Blog — Clinical Spanish

Spanish for public health nurses: the immunization-hesitant household at the community clinic where the primary barrier is not the vaccine but the form, the tuberculosis patient who completed two weeks of DOTS and stopped because the pills make him feel like a sick person rather than a working person, and the postpartum depression screen where ‘tristeza’ misses four of the nine PHQ-9 items a Spanish-speaking mother will endorse if asked in patient language

Marisol Fuentes runs three different programs at the county health department on three different days of the week. Tuesday mornings: the immunization clinic, where the waiting room fills by seven-thirty and empties by noon. Wednesday and Thursday: TB case management, which means driving to wherever the patients are, standing with them while they swallow six pills, and charting the visit in a parking lot before driving to the next address. Friday afternoons: postpartum depression screening visits, which means sitting at a kitchen table with a woman she met once at a prenatal class and asking nine questions about what the last two weeks have felt like. Three patient populations. Three programs. Three structural failure modes that repeat every week in every county health department in the six states with the highest Spanish-speaking patient volumes — and three sets of Spanish phrases that change the outcome.

Failure mode 1: The immunization appointment that fails because the nurse explains the vaccine when the parent is afraid of the form

Luciana Torres, 29, comes to the immunization clinic on a Tuesday morning with three children. Her oldest is five. The school sent a letter in March and another one in April saying that kindergarten enrollment requires proof of immunization. She has had those letters in her bag for two months. She chose the county health clinic over the pediatrician’s office because she heard from her neighbor that the county clinic does not ask for insurance. She sits down. Marisol places the intake forms on the table. Luciana looks at the forms. Her hands do not move.

Marisol has been a public health nurse for eleven years. She knows what this stillness means, and it is not that Luciana is afraid of the MMR. It means there is something on the form that is asking her for something she does not have or is not sure she should give. The nurse who responds to this stillness by pulling out a pamphlet about vaccine safety has misread the room.

There are three distinct reasons a Spanish-speaking parent goes still at an immunization intake form. Each one requires a different response.

The documentation question. The form asks for a Social Security number. To an undocumented parent, a Social Security number field on a government form is not a blank to fill in. It is a question about their legal status, asked by an institution with a government seal on the wall. They have learned, through direct experience or through the experience of people they know, that giving a government agency the wrong information — or any information — can have consequences. They do not know that the Vaccines for Children program is federally funded specifically for this population, that the SSN field is optional, and that the clinic has neither the authority nor the interest to share any intake information with immigration enforcement. They don’t know that because no one has told them yet, and the form itself does not say it.

The sentence that opens the appointment:

“Este programa se llama Vaccines for Children — Vacunas para Niños — y lo paga el gobierno federal para todos los niños en este país, con seguro o sin seguro, con documentos o sin documentos. No necesitamos número de seguro social para vacunar a sus hijos. El nombre del niño y la fecha de nacimiento es lo único que necesitamos.”

(This program is called Vaccines for Children and it is paid for by the federal government for all children in this country, with insurance or without insurance, with documents or without documents. We do not need a Social Security number to vaccinate your children. The child’s name and date of birth is all we need.)

Note the order: name the program first, then say “con documentos o sin documentos” explicitly and early — not buried in a paragraph of explanation, not offered as a reassurance after the parent has already tensed and withdrawn. The phrase lands differently when it comes before the parent has calculated the risk of sitting in this room.

The prior bad experience. A second parent who goes still at the form is not afraid of it — she has filled out forms before. She is remembering what happened the last time she came to a clinic with a child and a form. The clinic asked for a Medicaid card she didn’t have. Or the pediatrician’s office said they were not accepting new patients. Or the community health center put her on hold for forty minutes about the appointment and she left before anyone came back. She is sitting in this clinic with the form in front of her, waiting for the reason to leave.

The diagnostic question that distinguishes this from the first scenario: “¿Ha traído a sus hijos a vacunar antes, aquí o en otro lugar?” (Have you brought your children for vaccines before, here or somewhere else?) If she says “sí, pero allá nos pidieron papeles que no teníamos” (yes, but there they asked for documents we did not have), the barrier is the memory of a prior rejection, not a concern about this form. What she needs is a concrete experience that this clinic operates differently — which means the nurse takes the forms from the table, sets them aside, and says: “Primero vamos a ver qué necesitan sus hijos hoy. Los papeles los hacemos después.” (First let’s see what your children need today. The paperwork we do afterwards.) The reversal of sequence — clinical contact first, forms second — is often enough to establish that this clinic is not the last one.

