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Populations At Risk: The Case of Angel

Kritzia M. Rosas-Feliciano
Wayne State University

SW 4997

Populations At Risk: The Case of Angel

The Selected Case from Field Placement
My field placement is at Stone Crest Behavioral Health and Inpatient Treatment Center.
Stone Crest Psychiatric Hospital serves a wide variety of people of different age groups and
different ethnic backgrounds who suffer from any type of mental illness. It was rather difficult to
select a case to go into further discussion for a population at risk, because all of these individuals
are part of a population at risk due to their mental illness. A case that was different from many of
the other cases was the case of Angel Sanchez. Angel Sanchez is a 68-year-old schizophrenic
Hispanic male. During my first couple of weeks at Stone Crest Hospital I had the opportunity to
meet Mr. Sanchez. Angel had a language barrier and was having trouble communicating with

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the staff and other patients. Since I my primary language is Spanish I was assigned to translate
or interpret for Mr. Sanchez in order for him and the staff to have a better understanding of his
situation. I would be with Mr. Sanchez for the duration of the time that I was at my field
placement helping him communicate with the staff and other patients. Being at the bedside with
Angel experiencing his daily activities gave me a better understanding of what the patients day
is like at the facility. I had the chance to translate for him during group therapy, social work
assessments and discharge planning. Before I was able to aid Mr. Sanchez with his language
barrier, the staff members were using a phone interpreter system where the interpreter is on the
phone and was able to interpret for the staff member and the client. The staff complained that it
was not an effective way to communicate with Mr. Sanchez, because the client was unable to
focus on the conversation over the phone. The phone interpreting system seemed to cause more
confusion than clarity to the client due to his mental illness.
Psychosocial Assessment
I was able to translate for Mr. Sanchez during the psychosocial assessment done by the
Social Worker. During the assessment the client seemed at ease to have an interpreter present. It
is very challenging to perform a psychosocial assessment with a client who has a mental illness,
because the answers they provide are not always applicable to the questions asked. The client
was also very repetitive. Once the client began talking about a specific topic, it was challenging
to get him to focus on the questions that were being asked. Instead, the client would continue to
repeat the same statement numerous times. The first question of the psychosocial assessment
was the reason for admission in the patients own words. Angel answered that policemen were
bothering him and that they brought him to the psychiatric hospital. Angel insisted that he was
not doing anything wrong and that he was not bothering anyone. He repeated several times that

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the policemen were the ones bothering him. The second question asked about the clients mental
and emotional status. This question dealt with the need for mental health services and family or
any support systems that the client might have. Mr. Sanchez said he had his ex-wife and his
uncle, but that he hardly ever sees his wife and that he doesnt know his uncles contact
information or his real name. Other questions about medications, abuse, neglect, domestic
violence and sexual abuse were asked, but Mr. Sanchez denied having experienced or dealt with
any type of abuse. While completing the psychosocial assessment Mr. Sanchez said he was
divorced and that he had two daughters. Angel repeated several times that he wanted his
daughters back. When asked where his daughters were, he responded that he does not know.
Angel Sanchez disclosed that he was from Cuba and that he served the military while he resided
in Cuba. Mr. Sanchez also said that he tried to enlist in the army when he came to the United
States, but he was unable to enlist for reasons that he couldnt articulate. Angels first language
is Spanish and his second is English, but he only knows a few words in English and is unable to
understand it, write or read it. Mr. Sanchez claimed not to have any suicidal or homicidal
ideations. The Social Worker was unable to get any full names or contact information of any
family members of the client. The clients substance abuse history showed that he is a tobacco
smoker and alcohol drinker, but denied the abuse of any drugs. Living arrangements were
discussed and Angel states that he lives with his uncle, but he is unable to provide the address or
any helpful information about his current place of residence. The Social Worker is looking for
group homes that would best fit Angel in case that there are no other options upon discharge.
During the psychosocial assessment Angel said that he dropped out of school after the sixth or
ninth grade, he was unable to accurately state which grade. As far as employment Angel said he
does handy work around the house and that he receives government assistance, but again he was

