Speech-Language Pathologists’ Collaboration with Interpreters: How to Reach Successful Outcomes

Conducting a speech and language assessment with the mediation of an interpreter is one of the greater challenges facing speech-language pathologists (SLPs)1 both in the United States and worldwide when needing to assess linguistically and culturally different clients (McLeod & Verdon, 2017; Santhanam & Parveen, 2018). The process requires the collaboration of three parties: the service provider, in this case, the speech-language pathologist, the consumer (the client and/or parent, relative or spouse) and the interpreter. This paper provides an overview of the literature on perspectives of educational and medical speech-language pathologists and process and presents an outline of a program to train both the interpreter and the speech-pathologist simultaneously to reach a successful collaborative outcome.

VARIA created in 1978 for those practicing in the legal professions, and a certificate was created in 1999. The requirements for each interpreting specialty can be found in the association's website. For example, the National Board of Certification for Medical Interpreters lists the requirements to receive and maintain a certificate as medical interpreter (https:// www.certifiedmedicalinterpreters.org/). An emerging field of specialization is community interpreting, which includes services provided by different agencies such as schools, social services, and banks, for example. The latter areas do have specific requirements for interpreters or translators who work in those settings (Laviosa & González-Davies, 2019;Pöchhacker, 2008). Preparation and collaboration between the parties involved is necessary to achieve a positive outcome. Too often, it is believed that by having a bilingual interpreter, the service provider and client is sufficient to "get the job done". The process is much more complex, and when there is not sufficient preparation, the outcome can have negative consequences, which has been documented in the medical literature more often than in the literature connected to speech and language services (Bishoff, & Hudelson, 2010;Dysart-Gale, 2007;Phillips & Travaglia, 2011). When a non-fluent school-age student in a majority language is not appropriately assessed (not assessed in their first language and/or not using services of a trained interpreter to assess their first language), they may have been incorrectly diagnosed as having or not having a language or learning disability (Burr et al., 2015;Morgan et al., 2015).
In this article, we review the outcome of surveys that have been conducted between the collaboration of speech-language pathologists and interpreters working in the educational and medically related fields. We offer some solutions on how to strengthen this complex collaborative process by outlining a simultaneous training for both professionals based on the available literature and our added experience, which spans approximately 75 years. 2 2. Focusing on the speech and language pathologist In the U.S. and other countries of the world, speech-language pathologists work with individuals from birth to age 90+. There are areas of specialization, such as the very young, birth to 3, school-age children, or adults. Their work sites may be within an educational setting or in health care facilities such as hospitals or rehabilitation centers, as well as private or specialized clinics. Speech-language pathologists have multiple responsibilities as they work with individuals who may have various types of speech disorders characterized by problems in articulation of sounds, the flow, rate, and rhythm of speech (e.g., fluency disorders) as well as pitch, tone, volume and quality of the voice. The specialists may also work with oral and written language challenges, communication issues and other areas, such as patients having difficulties organizing their thoughts, attending, remembering, and problem solving as well as swallowing. Speech-language pathologists may work with ac-2 Interpreting refers to rendering the meaning of what is said from one language to another orally, while translating does the same, but in writing. There are variations on how interpreting and translation may be rendered. For more detail in these areas, the reader is referred to sources like Allen, Johnson, McClave, and Alvarado-Little (2020). This paper focuses on interpreting, but the interpreter may need to conduct sight translations where they translate what they read orally.
Henriette W. Langdon, Terry Irvine Saenz FL.20221.0.02 s. 4 z 15 quired rather than developmental speech and language disorders such as traumatic brain injury, aphasia, Parkinson's, and other neurological problems. The profession of speech and language pathology requires slightly different skills depending on the setting, specifically, the medical setting or the school setting. In the U.S., the services provided in the schools are free whereas the ones available in a hospital or rehabilitation center are reimbursed by insurance. There are also private clinics where clients are typically seen for a fee paid out of pocket. In the schools, the speech-language pathologists develop the Individual Family Plan, or IFSP, when working with the 0-3 population, and the Individual Educational Plan, or IEP, when working with the older school population. For a complete description of different models of service provision in speech and language pathology in the U.S., the reader can refer to the American Speech-Language-Hearing Association (ASHA) website (no date) by going to https://www.asha.org/students/employment-settings-for-slps/). One of the aspects that differentiates the training of speech-language pathologists from that of special education teachers, for example, is their need to understand overall human development as well as anatomy, physiology, and neurology with a focus on hearing and speech and language. Educational speech-language pathologists need to document how the speech, language and/or communication of the child affects the student's ability to learn. Medical speech-language pathologists should have similar training, but their focus is more on how the client's health may affect their communication and their quality of life. Educational speech-language pathologists may collaborate with parents, other teachers, therapists (occupational, physical, and/or mental health) as well as psychologists and special education specialists. Medical speech-language pathologists may need to collaborate with related professionals such as a pulmonologist or a nutritionist, or other physicians who specialize in other medical areas that may be affecting the patient; for example, an ophthalmologist or internist, depending on the case.
