Working with interpreters

You have been allocated a referral – Dr A, an asylum seeker from Ethiopia – and are due to see her at 11am tomorrow. You are told that an interpreter has been booked for you. You have never worked with an interpreter before. What might your thoughts and feelings about this meeting be?

If you have never worked with an interpreter before, spend a few minutes thinking about what Dr A might be thinking or feeling about your meeting tomorrow and how this may impact on the meeting itself. She might be worrying about depending on an interpreter to voice and explain her emotions. She may even be unclear why she is being asked to meet you and may have concerns about what seeing a psychologist in Britain means.

Opportunities and challenges
A multicultural society contains a richness and diversity of languages, cultures and beliefs or views about psychological well-being and mental health (Owusu-Bempah & Howitt, 2000; Patel, 2000). Many people may not be fluent in the English language but will require access to a range of psychological services. In light of the Macpherson Report and relevant legislation (e.g. the Race Relations Act and the Human Rights Act), and in the interests of best practice and equity of service provision, fluency should not impede or preclude access to psychological services. Unfortunately, the vital contribution of the interpreter is often not recognised by health professionals (Tribe, 2004), and some people have mistakenly assumed that it is not possible to undertake psychological work with an interpreter. Raval (2003) lists some of the difficulties recorded in the literature of working with an interpreter in mental health settings.

In reflecting upon the referral of Dr A, it is possible that you felt apprehensive about the prospect of working with an interpreter in general and in particular with an asylum seeker who may have been through a range of traumatic experiences. You may feel that you haven't received sufficient training on this, as suggested by Rae (2004; see the article in The Psychologist archive at www.bps.org.uk/1v9h). However, it's worth investing the time: working with an interpreter may provide an opportunity not only to broaden clinical perspectives and skills but to enrich practice, service delivery and knowledge. The need to ensure that psychologists are prepared to deal with people across language and culture is vital. The Standing Committee for the Promotion of Equal Opportunities within the British Psychological Society is campaigning to get working with interpreters on the curriculum for all applied postgraduate qualifying courses in psychology in Britain as they believed it was a necessary skill in multicultural Britain. Interestingly, Raval (1996) found that practitioners said using an interpreter gave them an increased respect for trained interpreters and a positive view of using interpreting services, so it is important that psychologists are prepared to work with interpreters and that appropriate training in doing this is available.
Working with an interpreter can also provide an excellent opportunity for psychologists to learn about and consider different constructions and views of psychological well-being, idioms of distress and 'treatment' (Patel, 2000; Tribe & Raval, 2003 ).

Language and culture
Language does not stand alone: it embodies a range of views about culture and mental health which may differ from those familiar to many psychologists from background and training. Languages are not simply directly interchangeable; they are multidimensional and reflect to some extent different ways of viewing the world (Mudarikiri, 2003). This is illustrated in Hoffman's (1989) book Lost in Translation:
All immigrants and exiles know the peculiar restlessness of an imagination that can never again have faith in its absoluteness. Because I have learned the relativity of cultural meanings on my skin, I can never take one set of meanings as final. (p.221)
For some refugees and asylum seekers language carries a particular resonance, as it may be through what has been said about them in the past, or through things they said themselves, that they were forced to flee their country of origin (Patel, 2003; Tribe, 1999). The idea of discussing emotions and experiences through an interpreter with a psychologist who is a stranger can prove an unusual, alien and challenging experience (see box).

In fact, the experience of being unable to express oneself verbally can be a frightening and disempowering experience for anyone. This may be amplified for an asylum seeker or refugee who will need to describe and express their reasons for seeking asylum clearly and accurately if their asylum application is to be properly considered. Most refugees are highly educated and qualified (CRE, 1997) but may have had no reason to learn English before flight. Feeling dependent on an interpreter can sometimes appear to be a leap of faith.

These are issues which require sensitivity and skill on the part of the psychologist. Working with an asylum seeker or refugee may require additional time spent in investing and developing the therapeutic alliance and building trust, what has been labelled developing stability and safety given the histories of many asylum seekers prior to seeking asylum. Time should also be spent ensuring that what you offer to the client is appropriate to their needs and explanatory health models.