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unable to state which government assistance he receives. Angel claims to have very little family
support; the only support he receives is from his uncle who provides shelter for him. Mr.
Sanchez says that he is Catholic and he very seldom goes to church. When asked about his
strengths, the client flexed his arm muscle and showed the Social Worker and the Interpreter his
muscles and said that he was very strong. Angel seems very proud of his physical strength and
about the time he served in the military.
Member of an At Risk Population
Not only is Angel Sanchez part of the mentally ill at risk population, he is also an ethnic
minority with a language barrier. Having a mental illness such as schizophrenia is a very
challenging condition and adding the language barrier to the clients situation causes him to be at
a greater risk of suffering from social oppression. According to Pearlson (2000), Schizophrenia
is a common chronic and disabling brain disease of unknown etiology, pathogenesis, and
mechanism (p. 556). Genetic factors play a major role in the cause of schizophrenia, but the
environment of an individual may be necessary for schizophrenia to manifest. According to
Pearlson (2000), a clinical diagnosis of schizophrenia is based on behavioral observations and
self-reported abnormal mental experiences. The diagnosis is determined by ruling out the
possibility of other psychiatric and neurological disorders. Diagnosis is reliable but of unclear
validity (p. 556). Suffering from an illness that the cause, development and the way it functions
are unknown can be very difficult to handle for any human being, let alone an oppressed
minority with language barriers. Symptoms of schizophrenia are divided into positive symptoms,
which are manifestations that should not be there, and negative symptoms, which are a lack of
characteristics in the patient that should be there. The author of Neurobiology of Schizophrenia

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describes the symptoms in great detail to provide a better understanding of what the client is
experiencing.
Pearlsons (2000) study found the following:
Positive symptoms cause acute problems but may persist. They include delusions (fixed
false beliefs that are idiosyncratic to the persons culture and impervious to rational
refutation), hallucinations (realistic sensory perceptions that are not generated by stimuli
outside of the subject experiencing them), thought disorder (difficulties generating
coherent verbal expressions), and bizarre behavior (eg, wearing an aluminum foil helmet
to prevent theft of ones thoughts). Secondary depressive symptoms are not uncommon.
Negative symptoms include emotional flattening: social withdrawal; apathy; impaired
judgment; poor initiative, motivation, and drive; lack of insight; difficulty in planning;
impaired problem solving and abstract reasoning; and decreased concern for personal
hygiene. Men have more negative symptoms, earlier onset, and worse long-term outcome
than females. (p. 556)
The struggle that Angel was facing having these symptoms and not being able to communicate
with the people that were caring for him at the hospital must have been damaging to him and his
treatment.
According to Padilla and Ruiz (1973), demographers have concluded that ethnic minority
group members, and particularly minority group members who are poor, receive less health care
than the rest of the population (p. 9). In the case of Angel Sanchez he was receiving less health
care than the rest of the patients in the hospital due to his language barrier, therefore being
unable to receive his full treatment during his stay at the hospital.
Padilla and Ruizs (1973) analysis found the following:

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Studies surveyed in this analysis confirm the demographic findings; in fact, some indicate
that the problem may be more serious in mental health care. Furthermore, studies dealing
with the national delivery of health services to ethnic minority group members reveal that
Spanish speaking, Spanish surnamed (SSSS) possibly receive the least amount of mental
health care of any population subgroup. (p. 9)
Padilla and Ruizs findings show that Spanish-speaking individuals with language barrier issues
will be highly affected by receiving the least amount of mental health care. The Hispanic
population is subject to high stress indicators, which are correlated with mental break down
following the need for treatment. According to Padilla and Ruiz (1973), the indicators include:
poor communications skills in English; poverty, limited education, low income, depressed social
status, deteriorated housing, and minimal political influence; the change of environment from a
rural agricultural culture to an urban technological society; acculturation to a society which
appears prejudicial, hostile, and rejecting. These authors conclude that such stresses would cause
greater occurrence of mental disturbance (p. 10). Several studies to date have reported data that
shows that Hispanics with language barriers require more mental health care. The SSSS patient
typically fails to obtain the assistance needed with cognitive skills or emotional strength to avoid
or endure future stress (Padilla & Ruiz, 1973, p. 12). Angel Sanchez falls in this category of
individuals who fail to get the treatment necessary to learn the coping skills needed to deal with
his mental illness due to the language barrier. This was the case for Angel Sanchez the days that
I was not there to translate for him during group therapy sessions. Angel was able to obtain full
therapeutic treatment where he could learn new coping skills to deal with his mental illness only
2 days out of the week. Non-English speaking Hispanics receive proportionately less mental
health care and when delivered it tends to be of poorer quality. Padilla and Ruiz (1973) explained

