Interpreting in mental health contexts via skype



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INTERPRETING IN MENTAL HEALTH CONTEXTS VIA SKYPE

(Produced for the 4th International Conference on Public Service Interpreting and Translation, Universidad de Alcala, Madrid, Spain, May 2011)


Beverley Costa

Mothertongue multi-ethnic counselling service

www.mothertongue.org.uk

Abstract

In order to provide equitable services, mental health clients should be offered treatment in their preferred language. The reasons for a client’s language choice in therapy are complex and often an interpreter will be needed for the clinical sessions. Interpreting in a mental health context places specific demands on the interpreter. The paper explores these demands and demonstrates practical ways of working effectively face to face and remotely via Skype. Drawing on the experiences of Mothertongue multi-ethnic counselling service, models of collaborative working and training for interpreters and clinicians are discussed.



Resumen

Para poder proporcionar servicios ecuánimes, los pacientes con problemas de salud mental deberían ser atendidos en la lengua que ellos elijan. Las razones que el paciente tiene para elegir el idioma para la terapia son complejas y frecuentemente será necesaria la asistencia de un intérprete para las consultas. En el contexto de la salud mental los intérpretes deben satisfacer demandas específicas. Este estudio explora dichas demandas y muestra unas formas prácticas para trabajar de manera efectiva, tanto cara a cara como de forma virtual usando Skype. Aprovechando las experiencias de Mothertongue, un servicio de asesoramiento multi étnico, en el estudio se consideran modelos de colaboración y de formación para intérpretes y para los profesionales dedicados a la salud mental. 


Introduction

Increasingly Mental Health Services have to call on the support of interpreters in order to treat clients whose first language differs from the official language of the country in which they reside. Clinicians and interpreters have become aware that interpreting in a mental health context differs from interpreting in other contexts. As a result, models and guidelines for clinicians and interpreters working together are being established.

Mothertongue multi-ethnic counselling and listening service was established 10 years ago in Reading, UK. It provides culturally sensitive professional therapeutic support services for people from Black and Minority Ethnic (BME) communities in a range of languages directly and also via interpreters. This paper draws on the experience of this organisation together with the experiences of other professionals working in this field. It explores the clinical processes involved rather than the linguistic and technological processes. It focuses on the clinical context of the interpreting and the challenges when working as an interpreter remotely.

In order to demonstrate the specific demands of interpreting in a mental health context, we will consider first the particular demands of the clinical context, followed by the way in which the public perception of mental health professionals impacts on the work of the interpreter. A set of guidelines and a model of interpreting have been developed to address these issues. Finally the paper considers how these need to be adapted when the Mental Health Interpreter (MHI) is interpreting for a consultation via Skype.



The clinical context

Language is at the centre of our ability to structure and provide meaning to our experiences, to form relationships with others; express our needs and feelings, conceptualise ideas and give shape to our imaginations. The way in which language is used to communicate is a reflection of social and cultural norms, which help to regulate the individual and the community. In therapeutic work it is often considered that it is best to work in a client’s mother tongue if possible and if that is not possible, through an interpreter.   Sue & Sue (1999), referring to clinical work in the USA, make the point that the use of English as the standard means of communication immediately disadvantages a non-native English speaker. Fernando (2003) suggests that bilingual client-facing mental health professionals are preferable. Perez Foster (1998:135) proposes that the “the use of a translator in a psychodynamic or psychoanalytically oriented treatment approach would almost be untenable (…) for a variety of reasons which include the complexities of transferential projections.”

Despite these objections, it has been shown that it is possible to do very effective clinical work with the use of interpreters by organisations such as The Medical Foundation for the Care of Victims of Torture and Mothertongue (both UK based). It has even been argued (Thompson and Woods 2009a: 4)) that the presence of an interpreter can enhance the clinician’s work: “through learning about different cultural perspectives, idioms of distress and the role of language in the therapeutic endeavour.” Bradford & Munoz (1993:58) believe that in therapeutic work: “the translator becomes an extension of the therapist (…) the exercise of their respective roles entails momentary experiences of their sharing a single identity” This requires the clinician and the interpreter to prepare together and to work as a collaborative team.

In training, when participants are asked to imagine the fears of working with an interpreter in a therapeutic context, both interpreters and therapists regularly cite anxiety about their role in the therapeutic relationship and about being able to trust in the other professional. As previous references to clinicians have also illustrated, interpreters may face resistance to their presence from clinicians. However, there are not enough trained clinicians who can cover every language required and so frequently interpreters are regarded as a “necessary nuisance” (Tribe & Woods 2009a: 4) and a costly resource. Nevertheless, they may provide for many the only way to access mental health services, Tribe & Raval (2003).

When it is agreed to use an interpreter in therapeutic work, it is important to remember that the interpreter will be speaking in a language that may be highly charged for the client. What impact does that have on the client and on the therapy? Language and language choice in the therapy room represent a container for the expression of great, powerful emotions. Clients often have deeply distressing stories to tell, full of incidents that may remind us of pain in our own lives – relationship crises, losses, bereavements, betrayal etc.