Interpreting what?
The issue of whether interpreters should merely translate the spoken word or play a role in interpreting cultural meanings and variables which may have relevance to the psychological issues in question is a complicated one. The word interpret comes from the Latin interpretari, 'to explain, translate'. The Oxford Dictionary gives several meanings for the word interpret, these include; explaining the meaning of (words, a dream, etc.); to elucidate; to explain or understand (behaviour in a specified manner). It is crucial that every individual's process of meaning making is recognised, respected and accurately conveyed. Without this, the usefulness of any referral may be compromised.

It is also relevant to bear in mind that the dominant discourse and language of psychology was developed in 'the West' and encapsulates many of the cultural precepts developed here (e.g. adolescence, and family roles), sometimes ignoring or overriding other views. Add to this the issue of how language may be changed in the process of being interpreted by another individual, which is still not thoroughly understood (Haenal, 1997; Holder, 2004; Marshall et al., 1998), and you will appreciate how complex these issues are.

Some general guidelines
Here we can only make a couple of key points that can form a basis for further reflection and for developing guidelines to fit specific contexts and requirements. The interested reader should consult any guidelines developed by their employers or national agencies, and refer to Farooq and Fear (2003), Tribe and Raval (2003), www.mentalhealth.harpweb.org.uk and the references given at the end of this article. Interpreters may be located through your employing agency's pool of interpreters (in some trusts link workers or health advocates are also employed) or through local interpreting agencies. It is important to check which agencies and arrangements your employer uses and what kind of training the interpreter will have received before starting to work with them.

If you have never worked with an interpreter before, try to have a discussion with them well in advance of the meeting (and after as well) to enable you to consider some of the key issues together. It is important to remember that an interpreter is a partner in a multidisciplinary professional meeting who provides an essential link between you and the client. They are also an invaluable source of information. As with any such meeting, the two of you may wish to undertake some form of contract regarding practicalities, priorities, style of working, issues of confidentiality and boundaries. There may also be important cultural or linguistic issues that need discussion prior to meeting with the client.

Working in partnership with an interpreter can be assisted if you:
- Create an atmosphere where each member of the triad feels able to ask for clarification and explanation when necessary.
- Consider issues of transference and the dynamics of working with an interpreter.
- Provide trained and experienced interpreters with on-going support from either an organisation or individual
- Train psychologists in working with interpreters.
- Minimise the use of specialist or technical language.
- Use an interpreter who has experience of (and ideally training in) working within mental health.
- Consider the seating arrangements – an equilateral triangle usually works best.
- Try and find someone from the same country. Matching for gender, age and religion may be useful, though needs careful consideration. Do not use a relative – evidence suggests this is a bad idea.
- Remember that you hold clinical responsibility for the meeting and explain this clearly.
- Try and speak slowly and clearly and in short segments, because the interpreter has to remember what you have said and then interpret it.
- Ensure that you use the same interpreter for the duration of your work with a client.

If culturally appropriate and accessible services are to be offered, interpreters will be required to share their skills and expertise with psychological services and they should be valued accordingly through relevant career structures, training and professional status. This should benefit everyone through enriching and expanding service provision, and ensuring that psychological services meet the needs of the entire community, including asylum seekers and refugees.

Dr Rachel Tribe is a reader in psychology and Programme Director for the Professional Doctorate in Counselling Psychology at the University of East London. E-mail: [email protected].

Typical referrals
Abdi was referred to the psychologist working at his local health centre by his GP, Dr Jones. Dr Jones knew that Abdi had experienced a range of traumatic experiences before fleeing his country of origin and he had found it difficult to get Abdi to speak about these. Dr Jones knew that Abdi was extremely socially isolated: he was concerned about his psychological well-being and thought he could benefit from seeing a psychologist.
Abdi was very bemused by this referral and initially felt that talking about his experiences to someone he did not know, from outside his family and religion, was a bizarre proposition and he could not imagine that it would help him. He was also very mistrustful of the interpreter and the psychologist. This was because his experiences of being betrayed in his country of origin had led to him feeling that secrecy about his experiences was a more functional and protective strategy. Sharing his experiences with strangers – who might then share with others what he told them, and could put him at risk – felt frightening.

