure from normal practice in the extreme situations that the MHA is intended to cover.

As examples, we never hear of patients (non-detained) saying that they are going home for the weekend – instead it is always that x is requesting leave and is that OK. We know that it is not our decision and that x can go whenever he likes, but the default perspective that we are in charge of / responsible for other people when we are actually just offering a service they can take or leave I think is damaging. It is worse still if x really thinks he has to ask, and not just that it is being reported in the language of the MHA.

Also we hear a lot in discussions of non-detained patients that “well we can’t detain him” as if there is an air of regret around that! It scares me that we have to think on our feet about ways to cope with the fact that we can’t just force the person to comply. That somebody is undetainable is a good thing, in my opinion, and that people who are detainable are so for reasons that are awful for them (that is, they need detention in their own best interests for specific reasons, that they are horribly ill and pose a risk to themselves or others.) If we regret that a person may not be detained, that suggests that we are losing the ability or the willingness to work with people collaboratively and that would be terrible.

I would be the first to roll my eyes at the political over-correctness of identity politics, for example levering in the word “people” after politically sensitive adjectives makes my flesh creep, however my concern here is that language use not only reflects, but influences our mind-set and attitude towards the people we work with, most powerfully in the way trainees, students and new staff absorb assumptions that it appears from our language that we make.

“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).

An Interactional Handicap:

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:

Client-centred issues:

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.

Therapist-centred issues:

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.

Interpreter-centred issues:

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.


Brasel B.B. (1976) “The effects of fatigue on the competence of interpreters for the deaf.” In H.J. Murphy “Selected readings in the integration of deaf students at C.S.U.N.” Centre on Deafness series (No.1). Northridge: California State University.

Council for the Advancement of Communication with Deaf People “C.A.C.D.P. Directory 1996/1997” C.A.C.D.P., Durham.

Elliot H., Glass L. & Evans J.W., eds (1987) “Mental Health Assessment of Deaf Clients: A Practical Manual.” Little, Brown & Co, Boston.

Gaviria M., Pathak D., Flaherty J., Garcia-Pacheco C., Martinez H., Wintrob R. & Mitchell T. (1984) “Designing and adapting instruments for a cross-cultural study on immigration and mental health in Peru.” Paper presented at the American Psychiatric Association Meeting. In Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.

Harvey M.A. (1982) “The Influence and Utilization of an Interpreter for Deaf Persons in Family Therapy.” American Annals of the Deaf 7, 821-826.

Hindley P. (1993) “Signs of Feeling. A prevalence study of psychiatric disorder in deaf and partially hearing children and adolescents.” RNID, London.

Hoyt M.F., Siegelman E.Y. & Schlesinger H.S. (1981) “Special Issues Regarding Psychotherapy with the Deaf.” Am J Psychiatry 136:6.

Jeffers J. & Barley M. (1975) “Speechreading (lipreading).” Charles C. Thomas. Springfield, Illinois. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.

Kyle J.G. and Woll B. (1985) “Sign Language. The study of deaf people and their language.” Cambridge University Press. Cambridge.

Menninger K. (1958) “The theory of psychoanalytic technique.” Harper and Row,New York.

Monteiro B.T. (1989) “Pitfalls in Diagnosis” Unpublished. Supra-regional Department of Psychiatry for the Deaf, Whittingham Hospital, Preston, Lancs.

Padden C. & Humphreys T. (1988) “Deaf in America: Voices from a culture.” Harvard University Press. Cambridge, MA.

Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.

Schein J. & Delk M. (1974) “The deaf population of the United States.” National Association for the Deaf. Silver Springs, Md.

Schlesinger H.S. & Meadow K.P. (1972) “Sound and Sign: Childhood Deafness and Mental Health.” Berkely. University of California Press.

Stansfield M. (1981) “Psychological Issues in Mental Health INterpreting.” RID Interpreting Journal, 1 18-31. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.

Stansfield M. (1987) “Therapist and Interpreter: A working relationship.” Paper presented at the Mental Health and Interpreting Conference, Annapolis, MD. In Roe D.L. & Roe C.E. (1991) “The Third Party: Using Interpreters for the Deaf in Counseling Situations.” Journal of Mental Health Counselling 13(1) 91-105.