The form itself as obstacle. A third parent cannot complete the form because she cannot read English and no Spanish version is available, or because the form is in Spanish but the vocabulary is administrative rather than patient-facing. The word “beneficiario” is not the same as “el niño que quiere vacunar.” The phrase “cobertura de seguro médico secundaria” is not comprehensible to someone who has never had primary coverage and has never been asked to distinguish them. The consent form that says “autorizo la administración de vacunas de conformidad con el calendario de vacunación recomendado” is not a form the parent can sign with understanding — she can sign it as a physical act, but she cannot consent to what she has not understood.

The consent walkthrough in patient Spanish: “Esta hoja le pide que dé permiso para que le pongamos las vacunas a sus hijos hoy. No es un contrato legal — no le pide información sobre usted. Solo le pregunta: ¿está de acuerdo en que vacunemos a sus hijos hoy? Si la respuesta es sí, firma aquí. El campo de número de seguro es opcional — puede dejarlo en blanco y las vacunas se hacen igual.” (This form is asking you to give permission for us to give the vaccines to your children today. It is not a legal contract — it does not ask for information about you. It is only asking: do you agree to let us vaccinate your children today? If the answer is yes, you sign here. The Social Security number field is optional — you can leave it blank and the vaccines happen the same way.)

After the consent walkthrough comes the vaccine explanation — not before. The parent who understands why she is signing and what she is not signing away is a parent who can actually hear the clinical information about what goes in the needle.

For the parent whose hesitancy is genuinely about the vaccine rather than the form — who has heard things from a cousin, who read something on her phone, who is asking about autism, about too many vaccines at once, about the ingredient list — see the immunization education in Spanish reference page for the specific vocabulary for those conversations. What matters here is the sequencing: ask which concern you are actually addressing before you begin addressing it. A nurse who explains the MMR vaccine — thoroughly, accurately, in careful patient Spanish — to a mother who is afraid of the form has wasted the explanation and lost the appointment.

Failure mode 2: The TB patient who stopped DOTS not because he felt better but because taking pills every day makes him feel like a sick person

Ernesto Villanueva, 52, was diagnosed with pulmonary tuberculosis six weeks ago. Smear-positive, culture-confirmed, drug-susceptible. He started directly observed therapy: six pills every weekday morning at the county health clinic, across the table from a public health nurse who watches him swallow them. He came for fourteen days in a row. On day fifteen he did not come. On day sixteen he did not come. On day seventeen Marisol called. He answered.

He says he feels better.

This is the explanation that TB case managers hear most often when a patient drops off DOT. And it is often true — patients with pulmonary TB typically start feeling better within two to four weeks of treatment, well before the six- to nine-month course is complete, well before the sputum cultures turn negative. The standard response to “me siento mejor” is an explanation of why the treatment must continue even when the patient feels well — the bacteria are still there, they will come back, incomplete treatment creates drug resistance. The explanation is accurate. It is also often not what is happening with Ernesto.

Marisol has had this conversation before. She does not lead with the explanation. She asks: “¿Cree que la bacteria todavía está ahí?” (Do you think the bacteria is still there?)

Ernesto says: sí.

He is not confused about the biology of tuberculosis. He knows the treatment works over months, not days. He is not under the misapprehension that feeling better means he is cured. He stopped coming to the clinic knowing that the bacteria was still there.

Marisol asks: “¿Hay algo en el tratamiento — no los efectos secundarios de las pastillas, sino el tratamiento mismo, el hecho de venir aquí todos los días — que le ha sido difícil?” (Is there anything about the treatment — not the side effects of the pills, but the treatment itself, the fact of coming here every day — that has been difficult?)

A long pause. Then: “Cuando tomo las pastillas, soy un enfermo. Cuando no las tomo, soy un trabajador.” (When I take the pills, I am a sick person. When I do not take them, I am a worker.)

This is a different problem from “me siento mejor.” Ernesto is not confused about the biology. He has made a decision about identity. The daily visit to the county health clinic — sitting in a waiting room, being observed swallowing medication by a government nurse, having his sputum collected and sent to a laboratory, being a person whose daily schedule is structured around a disease — is sustaining an identity as a sick person that he is not willing to maintain for nine months. He would rather carry the infection quietly than carry the role.