3. Why do speech and language pathologists need to collaborate with interpreters?
In the U.S., a specific law under the IDEA (Individual Disabilities Educational Act, 2004) continues to mandate that assessments be conducted in the student's primary, first, native, dominant or more frequently used language other than English. 3 The same mandate was written in the original law referred to as PL-94-142 (National Education Association of the United States, 1978), which was implemented in 1975. When a speech-language pathologist is not bilingual in the child's language, the assessment needs to be conducted with the collaboration of a trained interpreter (ASHA, 1985).
Mandates for language interpreting and translation in hospitals and rehabilitation settings for patients whose English is limited are more recent in the U.S. In 2000, President Clinton passed Executive Order (EO) 13166, Improving Access to Services for Persons with VARIA Limited English Proficiency. Being bilingual is not sufficient to become an interpreter, and special training is needed as specified by the National Council on Interpreting in Health Care (2007). However, a recent survey indicated that only 70% of hospitals in the United States provided this service, and there is quite a variation in quality of delivery depending on the type of hospital (private for profit vs. non-profit or government) as well as its location (Schiaffino et al., 2016). Another survey that was conducted that year similarly reported that only 56% of a total of 4,586 hospitals in the U.S. provided interpreting and translation services (Eldred, 2018).
Recent surveys indicate that the U.S. includes speakers of many different languages ( Table 1). The largest numbers of speakers of a language other than English are Spanish speakers (14% of the total population), followed by other diverse languages such as Chinese languages (the percentages drop dramatically to 1.19%). Other lower percentages include Tagalog, Vietnamese, Arabic, French, and Korean (about half or less %) (Statista Research Department, 2021). These percentages may appear to be insignificant, given the size of the general population, but a language barrier may occur when any speaker of another language cannot communicate in the language majority of the country (English in this case). As many as 350 languages that are spoken in the U.S. have been identified (Koyfman, 2017). Many languages are spoken within one country as well; in Poland, the eight most frequently spoken languages are listed in Table 1. Since 1980, the number of persons who speak another language in the U.S. has almost tripled to 67.5 million and it is estimated that 25.6 million persons do not speak English very well. This means they need someone to interpret what is said to them or need written information in their own language. In California, 45% of residents speak another language, in Texas -36%, in New Mexico -34%, in New Jersey -32%, and in New York -31% (Zeigler & Camerota, 2019). Although Poland is a small country compared to the U.S., it includes a population that speaks other languages than Polish (WorldAtlas, 2021). The authors were unable to find any source documenting whether speakers of other language than Polish speak the language sufficiently well to communicate without the mediation of an interpreter. However, because the country has many tourists visiting from different corners of the world, it is important to keep in mind that working with an interpreter of the various languages might be important. In 2018, tourism increased to 19 million in Poland, and Henriette W. Langdon, Terry Irvine Saenz FL.20221.0.02 s. 6 z 15 the largest proportion visited from Germany (34.2%) followed by Ukraine (10.4%) and the United Kingdom and Lithuania (4.2% each) (OECD library, 2020). In summary, a great variety of languages are spoken in the U.S. and Poland. The diversity of languages listed reflects the history of each country, as it does for most countries in the world. The number of different languages that speech-language pathologists may encounter in their work is maybe one of 7,139 known living languages spoken in the world (Eberhard, Fennig & Simons, 2021), and there is no match between trained bilingual speechlanguage pathologists in the languages they may encounter. The second-best alternative is to collaborate with a trained interpreter or translator as needed (ASHA, 1985). The latest numbers released by ASHA (2020a) report that among the 208,000 members of their professional community, only 6.6% can provide services in another language than English, and services are available in one of 82 different languages. The majority reported being able to provide those services was in Spanish (66.2%). About 46% worked in schools/universities, and a similar number were found in other settings like clinics, hospital and rehabilitation centers. Even though the number of available bilingual speech-language pathologists is increasing, the demand for services in certain languages and clients continues to exceed the supply. Therefore, the need for interpreters and translators in speech-language pathology has never been greater, and interpreters play many crucial roles in an interpreted interaction.