Ms J, from Iraq, described feeling 'infantalised and ashamed' by her inability to speak for herself when she first came to England. Being reliant upon another person in some way appeared to replicate her experience of being detained and held in her country where she felt she had no voice or ability to change her circumstances. This was despite the fact that she held a high-level professional qualification and was fluent in two other languages.

TRANSLATING THE WORDS vs. INTERPRETING CULTURAL MEANINGS
Mr Ali came into the session and talked about his home being inhabited by evil spirits, which he said he felt powerless to control and which he described as taking over his life and making him feel sad and hopeless.
A purely linguistic interpreter might have merely translated the words and left it at that. The psychologist might then, from their own world view, have taken this construction as evidence of psychopathology, perhaps believing the man was suffering from delusions or hallucinations.
An interpreter familiar with the cultural meanings and variables underlying these words to the psychologist would work somewhat differently (sometimes referred in clinical practice and the literature as a 'bicultural interpreter'). They would ensure that a linguistic and cultural interpretation was offered that might enhance the understanding of a client's presenting issues and world view.
In Mr Ali's case the description of evil spirits was a common cultural explanation, very familiar to the bicultural worker, relating to describing the bad feeling present in his home that related to difficulties in his relationship with his wife, which he blamed on external forces and was certainly not evidence of underlying psychopathology.

Discuss and debate
How might your service consider ensuring that the language needs of all your clients are met?
What can you do to ensure that different idioms of distress and explanatory health beliefs are acknowledged and incorporated into your work with refugees and asylum seekers?
How will you ensure that interpreters working within your service are treated with respect and supported?
Many asylum seekers and refugees report feeling that they were 'silenced' or their voices were taken away from them by political regimes which did not allow for multiple accounts/voices or which stifled criticism prior to them seeking asylum in Britain; how might this  be present in your work? 
Have your say on these or other issues this article raises. E-mail 'Letters' on [email protected], or members can contribute to our online forum via www.thepsychologist.org.uk.

References
Commission for Racial Equality (1997). Roots of the future ethnic diversity in the making of Britain. London: Author.
Farooq, S. & Fear, C. (2003). Working through interpreters. Advances in Psychiatric Treatment, 9, 104–109.
Haenal, F. (1997). Aspects and problems associated with the use of interpreters in psychotherapy with victims of torture. Torture, 7, 68–71.
Hoffman, L. (1989). Lost in translation. London: Vantage.
Holder, R. (2004, April). Impact on psychological therapy of working with asylum seekers and refugees across languages. Paper presented at the BPS Annual Conference, London.
Marshall, P.A., Koenig, B.A., Grifhorst, P. & van Ewjik, M. (1998). Ethical issues in immigrant health care and clinical research. In S. Loue (Ed.) Handbook of immigrant health (pp.203–226). New York: Plenum Press.
Mudarikiri, M.M. (2003). Working with interpreters in adult mental health. In R. Tribe and H. Raval (2003) Working with interpreters in mental health. London & New York: Routledge.
Owusu-Bempah, K. & Howitt, D. (2000). Psychology beyond Western perspectives. Leicester: BPS Books.
Patel, N. (Ed.) (2000). Clinical psychology, 'race' and culture: A training manual. Oxford: BPS/Blackwell.
Patel, N. (2003). Speaking with the silent. In R. Tribe and H. Raval (2003) Working with interpreters in mental health. London & New York: Routledge.
Rae, A. (2004). Now you're talking my language. The Psychologist, 17, 580–582.
Raval, H. (1996). A systemic perspective on working with interpreters. Clinical Child Psychology & Psychiatry, 1, 29–43.
Tribe, R. (1999). Bridging the gap or damming the flow? British Journal of Medical Psychology, 72, 567–576.
Tribe, R. (1999). Therapeutic work with refugees living in exile: Observations on clinical practice. Counselling Psychology Quarterly, 12, 3, 233–243.
Tribe, R. & Raval, H. (2003). Working with interpreters in mental health. London & New York: Routledge.
Tribe, R. (2004). Working with interpreters in legal and forensic settings. In K. Barrett & B. George (Eds.) Race, Culture, Psychology and the Law. New York: Sage.