The information-gap response to this — restating that the bacteria is still there, that it will get worse, that it is contagious — does not help. Ernesto knows all of this. The response that helps is the identity re-frame.

“Lo que me está diciendo tiene sentido, y quiero responderle con la misma honestidad. Lo que usted está haciendo — venir aquí, tomar las pastillas, terminar el tratamiento — no es lo que hace un enfermo. Es lo que hace un hombre que quiere seguir trabajando en diez años. El hombre que ignora la tuberculosis y decide que ya se siente bien — ése termina en el hospital, con un tratamiento mucho más largo, que ya no puede hacer en diez minutos en las mañanas antes del trabajo. El hombre que termina el tratamiento vuelve a la obra, y la bacteria ya no lo puede tocar.”

(What you are telling me makes sense, and I want to answer you with the same honesty. What you are doing — coming here, taking the pills, finishing the treatment — is not what a sick person does. It is what a man does who wants to keep working in ten years. The man who ignores tuberculosis and decides he already feels fine — that man ends up in the hospital, with a much longer treatment, one he can no longer do in ten minutes in the morning before work. The man who finishes treatment goes back to the worksite, and the bacteria can no longer touch him.)

The re-frame has three structural elements. First: it acknowledges that Ernesto’s feeling is accurate — he does feel different when he takes the pills, and that difference is real — before arguing with it. Second: it reattaches the medication to the identity he has, not the identity he fears. He is a worker. Finishing the treatment is what workers do. Third: it makes the alternative concrete and bad in terms he understands — not “tuberculosis resiste’ the antibiotics,” which is a mechanism, but “you end up in a hospital with a treatment you can’t do before work,” which is a life consequence.

There are also legitimate side effects to address. Rifampin, one of the four first-line drugs, turns urine and other body fluids orange — a side effect that startles patients who were not warned. “Una cosa que debería saber: una de las pastillas va a hacer que su orina salga de color naranja. Es completamente normal — es una de las pastillas haciendo su trabajo. Si no sabe eso antes de que pase, puede asustar.” (One thing you should know: one of the pills will make your urine come out orange. It is completely normal — it is one of the pills doing its job. If you do not know that before it happens, it can be frightening.)

For nausea, which occurs in a meaningful fraction of patients on the standard four-drug regimen: “¿Las ha estado tomando con el estómago vacío o con comida?” (Have you been taking them on an empty stomach or with food?) Many patients are not told that the pills are better tolerated with a meal, and nausea that a small meal resolves becomes a reason to stop treatment that the nurse never hears about because the patient never mentioned it. The question surfaces it.

The DOT visit itself can be made shorter and less identity-freighted. “Sé que venir aquí todos los días es un recordatorio de que está en tratamiento. ¿Qué pasaría si hacemos las visitas más rápidas? ¿Puedo encontrarle en la entrada de la obra a las seis y media, usted toma las pastillas ahí, y sigue su día en menos de cinco minutos?” (I know that coming here every day is a reminder that you are in treatment. What if we make the visits faster? Can I meet you at the entrance to the worksite at six-thirty, you take the pills there, and you continue your day in less than five minutes?)

The consequences conversation — resistance, transmission, the extended treatment — comes after the identity re-frame, not before. A patient who has been met with the identity argument first can hear the clinical argument second. A patient who receives the clinical argument before the identity argument has not been heard at all, and the clinical information lands on a surface that is not prepared to receive it. See the Spanish for community health nurses post for the TB contact investigation vocabulary — what to say to a household that will not submit to TST for a smear-positive index case. The vocabulary for getting a household to accept a skin test is structurally different from the vocabulary for keeping the index case in treatment.

Failure mode 3: The postpartum depression screen where ‘tristeza’ generates a false negative

Valentina Ochoa, 27, is eight weeks postpartum with her second child. The baby was born at thirty-seven weeks, spent four days in the NICU, and came home healthy. Valentina works part-time at a nail salon. Her husband works nights. She comes to the postpartum visit with her sister because there is no one else to watch the baby. She looks tired in a way that is different from the tiredness of a woman who has an infant — not the flat exhaustion of disrupted sleep but something heavier and more central, as if the tiredness is not on the surface of her but inside it.

Marisol has seen this before. She asks the question she was trained to ask: “¿Se ha sentido triste últimamente?” (Have you been feeling sad lately?)

Valentina says: “No. Estoy cansada, eso sí. Pero es el bebé.” (No. I am tired, yes. But it is the baby.)

