By Laurie Scarborough
In a country like South Africa, which has 11 official languages, there can be huge variety of language and culture. While this celebrates the diversity of the nation, it can create some challenges to mental health workers, who in South Africa are predominantly white and English-speaking. This limiting scope of practice for many of the mental health care professionals means that for many people, psychological care is not possible without the employment of an interpreter. Language is of particular importance to counsellors because it is through language (talking and listening) that assessment and interventions can be delivered (Lago & Thomson, 1996; Leanza, Miklavcic, Boivin, & Rosenberg, 2014). It is therefore quite difficult when clients and counsellors do not share a language, because communication is then stalled and even with the use of an interpreter, a normal dialogue is impossible and becomes filtered through a third person (Ravel & Smith, 2003).
The word interpreter, instead of translator, is used here quite purposefully, because it connotes the multiple roles that interpreters have in a mental health counselling setting, in which they not only act as translators of words, but also as interpreters of emotion and cultural meanings. This is particularly important in relationships where the client and therapist may not only speak different languages, but might come from completely different cultures and world views.
In 1999 there were no official interpreters employed in government health facilities (Drennan & Swartz, 1999) and little recent information is available for current interpreter availability in state hospitals and clinics. The lack of interpreters is an ethical problem because health care, including mental health care, should be equally available to all people who need it. Instead of official interpreters, non-governmental organisations often provide interpreters but these interpreters have poor training in interpretation, especially in mental health care (Drenna & Swartz, 1999). Mental health interpreting is quite different to legal or medical interpreting models, because it requires a long-term relationship with a client and also high levels of emotional content (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005).
This essay will discuss theoretical issues with interpreting in the way that language, communication and cognition interact with interpreting in a mental health care setting. After this follows a discussion on problems with interpreting in mental health care and then good practice guidelines with utilising interpreter services.
Language, communication and cognition
The Sapir-Whorf hypothesis of linguistic relativism postulates that the language you speak determines how you encode and therefore perceive the world (Fromkin et al., 2007; Lago & Thomspon, 1996). We are thus “constrained” by the language we speak (Lago & Thompson, 1996) and language in fact represent our world view (Tribe, 2007; Tribe & Morrissey, 2004). Using a simple lexicon example, in Navaho, blue and green are represented by a single word (Fromkin et al., 2007) and research shows that people who speak this language have more difficulty differentiating between blue and green (Lago & Thomspon, 1996). We can see in this example how language shapes how we perceive and think about the world, and thus the question if we do not have words for something (be it a colour, an emotion, a thought), can we still experience it (Lago & Thomspon, 1996)? German has no word for the mind and Sesotho and Polish have no word for counsellor (Tribe, 1999). Thus under the Sapir-Whorf hypothesis, can they differentiate the different role of a counsellor to say the closest linguistic substitution, “advice-giver”? This is relevant to psychology because if two people from different language are encoding the world in such differing ways, can they really reconcile these differences to form a productive therapeutic relationship?
Language is also linked to cultural meanings and mental health could be perceived differently in each language (Tribe, 2007). Psychological vocabulary is based on Western language and culture (Tribe, 1999), but the client may come from a different perspective or use different terminology which may be foreign to a counsellor of a different language, even after translation, due to these cultural differences. For example, African students in Britain complained of itching in their heads and stomach pains, but after consultation with African colleagues, it was discovered that these students were somaticising mental health problems and that these symptoms were actually an indication of anxiety and depression (Lago & Thomspon, 1996). You can see here how interpreters need not only translate the words, but also the cultural meanings (Miller et al, 2005). Language creates cultural experience as well as forms part of your identity (Smart & Smart, 1995) and this is important in work with interpreters because it highlights the need to translate cultural meanings.
Finally, language exists only in the “social reality” of its speakers and these realities could be very different between client and counsellor (Lago & Thompson, 1996). This could create difficulties in seeing things from each other’s perspective and for the counsellor this could impact on empathy.
Problems around interpreting in mental health counselling settings
An interpreter’s presence affects the counsellor in a number of ways. Counsellors commonly feel uncomfortable with the interpreter because they cannot know what they are missing in the translation process (Raval & Smith, 2003). This indicates problems around trust with the interpreter (Raval & Smith, 2003). Counsellors often feel powerless or excluded from the therapy relationship (Leanza, et al, 2014; Miller, et al, 2005; Paone & Malott, 2008; Tribe & Keefe, 2009), or even threatened by the presence of the interpreter (Paone & Malott, 2008; Tribe, 1999). This could be because counsellors are worried about the power relations within the therapy session. They may feel as though the interpreter holds the power because they are controlling the communication, when the counsellor is actually who should be controlling the conversation and the session (Drennan & Swartz, 1999; Tribe, 2007). Counsellors also found that establishing a working relationship with the interpreter could sometimes be difficult, leading to difficulties forming an alliance with the client (Raval & Smith, 2003).