You have been allocated a referral – Dr A, an asylum seeker from Ethiopia – and are due to see her at 11am tomorrow. You are told that an interpreter has been booked for you. You have never worked with an interpreter before. What might your thoughts and feelings about this meeting be?

If you have never worked with an interpreter before, spend a few minutes thinking about what Dr A might be thinking or feeling about your meeting tomorrow and how this may impact on the meeting itself. She might be worrying about depending on an interpreter to voice and explain her emotions. She may even be unclear why she is being asked to meet you and may have concerns about what seeing a psychologist in Britain means.

Opportunities and challenges

A multicultural society contains a richness and diversity of languages, cultures and beliefs or views about psychological well-being and mental health (Owusu-Bempah & Howitt, 2000; Patel, 2000). Many people may not be fluent in the English language but will require access to a range of psychological services. In light of the Macpherson Report and relevant legislation (e.g. the Race Relations Act and the Human Rights Act), and in the interests of best practice and equity of service provision, fluency should not impede or preclude access to psychological services. Unfortunately, the vital contribution of the interpreter is often not recognised by health professionals (Tribe, 2004), and some people have mistakenly assumed that it is not possible to undertake psychological work with an interpreter. Raval (2003) lists some of the difficulties recorded in the literature of working with an interpreter in mental health settings.

In reflecting upon the referral of Dr A, it is possible that you felt apprehensive about the prospect of working with an interpreter in general and in particular with an asylum seeker who may have been through a range of traumatic experiences. You may feel that you haven't received sufficient training on this, as suggested by Rae (2004). However, it's worth investing the time: working with an interpreter may provide an opportunity not only to broaden clinical perspectives and skills but to enrich practice, service delivery and knowledge. The need to ensure that psychologists are prepared to deal with people across language and culture is vital. The Standing Committee for the Promotion of Equal Opportunities within the British Psychological Society is campaigning to get working with interpreters on the curriculum for all applied postgraduate qualifying courses in psychology in Britain as they believed it was a necessary skill in multicultural Britain. Interestingly, Raval (1996) found that practitioners said using an interpreter gave them an increased respect for trained interpreters and a positive view of using interpreting services, so it is important that psychologists are prepared to work with interpreters and that appropriate training in doing this is available.

Working with an interpreter can also provide an excellent opportunity for psychologists to learn about and consider different constructions and views of psychological well-being, idioms of distress and 'treatment' (Patel, 2000; Tribe & Raval, 2003 ).

Language and culture

Language does not stand alone: it embodies a range of views about culture and mental health which may differ from those familiar to many psychologists from background and training. Languages are not simply directly interchangeable; they are multidimensional and reflect to some extent different ways of viewing the world (Mudarikiri, 2003). This is illustrated in Hoffman's (1989) book Lost in Translation:
All immigrants and exiles know the peculiar restlessness of an imagination that can never again have faith in its absoluteness. Because I have learned the relativity of cultural meanings on my skin, I can never take one set of meanings as final. (p.221)

For some refugees and asylum seekers language carries a particular resonance, as it may be through what has been said about them in the past, or through things they said themselves, that they were forced to flee their country of origin (Patel, 2003; Tribe, 1999). The idea of discussing emotions and experiences through an interpreter with a psychologist who is a stranger can prove an unusual, alien and challenging experience (see box).

In fact, the experience of being unable to express oneself verbally can be a frightening and disempowering experience for anyone. This may be amplified for an asylum seeker or refugee who will need to describe and express their reasons for seeking asylum clearly and accurately if their asylum application is to be properly considered. Most refugees are highly educated and qualified (CRE, 1997) but may have had no reason to learn English before flight. Feeling dependent on an interpreter can sometimes appear to be a leap of faith.

These are issues which require sensitivity and skill on the part of the psychologist. Working with an asylum seeker or refugee may require additional time spent in investing and developing the therapeutic alliance and building trust, what has been labelled developing stability and safety given the histories of many asylum seekers prior to seeking asylum. Time should also be spent ensuring that what you offer to the client is appropriate to their needs and explanatory health models.

Interpreting what?