Roles of interpreters
The skills and preparation of interpreters has been described in the literature and will not be repeated in detail here (Allen et al., 2020;Langdon & Saenz, 2016). Interpreters should have a high level of mastery of the languages in which they interpret (oral and written) including the vocabulary of the profession they are interpreting (legal is different than international or medical); they should be able to adapt to various dialects of a given language; they must be knowledgeable of the different techniques that may need to follow in the interpreting process; they should understand the cultures of the two languages they interpret for, and their interaction; they should respect confidentiality and be a continual learner. An interpreter's charge is to render the meaning of a message transmitted orally in L1 (first language) into L2 (second language) and vice-versa, whereas the translator's charge is to render the meaning in the written modality. However, the interpreter may assume one or up to other four main roles within that interaction: message converter, message clarifier, cultural clarifier, and patient (client) advocate (Avery, 2001;Isaac, 2002). The interpreters collaborating with a speech and language pathologist who assesses and works with patients with developmental or acquired communication disorders have additional charges that may not be necessary in other encounters. More specifically, they must work with those patients who might present with very specific speech and language errors and participate in the assessment process (rather than serving as interpreter or conveyer of information in another language; as detailed in Huang, Siyambalapitiya & Cornwell, 2019). Researchers Roger & Code (2011) describe the complex interaction that takes place between the interpreter and the speech-language pathologist in carrying out an assessment VARIA of patients with aphasia. Similar challenges are common in assessing and working with the pediatric population, where a child might have a speech and/or language disorder. In those contexts, the role of interpreter transcends the description of their charge of interpretation. In these cases where the interpreter is asked to interpret what the patient said, their role is more like that of an "assistant". Roger & Code (2020) draw their work based on the assessment of adult patients whose languages were Cantonese, Tagalog, Greek and Vietnamese. This different role assumed by the interpreter while working with younger patients is also described by Langdon & Saenz (2016).
The following section provides a summary of surveys on collaboration between interpreters and translators and speech-language pathologists in the educational (school) and other settings (hospitals, rehabilitation, private clinic, universities).

Speech-language pathologists and interpreters working in the educational setting
Upon conducting literature searches using the keywords such as "speech and language pathologists", "interpreters", and "collaboration", in PubMed, EBSCO Host, and JSTOR, the authors were able to locate 11 surveys asking speech-language pathologists about their feedback in working with interpreters and their training in working/collaborating with these individuals as well as the efficacy of the process within the educational setting. Saenz & Langdon (2019) described general characteristics of the 11 surveys that were found on this topic that spanned over 15 years, from 2003 to 2018, respectively. Highlights of the findings were as follows: 1) A lack of confidence in working with interpreters in some cases (Guiberson & Atkins, 2012;Kritikos, 2003;Palfrey, 2013); and 2) lack of availability of interpreters (Guiberson & Atkins, 2012;Kritikos, 2003;Roseberry-McKibbin et al., 2005;Saenz & Langdon, 2019). There was also an emergent theme of the lack of preservice training and/or continuing education in working with interpreters (Centeno, 2015;Guiberson & Atkins, 2012;Kritikos, 2003;Hammer et al., 2004;Williams & McLeod, 2012). Additionally, some surveys indicated that some respondents did not use the services of interpreters when assessing bilingual individuals (Caesar & Kohler, 2007;Guiberson & Atkins, 2012;Hersch et al., 2015;Williams & McLeod, 2012) (cited from Saenz & Langdon, 2019).
Given the high number of languages represented in some school districts, and the growing variety of languages and cultures, it is of note that there have been very few studies on the interpreting process carried out in the educational setting. Furthermore, studies indicate the lack of uniform training, confidence in working with an interpreter and even the absence of assessing a student in their first language when needed (e.g. Guiberson & Atkins, 2012;Kritikos, 2003;Palfrey, 2013). There have been even fewer studies researching how speech-language pathologists and interpreters collaborate in other settings such as healthcare, as will be detailed in the section below (pertaining to hospitals, rehabilitation and private clinics).