Not only is the counsellor affected by an interpreter, but so too is the interpreter affected by working in the field of mental health. Stress and distress could be experience by the interpreter (Drennan & Swartz, 1999), especially in interpreters who are not properly trained in mental health interpreting because of the high levels of emotional and distressing content. This could lead to interpreter drop-out (Miller, et al, 2005; Paone & Malott, 2008) which could impact on the clients. Interpreters can feel embarrassed by what what the client is saying or by questions the counsellor asks, because they have not done the internal work that the counsellor has in order to feel comfortable with certain questions and topics (Raval & Smith, 2003). Matters concerning sex, finances and suicidal or homicidal ideation are particularly uncomfortable for interpreters (Luis & Marcos, 1979; Paone & Malott, 2008). Also interpreters exposing their distress or embarrassment to clients is inappropriate and could prevent the client from feeling comfortable to share further (Paone & Malott, 2008).
An interpreter can also affect the therapeutic relationship, since they are not invisible, but rather a presence in the room (Leanza, et al, 2014; Miller, et al, 2005) and come with their own ideas and baggage that they bring into the therapy relationship (Drennan & Swartz, 1999; Leanza, et al, 2014) which could influence what they are comfortable translating or could influence their translations in subtle ways that the counsellor may not even realise (Drennan & Swartz, 1999; Leanza, et al, 2014). First, a therapy dyad becomes a triad and the dynamic of this needs to be managed (d’Ardenne, et al 2007; Tribe & Keefe, 2009). There are issues around transference and countertransference (Sayed, 2003; Tribe, 2007). The alliance between client and counsellor is disrupted by the interpreter (Miller, et al, 2005). The client can often form a primary relationship or alliance with the interpreter instead of the counsellor (Leanza et al., 2014; Miller, et al, 2005; Tribe & Morrissey, 2004), because that is who they can directly communicate with (Tribe & Morrissey, 2004) and clients may perceive an interpreter as more similar to them and from the same cultural background (Leanza et al., 2014). Clients may seek help straight from the interpreter because they can directly communicate with them, especially when they are in crisis (Miller et al., 2005). Transference then goes to the interpreter instead of the counsellor (Drennan & Swartz, 1999; Raval & Smith, 2003), however the interpreter is not trained to understand transference, and may behave like a friend in one session and therapist in another (Sayed, 2003), causing confusion for the client. It is also possible that the presence of both a counsellor and an interpreter (who the client may have a primary bond with) could cause role confusion (Paone & Malott, 2008), which is a problem for all three in the triad. The counsellor not only has countertransference to the client, but also to the interpreter (Leanza, et al, 2014). The interpreter also has countertransference towards the client, which could affect counselling in a number of ways. An interpreter could over identify with the client and protect them, and then disagree with the counsellor on the direction of the therapy, which can interfere with translation duties (Luis & Marcos, 1979). Alternatively, interpreters could normalise certain painful memories of the client because they are uncomfortable (Leanza et al., 2014). In order to defend against painful memories and emotions that may come up in therapy for the client, the interpreter could become dismissive or even judgemental which sets back trust and rapport with the client (Lago & Thompson, 1996). An interpreter’s countertransference may have more of an impact than a counsellor’s countertransference, because a counsellor has been trained to assess and manage their countertransference.
There are issues around confidentiality with interpreters entering into the therapy relationship (Freed, 1988; Leanza, et al, 2014; Tribe & Morrissey, 2004), and clients may take longer to establish trust and rapport with the counsellor because of this (Drennan & Swartz, 1999; Matoane, 2012; Miller, et al, 2005). These trust issues can prevent a successful therapy encounter (Lago & Thompson, 1996).