The issue of whether interpreters should merely translate the spoken word or play a role in interpreting cultural meanings and variables which may have relevance to the psychological issues in question is a complicated one. The word interpret comes from the Latin interpretari, 'to explain, translate'. The Oxford Dictionary gives several meanings for the word interpret, these include; explaining the meaning of (words, a dream, etc.); to elucidate; to explain or understand (behaviour in a specified manner). It is crucial that every individual's process of meaning making is recognised, respected and accurately conveyed. Without this, the usefulness of any referral may be compromised.

It is also relevant to bear in mind that the dominant discourse and language of psychology was developed in 'the West' and encapsulates many of the cultural precepts developed here (e.g. adolescence, and family roles), sometimes ignoring or overriding other views. Add to this the issue of how language may be changed in the process of being interpreted by another individual, which is still not thoroughly understood (Haenal, 1997; Holder, 2004; Marshall et al., 1998), and you will appreciate how complex these issues are.

Some general guidelines

Here we can only make a couple of key points that can form a basis for further reflection and for developing guidelines to fit specific contexts and requirements. The interested reader should consult any guidelines developed by their employers or national agencies, and refer to Farooq and Fear (2003), Tribe and Raval (2003), www.mentalhealth.harpweb.org.uk and the references given at the end of this article. Interpreters may be located through your employing agency's pool of interpreters (in some trusts link workers or health advocates are also employed) or through local interpreting agencies. It is important to check which agencies and arrangements your employer uses and what kind of training the interpreter will have received before starting to work with them.

If you have never worked with an interpreter before, try to have a discussion with them well in advance of the meeting (and after as well) to enable you to consider some of the key issues together. It is important to remember that an interpreter is a partner in a multidisciplinary professional meeting who provides an essential link between you and the client. They are also an invaluable source of information. As with any such meeting, the two of you may wish to undertake some form of contract regarding practicalities, priorities, style of working, issues of confidentiality and boundaries. There may also be important cultural or linguistic issues that need discussion prior to meeting with the client.

Working in partnership with an interpreter can be assisted if you:
- Create an atmosphere where each member of the triad feels able to ask for clarification and explanation when necessary.
- Consider issues of transference and the dynamics of working with an interpreter.
- Provide trained and experienced interpreters with on-going support from either an organisation or individual
- Train psychologists in working with interpreters.
- Minimise the use of specialist or technical language.
- Use an interpreter who has experience of (and ideally training in) working within mental health.
- Consider the seating arrangements – an equilateral triangle usually works best.
- Try and find someone from the same country. Matching for gender, age and religion may be useful, though needs careful consideration. Do not use a relative – evidence suggests this is a bad idea.
- Remember that you hold clinical responsibility for the meeting and explain this clearly.
- Try and speak slowly and clearly and in short segments, because the interpreter has to remember what you have said and then interpret it.
- Ensure that you use the same interpreter for the duration of your work with a client.

If culturally appropriate and accessible services are to be offered, interpreters will be required to share their skills and expertise with psychological services and they should be valued accordingly through relevant career structures, training and professional status. This should benefit everyone through enriching and expanding service provision, and ensuring that psychological services meet the needs of the entire community, including asylum seekers and refugees.

Dr Rachel Tribe is a reader in psychology and Programme Director for the Professional Doctorate in Counselling Psychology at the University of East London. E-mail: [email protected].

Typical referrals
Abdi was referred to the psychologist working at his local health centre by his GP, Dr Jones. Dr Jones knew that Abdi had experienced a range of traumatic experiences before fleeing his country of origin and he had found it difficult to get Abdi to speak about these. Dr Jones knew that Abdi was extremely socially isolated: he was concerned about his psychological well-being and thought he could benefit from seeing a psychologist.

Abdi was very bemused by this referral and initially felt that talking about his experiences to someone he did not know, from outside his family and religion, was a bizarre proposition and he could not imagine that it would help him. He was also very mistrustful of the interpreter and the psychologist. This was because his experiences of being betrayed in his country of origin had led to him feeling that secrecy about his experiences was a more functional and protective strategy. Sharing his experiences with strangers – who might then share with others what he told them, and could put him at risk – felt frightening.