Speech and language pathologists working with interpreters in healthcare settings
The number of surveys conducted on the collaboration between speech and language pathologists and interpreters in healthcare settings is very limited. One of the first publications on the topic (Blackstone at al., 2011) emphasized the key role played by the interpreter/translator in working with patients whose proficiency is limited in the dominant language. The authors provide some very helpful resources, particularly the Commission's Road Map published by The Joint Commission (2014) and include specific guidelines for optimal communication and care for patients that are related to sensory and/or second language proficiency. Documents recommended for interpretation and translation have been divided into two categories, vital and non-vital. Vital documents include informed consent, complaint forms, intake forms that may have clinical consequences, notices of eligibility criteria for, rights in, denial or loss of, or decreases in benefits or services. Non-vital documents are considered menus, third party documents and general information, which are distributed to the public. However, the article does not include any information on surveys or data on the process of interpreting or translating for speech-language pathologists in health care settings.
The most comprehensive review on studies completed between interpreters and speechlanguage pathologists working specifically with adults with communication disorders was completed very recently (Huang at al., 2019). In total, the authors found only 10 studies that met their specific qualifications that spanned the years 2000 to 2015 from an initial pool of over 1000 studies. The interested reader may refer to the original article to review the specific selection process followed. The criteria followed were that the studies had to be written in English, had to focus on the collaboration between interpreters and speech-language pathologists in working with adults who suffered from acquired language disorders. Of the 10 studies that were ultimately selected, five were conducted in Australia, one in New Zealand, two in Norway and two in the United States. The studies were either surveys or single case studies. The reader may refer to a table that lists the name of the researchers, the type of study (survey, single case study), focus of the research, journal it was published, and the setting and location of the study (Huang et al., 2019, p. 695-696). Some of the challenges in collaborating with an interpreter in this setting were listed under different categories: 1) uncertainty regarding the accuracy of the interpretation (6) 4 ; 2) unclear role expectations; 3) lack of time (2); and participants talking over one another (2). Suggestions to remedy these problems were reported as well and included: 1) time to brief (4); 2) training for interpreters on how to collaborate with speech-language pathologists working with adults with acquired language disorders and vice versa, speech-language pathologists collaborating with interpreters; and 3) increased frequency of interpretation.

Finding potential solutions to the outlined dilemmas
There is no question that the dilemmas that have been outlined in the review of collaboration between interpreters and speech-language pathologists working in different settings necessitate a solution given the increasing demand for services of an interpreter when the speech-language pathologist does not share the same language as their clients. Most typically, speech-language pathologists may have received some training and have a knowledge on how to collaborate with interpreters in the field, but the interpreter typically does not receive training on how to collaborate with speech-language pathologists even when they are trained to be a medical interpreter. The best solution for both professionals is to receive training together. There are studies that have focused on training these two professionals simultaneously (Zang at al., 2019a(Zang at al., , 2019b. The first pilot conducted by the authors consisted in training both speech-language pathologists and interpreters face to face. Results indicated that their knowledge and confidence in working together improved in the two months from the conclusion of the training, but their skills decreased within two months. The authors attribute this difficulty to organizational and systems variables that were outside of the control of the participants. The subsequent study conducted (Zhang at al., 2020) was implemented through e-learning. The materials consisted of specific information for speech-language pathologists (120 minutes in length), and 90 minutes in length for interpreters. The materials included different references, videos, and handouts. The study was carried out in Australia with 60 speech-language pathologists and 140 interpreters. The main outcomes were that both professionals' confidence and knowledge increased, more so for those who had had more limited experience in working with one another. The e-learning method was more successful compared to the face-to-face. The authors question whether a combination approach of face to face, and e-learning might be the most useful method of instruction. 8. A program in training for interpreters collaborating with speechlanguage pathologists in various settings Langdon and Cheng (2002) and Wolf (2016) outlined some of the components of a program where speech-language pathologists and interpreters would be trained together. This program would be best conducted with a combination of distance learning and face to face meetings. Table 2 provides a breakdown of the contents of a revised proposed program.

Components of the program
Sixteen hours (16 hrs.) would be devoted to content learning. The first three hours (3 hrs.) would include a review of the program, information on each profession, and a review of each profession's Code of Ethics as well as special issues regarding bilingualism. In the following 10 hours, the interpreters would receive training on language development and disorders as well as assessment in children and adults. Speech-language pathologists would devote time to study different cultures, including rearing practices, perceptions about abilities and disabilities, and attitudes towards medically related procedures in different ethnic groups. The following three hours would be devoted for interpreters to learn about various special educations procedures including identification, classification of various types of disabilities, while speech-language pathologists would learn about interpreting and translating techniques as well as best procedures to enhance the process. To pass each section, participants will have to pass multiple choice exams and a couple of essay papers.