The screen ends there in too many clinical encounters. Marisol knows not to let it end there.

The PHQ-9 has nine items. ‘Tristeza’ — sadness, feeling down — corresponds to item 2. A mother experiencing predominantly anhedonia (item 1), worthlessness (item 6), concentration difficulties (item 7), and psychomotor slowing (item 8) will answer “no” to “¿se ha sentido triste?” and mean it. She is not sad in the way that word typically lands in patient Spanish — she is not crying, she is not grieving, she does not feel a heavy emotional weight she can identify and name. She feels nothing where feeling used to be. That is anhedonia. And anhedonia is not ‘tristeza.’

The four PHQ-9 items that require different vocabulary:

Item 1: Anhedonia. Not “¿se ha sentido triste?” — instead: “¿Ha habido días en que las cosas que antes le gustaban — hablar con una amiga, salir, escuchar música, hacer algo para usted — ya no le interesan, o ya no le dan gusto, aunque quiera que le den gusto?”

(Have there been days when the things you used to enjoy — talking with a friend, going out, listening to music, doing something for yourself — no longer interest you or bring you pleasure, even if you want them to?)

The phrase “aunque quiera que le den gusto” (even if you want them to) is important. It separates anhedonia from preference. A mother who says “no tengo tiempo para nada de eso” (I have no time for any of that) is describing a schedule problem. A mother who says “no sé — antes me gustaba hablar con mi comadre, pero ahora cuando llama no tengo ganas de contestar aunque quisiera” (I don’t know — I used to enjoy talking with my friend, but now when she calls I don’t want to answer even though I wish I did) is describing anhedonia. Those are different symptoms requiring different follow-up.

Item 6: Worthlessness. Not “tristeza.” The patient Spanish for worthlessness in the postpartum context: “¿Ha tenido pensamientos de que no está haciendo las cosas bien como mamá, o de que su familia estaría mejor sin usted, o de que usted no sirve de nada?”

(Have you had thoughts that you are not doing things well as a mother, or that your family would be better off without you, or that you are not worth anything?)

Note that this question bridges partially into item 9 territory — “su familia estaría mejor sin usted” is both a worthlessness cognition and a passive suicidal ideation. If she endorses this component, it requires follow-up with the item 9 question regardless of how the rest of the screen scores.

Valentina’s response to this question: “Siempre siento que no lo hago bien. El bebé llora y no sé qué tiene. Mi hija mayor me busca y no tengo energía para ella. Mi esposo trabaja de noche y cuando llega en la mañana yo ya esté agotada y él no entiende. Siento que soy mala mamá.” (I always feel like I’m not doing it right. The baby cries and I don’t know what he has. My older daughter comes to me and I have no energy for her. My husband works nights and when he comes home in the morning I am already exhausted and he doesn’t understand. I feel like I am a bad mother.)

This is not ‘tristeza.’ This is worthlessness with a coherent narrative built around it. A nurse who responds with reassurance — “usted no es mala mamá” — before completing the screen has short-circuited the PHQ-9 at item 6. The reassurance is well-meaning. It is also premature. The screen has three more items, including item 9.

Item 7: Concentration difficulties. Not “tristeza.” “¿Ha notado que se le olvidan las cosas más de lo normal, o que le cuesta trabajo concentrarse en algo — leer algo, seguir una conversación, terminar una tarea que antes hacía sin pensar?”

(Have you noticed that you are forgetting things more than usual, or that it is difficult to concentrate on something — reading, following a conversation, finishing a task you used to do without thinking?)

The qualifier “más de lo normal” (more than usual) matters in the postpartum context because sleep deprivation alone impairs concentration. The item 7 positive in postpartum depression is concentration impairment that exceeds what the patient attributes to sleep loss — the tasks that should be manageable even on three hours of sleep, that aren’t. “A veces me olvido cosas que siempre supe. El número de teléfono de mi hermana que sé de memoria — tuve que buscarlo el martes. No es el sueño.” (Sometimes I forget things I always knew. My sister’s phone number that I know by heart — I had to look it up on Tuesday. It is not the sleep.)

Item 8: Psychomotor slowing. Not “tristeza.” “¿Ha habido días en que nota que se mueve más lento de lo normal, o que le cuesta mucho trabajo empezar a hacer las cosas del día aunque sepa lo que tiene que hacer — levantarse, preparar el desayuno, bañarse?”