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that institutional policies discourage self-referrals from SSSS or discourage continuations in

treatment once referred. Institutional policies such as language barriers where only five members
of a professional staff of 120 spoke any Spanish, and none of the directional and instructional
signs were in Spanish. Also, culture-bound values such as whenever a therapist from one culture
diagnoses and prescribes treatment for patients of another culture, there is a natural probability of
professional misjudgment. Needless to say that most non-English speaking Hispanics do not
seek help because they fear that no one will be able to help them because they dont speak their
language. Social and behavioral scientists have long recognized that language is one of the most
significant variables in the study of different cultural groups (p. 18-19).
Effects of Membership in the Oppressed Population
According to McGrath and Emmerson (1999), there has been a growing awareness of
the association between a longer duration of untreated psychosis and worse outcomes in the
medium term and the long term (p. 1047). This will have a greater impact on the psychosocial
networks (including those of work, family, education, and friends) of people who are psychotic
and who remain untreated. Prolonged, untreated psychosis can result in a poorer long-term
prognosis because of altered neurobiological mechanisms (McGrath & Emmerson, 1999, p.
1947). In the case of Angel Sanchez his treatment was not being fully provided to him when I
was not there to help him translate during the group therapies throughout the day. Mr. Sanchez
was receiving his medication, which is part of his treatment, but he was deprived of psychosocial
interventions due to his language barrier and the lack of interpreters in the facility. The outcome
of shortening Angel Sanchez from fully receiving treatment caused him to have a prolonged stay
at the psychiatric hospital.
Ethical Dilemma and Solutions

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The dilemma was that the client was not able to speak English he could only speak
Spanish. The hospital only had access to an interpreter over the phone to use to translate about
medical information, but the staff was unable to get much information out of the client and it
seemed to not be working for Angel. I am an intern and I am bilingual, but I am not an
interpreter. The hospital decided to use me to translate for the client and be with him during the
time that I was there. Its an ethical dilemma because I am not a certified interpreter, even though
I speak fluently and I was confident in my language skills. On the positive side all the staff
members noticed a change in the clients condition and overall attitude when I was with him.
The client was able to participate in group therapy and was able to ask his doctor questions and
share any concerns that he had during his stay, which brought him peace of mind.
Policy Impact on Client
According to Betancourt, Green and Carrillo (2002), Washingtons Department of Social
and Health Services launched its Language Interpreter Services and Translations (LIST) program
in 1991 (p. 8). A series of lawsuits filed by the Office of Civil Rights in the 1980s provided the
incentive for the development of LISTs. According to Chen, Youdelman and Brooks (2007),
healthcare providers are often unclear about their legal obligations to provide language services.
In the federal arena, the 1964 Civil Rights Act continues to be the single most important piece of
legislation for providing LEP individuals a legal right to language assistance services (p. 362).
Betancourt, Green and Carrillo (2002) state that Washingtons Medicaid and public assistance
programs were not providing interpreters and translation services for consumers with limited
English proficiency (LEP) and were therefore violating claimants rights to equal access to
services under federal law. The state developed an administrative remedy to guarantee equal
access to services for LEP consumers by providing interpreter and translation services (p. 8).

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The current policy states that clients with limited or no English proficiency are offered
translation assistance at no cost. Department literature, brochures, and forms are available in
seven languages. LIST has a training and certification program for interpreters and translators.
The certification qualification includes a written and oral testing and an extensive background
check. Providers or the social service program staff typically makes the translations requests
with eight languages readily available and all other languages accessible on-call. Interpreters bill
costs directly to LIST and the rest of the department programs for services. The program also
provides services for translation of documents (Betancourt, Green, & Carrillo, 2002, p. 9).
According to Flores (2005), twenty-one million Americans are limited in English
proficiency (LEP), but little is known about the effect of medical interpreter services on health
care quality (p. 255).
Floress (2005) study shows the following:
The quality of care is compromised when LEP patients need but do not get interpreters.
LEP patients' quality of care is inferior, and more interpreter errors occur with untrained
interpreters. Inadequate interpreter services can have serious consequences for patients
with mental disorders. Trained professional interpreters and bilingual health care
providers positively affect LEP patients' satisfaction, quality of care, and outcomes.
Evidence suggests that optimal communication, patient satisfaction, and outcomes and
the fewest interpreter errors occur when LEP patients have access to trained professional
interpreters or bilingual providers. (p. 255)
This policy of having an interpreter is needed in all healthcare facilities, but it can also be
problematic when it comes to situations such as Angels case because the only person he had that
could help him was an untrained interpreter. If all facilities had trained interpreters on staff

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personally there it wouldnt be an issue, but just having the phone interpreters was not much help
for a patient with a mental illness.
Chen, Youdelman and Brooks (2007), discuss the Civil Rights Act for language rights in
health care:
The legal foundation for language access lies in Title VI of the1964 Civil Rights Act,
which states: No person in the United States shall, on the ground of race, color, or
national origin, be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity receiving federal financial
assistance. Congress passed the Civil Rights Act to ensure that federal money was not
used to support discriminatory programs or activities. In interpreting Title VI, the
Supreme Court has treated discrimination based on language as equivalent to national
origin discrimination. Title VI applies across all federal agencies, from the Department of
Justice to the Department of Transportation; the Department of Health and Human
Services (HHS) has further expounded these requirements for the healthcare arena. In
1980, it issued a notice stating, No person may be subjected to discrimination on the
basis of national origin in health and human services programs because they have a
primary language other than English. The third factor in the OCR Policy Guidance
suggests that, given the nature and importance of healthcare services, healthcare
providers have a special obligation to ensure language access for their patients. The
fourth factor, related to resources and costs, suggests that among healthcare providers,
large organizations such as hospitals, health plans, and health systems should universally
be providing language assistance services. (p. 362-363)
Despite the federal right to language access for LEP patients in healthcare settings,

