In England and Wales, the Mental Health Act can be used to detain people experiencing a mental health crisis, and who may pose a danger to themselves or others. However, some of those assessed under these powers will not use spoken English. Here, Professor Alys Young, Dr Rebecca Tipton, and Dr Natalia Rodríguez-Vicente explore the effects on the assessment process, equity, and outcome when an interpreter is involved, and how policymakers can ensure better regulation and data collection.

• In 2020-21, there were over 53,000 detentions under the Mental Health Act 1983.
• It is compulsory to collect data on ethnicity and gender – but not the language of the person being assessed.
• There are no minimum or regulated training requirements for interpreters taking part in statutory Mental Health Act assessments, as well as a lack of understanding from assessors on how to work with interpreters in the process.
• Without additional requirements to audit language characteristics and interpreter use (alongside ethnicity and gender), potential inequities in practice and outcome of assessments cannot be identified.
• Evidence-based co-training of interpreters and mental health professionals would transform practice.

Few pieces of legislation can result in the deprivation of a person’s liberty on grounds of health. One of these is the Mental Health Act 1983 (MHA), which is law in England and Wales and is similar to legislation in other countries of the UK and around the world. The MHA allows for the formal assessment of a person experiencing serious mental ill-health and who might be a danger to themselves or others, and can result in their compulsory detention in a suitable psychiatric facility for assessment, treatment, protection, and care.

In addition to psychiatric assessment, Approved Mental Health Professionals (AMHPs) apply a social care perspective at the point of assessment to ensure that options other than compulsory admission are investigated, the perspective of the person being assessed is taken into consideration, and their best interests are safeguarded. In 2020-21 there were over 53,000 detentions under the MHA. But what happens if your first, preferred, or only fluent language is different from spoken English, and you undergo assessment under the Mental Health Act?

Ethnicity and language

Proposed legislative reforms to the MHA are addressing disparities in assessment and outcome. In 2020-2021 rates of detention for the ‘Black or Black British’ group (341.7 detentions per 100,000 population) were over four times those of the ‘White’ group (72.4 per 100,000 population). However, attention to diversity in ethnic identity is not synonymous with a focus on diversity in language use.

Although gender and ethnicity are part of the minimum data set annually reported for MHA monitoring purposes, language is not. There are no national data sets on the preferred/first language of those assessed under the MHA, nor how many undergo an assessment where a spoken and/or signed language is required. This lack of attention is particularly surprising given the needs of migrants, refugees, and asylum seekers within the mental health system, and the increasing linguistic diversity of the UK. Census data for England and Wales records that 4.1 million people (7.1%) of the overall population were proficient in English but did not speak it as their main language. Furthermore, of the 5.1 million (8.9%) who did not report English as a main language, 17.1% (880,000) could not speak English well and 3.1% (161,000) could not speak English at all.

The INForMHAA (INterpreters For Mental Health Act Assessments) research project, led by The University of Manchester, has been investigating:

• Dilemmas faced in joint working between interpreters and AMHPs.
• What is most valued from the perspective of a person being assessed if an interpreter is involved.
• How to improve interpreter-mediated assessments in practice.

Interpreting in MHA assessments

Responsibility for effective communication in an MHA Assessment is shared, with AMHPs holding statutory powers and interpreters handling the inter-linguistic and inter-cultural exchanges. This distribution of responsibility means that there is a high need for and reliance on effective interprofessional working that combines both skillsets. Most interpreters will have little prior knowledge of working in mental health, let alone within an MHA assessment. Few AMHPs will have additional specialist training in working alongside interpreters. ‘Learning on the job’ is a common experience for both sets of professionals but this is occurring in a high stakes situation where compulsory detention may be the outcome for the person assessed. The appropriateness of this is questionable.

AMHPs have significant statutory responsibilities including ensuring great efforts are made to inform an assessed person of their rights, options, and consequences of what is happening. They have to assure themselves that what they need to say has been fully conveyed to the person being assessed; this is hard to know if you do not share their language. It can lead to them asking interpreters to ‘just translate what I say’. However, terminology such as ‘capacity’, ‘section’, ‘objection’, ‘voluntary admission’ have specific meanings and implications in the context of the MHA. An interpreter may understand the word, but their choice of vocabulary or expression to match it may not be nuanced enough for this particular circumstance. Word knowledge and language usage are not the same thing.

People may express themselves in a disordered manner when experiencing a mental health crisis. How they are using language is a vital window for AMHPs to understand the ways in which their mental health is being affected as well as their wishes. Sometimes people use inappropriate vocabulary, speak or sign at a faster rate, talk or sign but just don’t make sense. Interpreters without specialist training may see their job as making sense of what someone is saying, tidying up the language, or ensuring communication is smooth. In this context, that is misleading.

Professional regulation

AMHPs are highly trained, registered professionals whose standards, conduct and work are formally monitored to maintain registration. Conversely, there is no compulsory, only voluntary registration for spoken language interpreters in the UK. There is no minimum standard of qualification to work as an interpreter (although there is a recommended one), resulting in people who may be bilingual but who have never trained as an interpreter working in statutory contexts. There is a voluntary code of conduct and ethics, but without formal registration no consistent process of listing an interpreter as unsuitable or sanctioned. Sign language interpreting is in a different position, with postgraduate level qualification in interpreting leading to registration – but not statutory regulation.

Implications for policy

Without routinely collected data on use of interpreters and preferred languages of those assessed under the MHA, potential inequities in outcomes and standards of practice cannot be adequately monitored. Evidence-based guidance on working alongside interpreters in MHA assessments should be implemented to improve practice and reduce inequities.

The lack of qualification standards leading to formal registration in public service interpreting creates significant vulnerabilities in accountability in enacting a statutory duty and responsibility. A minimum standard of qualification with additional specialist training for working in statutory practice should be introduced for interpreters.

Extension training for AMHPs to work alongside interpreters and interpreters for working specifically in statutory mental health circumstances is required for standards of practice to improve.

In drafting new legislation and statutory guidance, the importance of disparities in process and outcome arising from language should be addressed to the same extent as those arising from ethnicity or gender.

Evidence-based professional guidance and training resources aimed at AMHPs and spoken and signed language interpreters will be available in early 2024 via the project website.

This project was funded by the National Institute for Health and Care Research School for Social Care Research (grant number P172). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR SSCR or the Department of Health and Social Care. The full research team also includes Jemina Napier, Chair of Intercultural Communication, Heriot-Watt University; Sarah Vicary, Professor of Social Work and Mental Health, Open University; Celia Hulme, NIHR Post-doctoral Fellow, The University of Manchester.

This article was originally published as part of our collection on mental health and wellbeing, Open Minds. Read more evidence-led policy insight on this topic in the full online collection.