Vernon M. & Andrews J. (1990) “The Psychology of Deafness. Understanding Deaf and Hard of Hearing People.” Longman, NY.

Vernon M. & Brown D.W. (1964) “A guide to psychological tests and testing 1 procedures in the evaluation of deaf and hard-of-hearing children.” Journal of Speech and Hearing Disorders, 29, 414-423.

Psychometric Assessment of Deaf People

There are very very few psychometric instruments available for use with prelingually profoundly deaf people. When testing such people therefore, there is a great deal to be borne in mind.
The most important point to consider is that of the validity and reliability of the tests used, both in and of themselves, and as a result of any changes that would need to be made to the formal administration in order to communicate the task to the client. Four main questions can help with this:

1. Does the test consist of verbal test items or performance items? Verbal items are inappropriate for deaf people, particularly prelingually deafened. Such people usually have difficulty with English syntax and vocabulary independent of cognitive function, as a result of English being a purely visual (and unspoken, and therefore considerably less frequently encountered) language for deaf people. Deaf people’s mean reading age (compared with hearing peers) has been estimated to be at the 3rd or 4th grade level irrespective of intellectual function.

2. Do instructions for the test require verbal communication? This is important even if the tasks themselves are considered to be “performance” tasks. For those measures that offer little or no flexibility in the way in which instructions are presented (such as the WAIS-III), departure from the formal administration departs also from the standard administration with the normative sample and comparison with that sample then becomes misleading in ways that cannot be predicted or allowed for. The same problem is more frequently met when comparing hearing people tested in the formal manner with those tested with more flexible instruction.

3. Do any test items discriminate against (or for) an individual with an auditory impairment? Test items may discriminate directly or indirectly against, or for, deaf people. Those that discriminate against are more common, but both for and against present problems of comparison with a normative sample. An immediately obvious example would be from the Vineland Social Maturity Scale which contains an item “Makes Telephone Calls”. Clearly this would underestimate the individual’s functioning. Perhaps less obviously, but equally critical, an attempt to address the cultural validity of this item by converting it to “Makes Minicom (Textphone) Calls” still underestimates the ‘true’ level of functioning since a deaf person’s experience of using a textphone differs entirely from a hearing person’s with a telephone (in terms of when one is first seen used, how often they are seen on TV, and so on.) Similarly there is some evidence that BSL users are advantaged when using the block tapping tasks (such as Corsi’s) – but advantaged in such a way that disappears when the person sits alongside the examiner instead of opposite.

4. Are deaf people included in the normative sample provided by the test developer? Apart from a very select handful of tests the answer to this question is always no. Norms for deaf people are rarely provided. There are good arguments for and against comparing this deaf person with deaf or ‘hearing’ norms, and the answer depends on the reason for testing. However there is only ever an argument for ‘hearing’ norms if that normative sample contained deaf people in equal proportion to the population of concern and that the results from that sub-sample are demonstrably as reliable as those of the hearing subjects. Such norms are rarely if ever established, and prelingually profoundly deaf people are more likely to be formally excluded from the normative study. The interpretation of results of clients who do not mirror individuals for whom the test was designed must therefore be explicitly cautious.

These main areas make the assumption that communication with the client, in sign, is unproblematic – that is, that the assessor is able to sign. When that is not the case, further issues of the reliability of the interpretation are raised:

5. How reliable is your communication support? The ability of the interpreter(s) must be stated in the report and considered when interpreting the results. Even if the interpreter is Level IV accredited and a registered Sign Language Interpreter, which ought really to be the only acceptable standard for psychometry, the reliability of the interpretation will decline significantly after 35 minutes. Two interpreters should be used and regular breaks should be introduced (which can itself conflict with a formal test administration). Interpretation will always add to the error in the estimated level of function, and it is impossible to say whether it contributes to an over- or an under-estimation. The extent of this error is, in part, a function of the competence of the interpreter(s).