The following 24 hours would be devoted to practical issues. The participants would be divided into teams of speech-language pathologists and interpreters that would be working together consistently throughout the training. In the best of cases, these teams would continue working together in their settings. They would be practicing collaborating during interviews, assessments and various conferences to report results of testing and assessments following the BID or Briefing, Interaction, and Debriefing model described in detail in Langdon and Saenz (2016). At the end of the training both speech-language pathologists and interpreters would have to pass a written exam that would prove knowledge of the information learned in their respective sections. They would also have to present a video of interaction of the team conducting an interview with parents or the client to gather information as well as assessing the individual using a language sample, if there are no other materials normed in the interpreter's language, and three subtests of tests in Spanish, The best candidates for this program would be licensed bilingual speech-language pathology assistants (SLP/A) and trained medical interpreters, if those are available in the different countries where a program would be implemented. If not, candidates could possess training in the areas of language development, sciences, and disorders in children and adults, interpreting, and be bilingual with an understanding of common communication practices and procedures. ASHA (2020b) specifically indicates that SLP/As may: 1) assist the speech-language pathologist with bilingual translation during screening and assessment activities exclusive of interpretation of the data; 2) serve as an interpreter for patients/clients who do not speak English; 3) provide guidance and treatment via telepractice to students, patients, and clients who are selected by the supervising speech-language pathologist as appropriate for this service delivery model. However, the second-best choice for candidates, in case no assistants in speech-language pathology are available, would be medical interpreters. To demonstrate that the interpreter has adequate bilingual skills, they would need to pass the language proficiency test available from Language Testing International that offers certification in as many as 120 different languages. In addition to linguistic skills, interpreters should continue developing their short-term memory skills, note-taking skills, consecutive interpreting with scripts, knowledge of most commonly used phrases and typical sentences in the field of speech-language pathology, knowledge of terminology specific to the profession (procedures for identification, diagnosis, intervention for various types of speech, language and communication disorders, and use of technology in translation [e.g., machine translation and online dictionaries]).
The courses should be taught by bilingual interpreters who have worked in the communication disorders field for at least two years and ideally include the speech-language pathologists who have collaborated with them. In Europe, the parameters may need to be revised depending on staff and trainers available that would be ready to engage in such training. For example, a few staff could be trained in the curriculum and then train other staff/students as the program grows and develops. It would be ideal for a needs assessment to be completed among current and eligible program staff and students so that the trainers would be aware of which areas to specifically focus on and develop. Curriculum and goals would be shared by all instructors and revised as the program progressed. Materials would be supplemented by various resources, including relevant articles, readings, role plays, discussions, written reflections, and videos. Participants would need to be present at all face-to-face sessions and complete all assignments. A point system would be used to appraise the quality of the assignments, and participants would need to receive a certain number of points to obtain the certification. Specific rubrics would be developed for each assignment to be as objective as possible in scoring the performance of participants so that they could progress to the training position.
Receiving a certification equivalent to that awarded to conference interpreters, interpreters for the deaf, court interpreters, and medical interpreters would enable interpreters working with speech-language pathologists to gain the professional status they deserve. The speech-language pathologists would be eligible for Continuation Education credits. In addition, it would serve to inform other speech-language pathologists that the interpreter has already been trained to work in the field and would require less time training or briefing before a session. Periodic follow-up meetings for the cohort to offer continued training would ensure maintenance of skills and continue to offer opportunities to train others as they progress throughout the program. Continuation education courses would be required from both groups to maintain their skills. For further details on having access to various forms to assess the success of an interpreted session, assess the interpreter's progress and collaboration with the speech-language pathologist, and the consumer's satisfaction with the process, the reader can access Langdon & Cheng (2002) and Wolf (2016). The program offered in this article will be a beginning in ensuring that interpreters and speech-language pathologists receive the training needed to serve clients of all ages who have a variety of speech, language and communication special needs. Future research efforts will need to focus on the effects on the program by measuring aspects such as more confidence for both interpreters and speech-language pathologists working in their respective settings (educational or medical) in working together.