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Angels case is a great example of the reality that many healthcare providers are not aware of
their responsibility, have not prioritized the issue, or have not been held accountable through
consistent enforcement of these laws (Chen, Youdelman, & Brooks, 2007, p. 363). Like in the
case of Angel Sanchez he was being aided by and intern who hasnt gone through the testing
process to be a certified interpreter. Thankfully I was skilled enough to translate everything that
was said to the patient and everything the patient said, but if I wasnt as fluent in both languages
it could have caused some potential confusion to the patient during his treatment. It is shocking
that such important laws are overlooked in the health care system. I wonder what the hospital
wouldve done if I werent there and the consequences it would have had on the patient and his
well-being.
Individual laws vary in scope and impact, and leave many important areas unprotected.
Many laws focus on patient education, notification, or informed consent; some also target a
specific healthcare setting, medical condition, or language. According to Chen, Youdelman and
Brooks (2007), several of Michigans laws address specific medical topics for specific
languages: one mandates that abortion consent forms be printed in English, Aramaic, and
Spanish; another requires that patients receiving HIV tests receive a pamphlet describing the test
in English or Spanish; a third stipulates distribution of a pamphlet with information about
prenatal care and parenting in English, Spanish, and other needed languages; and a fourth
requires a pamphlet on abortion risks and alternatives to be printed in English, Arabic, and
Spanish (p.364 ). Massachusetts on the other hand, requires all emergency departments and
acute psychiatric facilities to provide access to trained interpreters for their patients at all times.
Every state should have laws that protect those who are more vulnerable like the mentally ill. A
number of states have specific requirements regarding language access in mental health settings.

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Illinois requires state mental health facilities to provide interpreters for their patients throughout
the intake and evaluation process. Colorado, New Jersey, and Rhode Island have linked facility
licensure to the provision of language services. According to Chen, Youdelman and Brooks
(2007), since the release of EO 13166 and the OCR Policy Guidance, there has been little
movement on the federal front towards improving or increasing language access (p. 365). As a
result, most legislative and regulatory activity to address language barriers in healthcare settings
has occurred at the state level. Notable state legislative initiatives have occurred in three broad
areas: & continuing education for health professionals, & certification of healthcare interpreters,
& reimbursement for language services for Medicaid/SCHIP enrollees (Chen, Youdelman, &
Brooks, 2007, p. 366). We need a significant investment in developing our medical interpreter
workforce, in terms of increasing both the number and quality of trained medical interpreters.
Certification, which has gained traction in a number of states, is a critical part of assuring the
quality of interpreting and would benefit from coordination and standardization across states. We
need healthcare providers to understand the deleterious effects of language barriers and the
benefits of working with trained medical interpreters, so that they advocate for language
assistance services for their LEP patients in the same way they would advocate for any important
diagnostic test or therapeutic agent. Mainly we need LEP patients to be aware of their legal rights
(Chen, Youdelman, & Brooks, 2007, p. 367).
Conclusion
The case of Angel Sanchez is one of many cases that a minority is not given the total
health care needed for a normal recovery. Instead his treatment was delayed due to his language
barrier. The current policies in place need to be on a National scale rather than a state scale to
give those patients in need the help and therapy they deserve.

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References
Betancourt, J. R., Green, A. R., & Carrillo J. E. (2002). Cultural competence in health care:
Emerging frameworks and practical approaches. The Commonwealth Fund, 1-23.
Chen, A. H., Youdelman, M. K., & Brooks, J. (2007). The legal framework for language access
in healthcare settings: Title VI and beyond. Journal of General Internal Medicine, 22 (2),
362-367.
Flores, G. (2005). The impact of medical interpreter services on the quality of health care [A
systematic review]. Medical Care Research and Review, 62 (3), 255-299.
McGrath, J., & Emmerson, W. B. (1999). Treatment of schizophrenia. BMJ: British Medical

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Journal, 319 (7216), 10451048.
Padilla, A. M., & Ruiz, R. A. (1973). Latino mental health [Review of literature]. National
Institution of Mental Health (DHEW), 1-195.
Pearlson, G. D. (2000). Neurobiology of schizophrenia. Annals of Neurology, 48, 556566.

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