6. How reliable is perfect communication support for this measure? Even if the communication support is 100% perfect (and this is in truth only available in our imagination) then it is important that each item of each test be discussed in advance with the interpreters. (There is no such thing as a perfect translation. There can be a best translation but that is hard to find and is only a “working-best” until a better one is noted in the future.) However, even supposing perfect interpretation, the assessor must be fully aware of the nature of the signed administration in order that the psychometric equivalence of the standard and the signed administration of that item can be judged. For example, the Similarities subtest of the WAIS-III contains the question, in English, “In what way are a coat and a suit alike?” It is fairly easy to translate this into a British Sign Language equivalent with little debate. However the nature of the most common signs for coat and suit make it self-evident that both are articles of clothing – a response which receives maximum points. Conversely the signs ‘rhyme’ in terms of both being bimanual and symmetrical, sharing the same location in space, employing very similar movements, and handshapes differing only in terms of thumb position. It could be argued that these phonological similarities are unreasonably misleading and/or that they imply alternative false answers (the location of both signs is commonly used for emotions) in a way that the spoken English items do not.

These concerns all contribute unknown amounts of error to the estimated level of whatever psychological construct is under scrutiny (such as intellectual function). In addition the ways in which these concerns may be addressed (that is by departing from standard administration in a variety of ways) also contribute error to the estimate. The magnitude of this error and the overall direction of it are both unknowns and lower the reliability of the obtained results.
The validity of obtained results remains in question when the normative sample is exclusively hearing.

Generally, examiners should be advised to:

• Assess the deaf person with support from qualified British Sign Language Interpreters.
• Discuss each item of each test in advance with the interpreters, and afterwards such that any instances of note may be raised and accommodated in the interpretation of the results.
• Consider which, if any, tests to use in the light of points one to four above.
• Interpret results with extreme caution in the light of points one to six above.
• Make each of these shortcomings explicit in the report such that future readers will not jump to erroneous conclusions.
• And generally to assume that obtained results reflect a hypothetical minimum value, and never imply a ceiling to the individual’s ability or potential.

[Snip this URL as:]

Deafness Links

My Things
British Sign Language Fingerspelling * Photographic ABC in British Sign Language.
You CAN use your PC as a TDD * Software for TDD communication via your PC. With links.
Set up Hyperterminal as a minicom * Instructions with pictures based on Andy Arthur's instructions.

UK Organisations
BSMHD * The society for the promotion of the positive mental health of deaf people in Britain.
ESMHD * International Non-Government Organisation for the promotion of the positive mental health of deaf people in Europe.
National Deaf Services Home Page * Mental Health Services for Deaf People in the UK.
RNID * The largest deafness charity in the UK.
Sign Community * Formerly the British Deaf Association.
National Deaf Children's Society * The only UK charity solely dedicated to providing support, information and advice for deaf children and young people, their families and professionals working with them.
Royal Association in Aid of Deaf People (RAD) * Promoting the welfare and interests of Deaf people.
SENSE * The UK's largest organisation for children and adults who are deafblind or have associated disabilities.
Signed Performances in Theatre (SPIT) * The leading national body for promoting BSL interpreted performances of mainstream theatre.
Deaf Connections * One of the world's oldest charities working with Deaf and Hard of Hearing people.
Deafax * Using technology to promote Deaf literacy and achievement

Academic Organisations
Gallaudet University Home Page * The University for Deaf People in Washington.
Gallaudet Research Institute * GRI researchers gather and analyze data concerning the social, academic, and perceptual characteristics of deaf and hard of hearing populations, primarily to provide information needed by educators in the field.
National Technical Institute for the Deaf * The world's first and largest technological college for students who are deaf or hard of hearing.
University of Bristol - Deaf Studies Department * Europe's only academic institution that concentrates solely on research and education that aims to benefit the deaf community.

Other Useful Links
Forest Bookshop * Specialist in books and other media on Deafness and Deaf Issues.
See Hear * The BBC programme for Deaf people. Reviews and summaries.
A-Z of Deafblindness * Help to Blind or deaf people, and especially deafblind people, and those who provide specialised services for those who are deafblind.
World Recreation Association of the Deaf * Providing programs, services, and activities to hearing, deaf, and hard of hearing persons.
DEAF-INFO Web Site * Omer Zak's info. Particularly about the Deaf-L listserver.
ASLI * Association of Sign Language Interpreters.
Deaf Library * Karen Nakamura's online collection of reference material and links intended to educate and inform people about Deaf cultures.
"About" - Deafness * Guide to further deafness-related sites.
RNID library * Based at University College London.
Deaf-UK News and Discussion Group * Contents may be hot.
Typetalk * UK relay service.
Deafsign* Cath Smith's useful information and some nice clear things to play with.

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