Interpreting is not a perfect science. Sometimes certain parts of communication is lost during translation (Ravel & Smith, 2003). Interpreters are sometimes not able to make flawless translations or cultural interpretations. Some languages do not directly translate (Tribe, 1999; Tribe & Keefe, 2009) and some words or tenses may not transfer into other languages (Tribe & Morrissey, 2004). For example, translating English to many African languages is very complicated and cumbersome at times (Matoane, 2012). There are concerns around errors in interpreting (Paone & Malott, 2008) and how this can slow down assessment and diagnosis. Interpreters may know the language, but not understand the relevant cultural material (Drennan & Swartz, 1999; Leanza, et al, 2014) because of class, education and contextual differences between the client and the interpreter (Leanza, et al, 2014) which can cause misrepresentations in a translation. We saw with the African students in Britain example how important cultural information is to diagnosis. Things in speech like prosody and code switching can be very important as an indication of emotional state (Leanza, et al, 2014). These are not accessible to the counsellor (Luis & Marcos, 1979), so it is up to the interpreter to make the counsellor aware of these factors. This type of material may not be possible to translate however (Luis & Marcos, 1979), but the interpreter still needs to report any abnormalities. For example, patients with depression may speak in a monotone, or a person with schizophrenia may speak nonsensically (Leanza, et al, 2014), which is important for the therapist to know. However an interpreter may simply not translate a psychotic word salad or pick up on the relevance of monotonous speech, because they are not trained to do so (Paone & Malott, 2008). Thus the counsellor may miss important diagnostic material and diagnosis may be slowed down by an interpreter not reporting such things (Bradford & Munoz, 1993). Simply summarising or omitting details to save time can also cause errors (Drennan & Swartz, 1999; Paone & Malott, 2008) and important information could be omitted (Bradford & Munoz, 1993).
The cost an interpreter can hugely increase the financial burden of counselling for the client (d’Ardenne, et al, 2007). First the interpreter needs to be paid alongside the counsellor, but also the sessions are often longer, because everything needs to be said twice (Leanza et al., 2014; Sandhu, 1994) so this will increase costs of each session. Also the interpreter needs to be paid for meetings before and after each session. Working with an interpreter also causes slower progress with the client, partly because interpreters can make errors that may impact on diagnosis, which increase the length of therapy, increasing overall cost of the intervention (Paone & Malott, 2008).
Counsellors also found that intervention and interview styles were altered when using an interpreter. Interventions and interview style tended to be simpler (Raval & Smith, 2003), which simply means that a counsellor is not able to use all the tools in their arsenal with clients using interpreters, which could impact on therapeutic outcomes. For example, if a client begins to experience the beginning stages of an anxiety attack during a session, a counsellor may deliberately begin talking in a calm, slow manner, in order to calm the patient, however an interpreter is not trained to be able to do this, or may feel uncomfortable doing it, in which case the intervention is lost on the client (Bradford & Munoz, 1993).
Practice guidelines for working with interpreters
In order to address the problems around interpreting mental health settings, guidelines for practice have been developed. There are currently no standards for working with interpreters in mental health settings (Tribe & Keefe, 2009). Best practice standards have been developed in other areas of interpreting, but mental health interpreting has lagged behind in this regard (Drennan & Swartz, 1999), thus perhaps best practice standards should be released for this area to better delineate what works best in these relationships. There are however several patterns that seem to work well with working with interpreters.
Firstly, it seems clear that training for both the counsellor and the interpreter is needed (Drennan & Swartz, 1999; Leanza et al, 2014; Tribe, 2007; Tribe & Lane, 2009). Inexperienced interpreters are more likely to make translation errors (d’Ardenne, Ruaro, Cestari, Fakoury, & Priebe, 2007), which could compromise therapy progress. Thus using interpreters with a year or more of experience in specifically health interpreting is best (d’Ardenne et al., 2007). Interpreters need to be competent in the language but should also have cultural training so they can act as cultural interpreters as well (Luis & Marcos, 1979; Tribe & Lane, 2009). I would argue however, that both counsellor and interpreter need cultural training in order to create a more understanding and successful working relationship. It is also suggested that interpreters receive psychological training (Luis & Marcos, 1979; Tribe, 2007; Tribe & Lane, 2009), so they are better equipped to deal with the emotional aspects of the job that might be distressing (Leanza et al, 2014).
There is debate around whether interpreters should simply translate the word-for-word meanings, or whether they should include cultural information as well (Tribe & Morrissey, 2004). This cultural information could be very relevant to how the client perceives their world, and should therefore be included (Smart & Smart, 1995). Interpreters also need to be trained to interpret paralinguistic and prosodic material as well, such as gesture, affect, speech speed and timing and so on (Raval & Smith, 2003), as this could be relevant to clinical assessment and intervention, as previously mentioned. Interpreters need to understand normal prosodic features for the language (Leanza et al., 2014) so that they can detect abnormalities and alert the counsellor if this occurs. The method of interpreting this kind of information could be challenging as simply copying the client could turn into mimicry (Bradford & Munoz, 1993).
