Interpreting Through the Client's Daughter
A counselor at a community mental health center is assigned a 41-year-old woman who immigrated eight months ago from rural Guatemala. Her first language is K'iche'; her Spanish is limited and her English minimal. The agency has no K'iche' interpreter on contract. At intake, the client's 12-year-old daughter, who is fluent in Spanish and English, interpreted for 50 minutes, including questions about sexual history and trauma. The counselor administered a Spanish-language PHQ-9, which the daughter read aloud and the client answered; the total was 8, below the cutoff of 10. The client reports insomnia, fatigue, stomach pain, and persistent fright since a bus accident, and mentions consulting a curandera. Her supervisor says to keep working in Spanish because the client "seems to understand," and the agency requires a billable diagnosis by the third session.
1. Evaluate the decision to continue using the client's 12-year-old daughter as interpreter. What should the counselor do instead?
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It should stop immediately. Using a child as interpreter is a competence and consent problem, not a convenience problem.
Reasons: (1) role reversal and parentification - the daughter is now responsible for adult information and for her mother's care; (2) accuracy - a 12-year-old lacks the vocabulary for trauma and sexual history content in either language and will summarize, soften, or omit; (3) confidentiality within the family is breached, so the client cannot freely report domestic or safety concerns; (4) the child is exposed to material a 12-year-old should not hold, which is a child-welfare concern in itself; (5) informed consent was never genuinely obtained, because the consent process itself ran through the child.
The alternative: arrange a trained K'iche'-Spanish or K'iche'-English interpreter, by telephone or video if in-person is unavailable, even at the cost of longer or fewer sessions. If the client prefers, obtain her informed consent for a trained Spanish interpreter as an interim measure, with teach-back checks for understanding. Document the language access plan. If no competent interpretation can be arranged and the counselor cannot practice competently, the ethical answer is referral or consultation, not proceeding.
Also: obtain consent forms and releases in a language the client can read, and do not use the daughter to sign or explain them.
2. The Spanish PHQ-9 score is 8. How much weight should the counselor give this number, and how should it be used?
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Very little, and certainly not as a rule-out. Several things are wrong with the score as data:
- It was administered by proxy through a child, so the wording, ordering, and privacy of responses are uncontrolled.
- The instrument was not validated for K'iche' speakers with limited Spanish literacy; cutoffs derived from one population do not transfer automatically, and translated instruments require evidence of equivalence.
- Items are largely somatic (sleep, appetite, fatigue), which can inflate scores in some groups and be discounted by clinicians in others; here the score may be deflated by the client minimizing in front of her daughter.
- A score under the cutoff never rules out depression when the clinical interview suggests it.
What to do: treat the score as one data point. Re-administer with a trained interpreter or via interview format, add a functional assessment (sleep, work, caregiving, appetite, anhedonia), and use a cultural formulation interview to understand the complaint in her own terms. Document the limitations of the measure explicitly.
The billing deadline should not drive the diagnosis. A diagnosis can be rendered with a specified or unspecified category based on the clinical interview, with a plan to refine it, and the record should state what data are missing and why.
3. How should the counselor work with the client's susto narrative and her use of a curandera?
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Susto is a culturally recognized idiom of distress involving fright and soul loss, often following an accident or shock, and it is the client's own explanatory model. The counselor's job is neither to translate it into a DSM label nor to dismiss it.
Concretely: conduct a cultural formulation (DSM-5-TR Cultural Formulation Interview) covering the client's understanding of the problem, her expectations of treatment, stressors related to migration and separation, and prior help-seeking. Ask specifically about the bus accident - mechanism, injuries, whether anyone was hurt, nightmares, avoidance of buses, hypervigilance - because a trauma-related disorder is a real possibility that the susto framing may be masking. Ask what the curandera has done, what it cost, whether any remedies or medications were given, and how the client experiences it, without ridicule and without endorsement of unproven practices.
With the client's written consent, coordination with the curandera is legitimate and often improves engagement; without consent, it is not. The treatment plan can hold both: behavioral and trauma-focused work alongside spiritual care the client values. Document the explanatory model and how the plan accommodates it, and avoid framing her beliefs as a symptom to be corrected.