Ms J, from Iraq, described feeling 'infantalised and ashamed' by her inability to speak for herself when she first came to England. Being reliant upon another person in some way appeared to replicate her experience of being detained and held in her country where she felt she had no voice or ability to change her circumstances. This was despite the fact that she held a high-level professional qualification and was fluent in two other languages.

TRANSLATING THE WORDS vs. INTERPRETING CULTURAL MEANINGS
Mr Ali came into the session and talked about his home being inhabited by evil spirits, which he said he felt powerless to control and which he described as taking over his life and making him feel sad and hopeless.

A purely linguistic interpreter might have merely translated the words and left it at that. The psychologist might then, from their own world view, have taken this construction as evidence of psychopathology, perhaps believing the man was suffering from delusions or hallucinations.

An interpreter familiar with the cultural meanings and variables underlying these words to the psychologist would work somewhat differently (sometimes referred in clinical practice and the literature as a 'bicultural interpreter'). They would ensure that a linguistic and cultural interpretation was offered that might enhance the understanding of a client's presenting issues and world view.
In Mr Ali's case the description of evil spirits was a common cultural explanation, very familiar to the bicultural worker, relating to describing the bad feeling present in his home that related to difficulties in his relationship with his wife, which he blamed on external forces and was certainly not evidence of underlying psychopathology.

Discuss and debate
How might your service consider ensuring that the language needs of all your clients are met?
What can you do to ensure that different idioms of distress and explanatory health beliefs are acknowledged and incorporated into your work with refugees and asylum seekers?
How will you ensure that interpreters working within your service are treated with respect and supported?
Many asylum seekers and refugees report feeling that they were 'silenced' or their voices were taken away from them by political regimes which did not allow for multiple accounts/voices or which stifled criticism prior to them seeking asylum in Britain; how might this  be present in your work? 
Have your say on these or other issues this article raises. E-mail 'Letters' on [email protected], or members can contribute to our online forum via www.thepsychologist.org.uk.

References
Commission for Racial Equality (1997). Roots of the future ethnic diversity in the making of Britain. London: Author.
Farooq, S. & Fear, C. (2003). Working through interpreters. Advances in Psychiatric Treatment, 9, 104–109.
Haenal, F. (1997). Aspects and problems associated with the use of interpreters in psychotherapy with victims of torture. Torture, 7, 68–71.
Hoffman, L. (1989). Lost in translation. London: Vantage.
Holder, R. (2004, April). Impact on psychological therapy of working with asylum seekers and refugees across languages. Paper presented at the BPS Annual Conference, London.
Marshall, P.A., Koenig, B.A., Grifhorst, P. & van Ewjik, M. (1998). Ethical issues in immigrant health care and clinical research. In S. Loue (Ed.) Handbook of immigrant health (pp.203–226). New York: Plenum Press.
Mudarikiri, M.M. (2003). Working with interpreters in adult mental health. In R. Tribe and H. Raval (2003) Working with interpreters in mental health. London & New York: Routledge.
Owusu-Bempah, K. & Howitt, D. (2000). Psychology beyond Western perspectives. Leicester: BPS Books.
Patel, N. (Ed.) (2000). Clinical psychology, 'race' and culture: A training manual. Oxford: BPS/Blackwell.
Patel, N. (2003). Speaking with the silent. In R. Tribe and H. Raval (2003) Working with interpreters in mental health. London & New York: Routledge.
Rae, A. (2004). Now you're talking my language. The Psychologist, 17, 580–582.
Raval, H. (1996). A systemic perspective on working with interpreters. Clinical Child Psychology & Psychiatry, 1, 29–43.
Tribe, R. (1999). Bridging the gap or damming the flow? British Journal of Medical Psychology, 72, 567–576.
Tribe, R. (1999). Therapeutic work with refugees living in exile: Observations on clinical practice. Counselling Psychology Quarterly, 12, 3, 233–243.
Tribe, R. & Raval, H. (2003). Working with interpreters in mental health. London & New York: Routledge.
Tribe, R. (2004). Working with interpreters in legal and forensic settings. In K. Barrett & B. George (Eds.) Race, Culture, Psychology and the Law. New York: Sage.