(Have there been days when you notice you are moving more slowly than usual, or that it is very hard to start doing the things of the day even though you know what you need to do — getting up, making breakfast, bathing?)

The most common patient language for psychomotor slowing in this population: “Sí, me tardo mucho en arrancar. Sé que tengo que levantarme. Lo sé. Pero el cuerpo no responde. Me quedo ahí un rato mirando el techo antes de poder moverme.” (Yes, it takes me a long time to get started. I know I have to get up. I know. But my body does not respond. I stay there for a while looking at the ceiling before I can move.) This is not tiredness. This is a psychomotor symptom that is not captured by any question about sadness.

Item 9: Thoughts of self-harm. The opening frame before asking: “Le voy a hacer una pregunta que le hago a todas las mamás que vengo a ver en esta etapa — no porque piense que algo está mal, sino porque es parte del protocolo que seguimos con todas.”

(I am going to ask you a question I ask all the mothers I come to see at this stage — not because I think something is wrong, but because it is part of the protocol we follow with everyone.)

Then, only after completing the other eight items: “¿Ha tenido pensamientos de hacerse daño, o de que las cosas serían mejor si usted no estuviera?”

(Have you had thoughts of hurting yourself, or that things would be better if you were not here?)

Two structural choices that determine whether the mother can answer honestly. First: say “es parte del protocolo que seguimos con todas” — not “tengo que preguntarle esto.” The second framing signals that the question is an administrative requirement the nurse is reluctant to ask. The first signals that the question is a clinical standard the nurse asks because it matters. Second: ask item 9 last. By the time the nurse reaches it, Valentina has answered eight questions about her experience without being interrupted, corrected, or reassured prematurely. She has had eight opportunities to observe that the nurse is asking about her experience without judgment. The ninth question is proportionally less abrupt.

Valentina is quiet for a moment. Then: “A veces pienso que el bebé estaría mejor si yo no estuviera. No sé cómo explicarlo. No es que quiero hacerme daño. Es que me siento como que estorbo.” (Sometimes I think the baby would be better off if I were not here. I don’t know how to explain it. It is not that I want to hurt myself. It is that I feel like I am in the way.)

Marisol does not express alarm. She says: “Gracias por decirme eso — eso me ayuda a saber cómo ayudarla. ¿Puede decirme un poco más — son pensamientos que pasan y se van, o ha pensado en cómo lo haría?” (Thank you for telling me that — that helps me know how to help you. Can you tell me a little more — are they thoughts that come and go, or have you thought about how you would do it?)

The question does not express alarm. It expresses that the answer has value, and that more information is needed to act on it correctly. That distinction — clinical curiosity rather than alarm — is what keeps the conversation open. Valentina says the thoughts come and go. She has not made a plan. Marisol scores the PHQ-9: Valentina scores a 14. Moderate depression. The appointment she came in for is now a clinical opening.

The diagnosis explanation that does not pathologize or assign blame: “Lo que me describe — los días en que nada le da gusto, el sentir que no lo está haciendo bien como mamá, el cuerpo que no arranca en las mañanas, los pensamientos de que estaría mejor sin usted — tiene un nombre médico. Se llama depresión postparto. No es una falla de usted como mamá. Es algo que pasa en el cerebro cuando el cuerpo hace el cambio hormonal del embarazo al postparto. Le pasa a una de cada cinco mamás. Y se trata — no con fuerza de voluntad sino con ayuda específica que yo le voy a conectar hoy.”

(What you are describing — the days when nothing brings you pleasure, the feeling that you are not doing it right as a mother, the body that will not get started in the mornings, the thoughts that things would be better without you — has a medical name. It is called postpartum depression. It is not a failure of you as a mother. It is something that happens in the brain when the body makes the hormonal transition from pregnancy to postpartum. It happens to one in five mothers. And it is treatable — not with willpower but with specific help that I am going to connect you to today.)

The most common objection — which often comes before the diagnosis explanation, not after — is: “Pero yo quiero a mi bebé.” (But I love my baby.) The response that neither dismisses the objection nor confirms the fear embedded in it: “No lo dudamos. La depresión postparto no es no querer al bebé. Es que el cerebro en este momento no está produciendo las señales que hacen que sentir ese amor se sienta como sentir ese amor. No es que usted no lo sienta — es que algo está interfiriendo con cómo lo siente. Eso es lo que queremos tratar.” (We don’t doubt that. Postpartum depression is not not loving your baby. It is that the brain right now is not producing the signals that make feeling that love feel like feeling that love. It is not that you don’t feel it — it is that something is interfering with how you feel it. That is what we want to treat.)