Interpreters need to have supervision and support (Tribe, 1999). Meetings for debriefing before and after each session to discuss treatment plans and possible evaluations is important so the counsellor and interpret have a mutual understanding and establish goals for each session (d’Ardenne, et al, 2007; Hamerdinger & Karlin, 2003; Paone & Malott, 2008; Tribe, 2007; Tribe & Lane, 2009; Tribe & Morrissey, 2004), however this will incur additional costs as the interpreter does need to compensated for this time (Tribe & Lane, 2009). Supervision and support is also need for the interpreter because they are not trained to deal with the emotional distress that could be caused by being a witness to someone’s therapy (Tribe & Lane, 2009), and can also lead to fewer language misrepresentations (Luis & Marcos, 1979).
It is recommended that therapists speak slowly and clearly and use short phrases so as not to challenge the memory of the interpreter, which could cause unnecessary summarisation (Bradford & Munoz, 1993; Leanza et al., 2014; Tribe, 2007; Tribe & Lane, 2009; Tribe & Morrissey, 2004). Avoiding specialised language makes it easier for the interpreter, who might not have the specialised vocabulary to translate certain words into another language (Tribe, 2007). Interpreters may not have the vocabulary to translate technical psychological language (Smart & Smart, 1995). The client should also be cued to use shorter phrases for the interpreter (Bradford & Munoz, 1993). All this could however inhibit the counsellor and the client, who may feel that they need to use complicated language, or long phrases, to describe complicated emotions and thoughts. Using literal language is also more helpful than using language that depends on cultural understandings, such as proverbs, idioms, sarcasm or humour (Leanza et al., 2014; Paone & Malott, 2008; Tribe & Lane, 2009; Tribe & Morrissey, 2004) as this can cause confusion when translating especially if the same meanings are not transferred into the other language. The counsellor should encourage an environment where anyone in the triad can ask for clarification at any point (Tribe, 2007; Tribe & Morrissey, 2004). This may minimise confusion and misrepresentations.
Research shows that matching an interpreter for age, gender and even religion can be helpful (Tribe, 2007; Tribe & Lane, 2009; Tribe & Morrissey, 2004;). There are instances where this could be more important, for example a sexual abuse or domestic violence victim might only feel comfortable with an interpreter of the same sex (Tribe & Lane, 2009; Tribe & Morrissey, 2004; Smart & Smart, 1995), or women from certain parts of the world may feel uncomfortable sharing with a male interpreter (Leanza et al., 2014). However, this is then relevant to the counsellor involved as well. Pairing a client and interpreter from the same country can also be helpful (Tribe, 2007) as they are more likely to understand the cultural material.
Interpreters should be trained to use first-person pronouns (“I” or “me”) as they are original used by the client and counsellor (Paone & Malott, 2008). It becomes confusing when interpreters rather say “he” or “she” to refer to the client or counsellor because it becomes unclear who is actually speaking (Bradford & Munoz, 1993). It also interrupts the sense of identity and changes the relationship between client and counsellor (Bradford & Munoz, 1993).
Finally, it is important to use the same interpreter through the counselling intervention (Leanza, et al, 2014; Tribe & Lane, 2009; Tribe & Morrissey, 2004), so as not to cause unnecessary disruption or stress on the client (Leanza et al., 2014). Changing interpreters during therapy may also bring up confidentiality concerns and the client may lose trust in the counsellor as well as the new interpreter, which would then take time to re-establish (Leanza et al., 2014).
As it can be seen, there are a number of problems with interpreting in mental health settings, and this was by no means an exhaustive discussion of issues in the practice. There are a number of guidelines for working with interpreters that address these issues though. Also, the use of an interpreter may be the only way for someone to gain access to mental health care (Raval & Smith, 2003) and there is an ethical call to provide health care that anyone could utilise if needed (Leanza et al., 2014). Research also found that therapy efficacy was not impacted by the presence of an interpreter (d’Ardenne, et al, 2007), however clients and counsellors who speak the same language did notice improvement quicker (d’Ardenne, et al, 2007). Clients with interpreters also felt “better understood” (Tribe & Keefe, 2009) and attended follow-up sessions more frequently than clients without interpreters (Tribe & Morrissey, 2004). They also rated their counselling experience more highly than those without interpreters and perceived the counsellor as more competent (Paone & Malott, 2008). Despite negative impacts of interpreters on the therapy, it is still better than not providing any mental health care at all to people who speak languages unaccessible to counsellors.
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