The referral conversation that does not require the mother to initiate: “Hoy voy a llamar al clínico de salud mental y voy a pedir una cita para esta semana — no para la próxima semana, para esta. ¿Dónde le queda más fácil ir — cerca de su casa o cerca de donde trabaja?” (Today I am going to call the mental health clinic and ask for an appointment for this week — not next week, this week. Where is it easier for you to go — near your house or near where you work?) The question assumes the appointment is happening and asks a logistical preference. It transfers the referral from a suggestion the patient can decline to a plan with a pending logistics decision. The nurse makes the call before leaving the kitchen table.

For the broader vocabulary of depression, anxiety, and behavioral health encounters with Spanish-speaking patients, see the mental health Spanish phrases for nurses reference page. For the postpartum discharge conversation at the hospital — the early postpartum period before the six-week visit — see the postpartum discharge in Spanish reference page. The psychiatric inpatient assessment vocabulary is in the psychiatric assessment in Spanish blog post. This post covers the outpatient screen: the PHQ-9 in patient language, the four items that ‘tristeza’ misses, and the item 9 protocol for the postpartum visit.

Quick reference: the five questions that change the encounter

Immunization form — opening the visit when the parent won’t reach for the pen

VFC explanation: “Este programa se llama Vaccines for Children — Vacunas para Niños — y lo paga el gobierno federal para todos los niños en este país, con seguro o sin seguro, con documentos o sin documentos. No necesitamos número de seguro social. El nombre del niño y la fecha de nacimiento es lo único que necesitamos.” (This program is called Vaccines for Children and it is paid for by the federal government for all children in this country, with insurance or without, with documents or without. We do not need a Social Security number. The child’s name and date of birth is all we need.)

Prior-experience diagnostic: “¿Ha traído a sus hijos a vacunar antes, aquí o en otro lugar?” (Have you brought your children for vaccines before, here or somewhere else?)

TB DOTS — the identity re-frame for the patient who stopped because pills make him feel sick

Diagnostic: “¿Cree que la bacteria todavía está ahí?” (Do you think the bacteria is still there?) If yes — information is not the gap.

Re-frame: “Lo que usted está haciendo no es lo que hace un enfermo. Es lo que hace un hombre que quiere seguir trabajando en diez años. El hombre que termina el tratamiento vuelve a la obra, y la bacteria ya no lo puede tocar.” (What you are doing is not what a sick person does. It is what a man does who wants to keep working in ten years. The man who finishes treatment goes back to the worksite, and the bacteria can no longer touch him.)

PHQ-9 — item 1 (anhedonia) in patient Spanish

“¿Ha habido días en que las cosas que antes le gustaban — hablar con una amiga, salir, hacer algo para usted — ya no le interesan o ya no le dan gusto, aunque quiera que le den gusto?” (Have there been days when the things you used to enjoy no longer interest you or bring you pleasure, even if you want them to?)

PHQ-9 — item 6 (worthlessness) in patient Spanish

“¿Ha tenido pensamientos de que no está haciendo las cosas bien como mamá, o de que su familia estaría mejor sin usted, o de que usted no sirve de nada?” (Have you had thoughts that you are not doing things well as a mother, or that your family would be better off without you, or that you are not worth anything?)

Note: “su familia estaría mejor sin usted” also bridges to item 9. Endorsement requires item 9 follow-up regardless of total score.

PHQ-9 — item 9 protocol for the postpartum visit

Frame first: “Le voy a hacer una pregunta que le hago a todas las mamás que vengo a ver en esta etapa — no porque piense que algo está mal, sino porque es parte del protocolo que seguimos con todas.” (I am going to ask you a question I ask all mothers I come to see at this stage — not because I think something is wrong, but because it is part of the protocol we follow with everyone.)

Then, after the other eight items: “¿Ha tenido pensamientos de hacerse daño, o de que las cosas serían mejor si usted no estuviera?” (Have you had thoughts of hurting yourself, or that things would be better if you were not here?)

If endorsed: “Gracias por decirme eso — eso me ayuda a saber cómo ayudarla. ¿Son pensamientos que pasan y se van, o ha pensado en cómo lo haría?” (Thank you for telling me that. Are they thoughts that come and go, or have you thought about how you would do it?)