In the therapy room, it is essential for all the people involved to be fully attentive. Part of the professional formation for clinicians is to prepare them to listen deeply to people’s painful and dark stories and to be fully present with their emotions even when the stories they are hearing may have very real connections with their own experiences. They do not cut off from the experiences but neither do they become so emotionally involved that they become lost in the story themselves. It is not an easy process as they are, in the moment, emotionally connected and yet not overwhelmed by the emotion. In order for interpreters to work effectively in the therapeutic frame, we ask the same of them and yet they do not come to the task with the same professional preparation. This is why appropriate training to work in this context, together with supervision, is so essential. Muriel & Smith (2009:8) comment that even when support is offered to interpreters, “this doesn’t mirror the years of support, training and supervision that enable therapists to address the challenges of mental health practice.” The training for this work focuses not just on the language skills but also on the appropriate relationship skills, in particular the challenge of working as the third party in a traditionally dyadic therapeutic relationship. Some models of therapy (Perez Foster 1998) pay great attention to the transferential material elicited in the client and the clinician – that is to say the unconscious stimulation of feelings towards a person in the present, which have their origins in earlier more significant relationships. Once the interpreter enters the mix, they become part of the transference and therefore contribute to the ways in which the therapist and the client will be trying to make meaning of the experience together. The unconscious will not ignore the fact that there is a third person in the relationship.

One of the main aims of all psychotherapeutic endeavour is to help people to come to terms with themselves as a whole rather than to spilt off and close their eyes to parts of themselves they would rather not own. It is tempting to deal with the interpreter, as an addition – perhaps wanted, perhaps unwanted - to the consultation. If, however, the interpreter is not incorporated into the whole as an equal and integral component of the dynamic, the result will be a splitting off which will, in itself, be counter therapeutic.

The emotional intensity of the work of therapy will inevitably lead to pulls and pairings or alliances at any time during the therapeutic work and it is important to be able to understand this. Tribe and Thompson (2009:20) write about this fully with reference to the three different types of alliance and the further impact of traumatic material on the triad. They offer us the vision of a “co- working couple, therapist and interpreter, who can work effectively and thoughtfully to manage the changing shape of the triangular relationship between the three parties.”

It is clear that there needs to be a transparent way of working together as interpreter and clinician in order to learn how to work with each other and to reassess and renegotiate their collaboration. This can be achieved by ensuring that the interpreter and clinician meet to prepare for their co-working before meeting with the client, together, for the first time. In this pre-therapeutic meeting the clinician and interpreter can create a working alliance by establishing common norms for the communication and by sharing an understanding of the intended clinical outcomes. A debriefing session is held at the end of the consultation in order to reflect on what has been achieved and what needs to be learned. Various Codes of Practice have been drawn up for mental health clinicians and interpreters to work to (Tribe & Thompson 2008) (The Medical Foundation 2005)). A brief summary of suggested guidelines follows at the end of this paper.


The social context: public perceptions of mental health professionals

In contexts, such as interpreting for a lawyer or an immigration officer, the service provider has crucial information, which a client needs. Apart from a prescribing psychiatrist who offers medication, it will often seem unclear to clients what a mental health professional has to offer that a kind and well-meaning interpreter does not.

This is why guidelines are used which pay attention to the dynamics and relationships in the room. Without these, it can be very difficult for the clinician to form a therapeutic alliance with the client. In other contexts it may be acceptable and even perceived as helpful for an interpreter to take some control and to intervene in a session, as it will not jeopardise the authority of the service provider. However, a clinician needs to establish authority from the beginning, as it is the clinician who holds the clinical responsibility for the work. In this way both the client and the interpreter can feel safe and contained.

Clinicians who are not trained to work with interpreters may defer all responsibility to the interpreters or try to undermine them by, for example:



  • requiring interpreters to break bad news to clients

  • expecting interpreters to manage the consequences of misjudged interventions

  • wresting control from interpreters by discounting them or excluding them from the process

  • refusing to be available for the pre and post briefing meetings

  • ignoring the needs of interpreters

These are very delicate situations for interpreters where they will need to be assertive and to remind professionals of the limits and responsibilities of both their roles. At the same time they need to be sensitive to the clinician’s authority in the session. If the clinical professional allows the interpreter to take control of the session, then the clinician is abdicating the clinical responsibility, which is clearly unacceptable practice.

Frequently interpreters working with clinicians, who are untrained in working with interpreters, will need to be training the clinicians as they go along. Interpreters are not themselves trained to do this. Nevertheless they will need to call on their skills of subtle negotiation, assertiveness and communication.

Case example


An interpreter was booked to conduct a routine mental health assessment with a client - an unaccompanied young asylum seeker. The assessment was conducted by a Community Psychiatric Nurse (CPN). One of the questions from the assessment of the young man was: “Do you have any family?”

At this point the client started to hit his head on the table and to shout: “What does she think I am - a stone?”

He continued to hit his head and started to bleed. The CPN was shocked and confused and started to exclaim: “What have I done? What have I done?”

She seemed unable to do anything and left the room. It was left to the interpreter to calm the boy down and to clean him up. He told her that he was angry that the CPN had asked him if he had any family. As he put it, even though they were all dead, “I have come from people. I am not a stone.” Clearly the CPN’s intention in asking the question had not been to elicit this response. However, given the young man’s context and his recent traumatic losses, his response is not surprising.

The interpreter was frightened by this experience and determined not to accept another mental health interpreting assignment.

This situation could have been avoided by the interpreter’s employer ensuring that the commissioning service provider was familiar with and agreed to their norms of working prior to the booking being confirmed. This would include the need for the CPN and the interpreter to have met before the clinical session in order to establish the extent of each other’s roles and responsibilities and agreed ways of working together. Mistakes may be made by any of the professionals involved. That is just the normal way of the world. It could be a question of cultural insensitivity on the part of the clinician or it could be lack of understanding on the part of the interpreter. It is important to have a working alliance together so that any mistakes can be managed and contained in the best way possible for the client.

As these situations illustrate, having a set of guidelines that both the interpreter and the clinician can adhere to will help provide some sense of structure and clarity.

Part of the training for interpreters working with clinicians helps them to be assertive enough to remind clinicians of their responsibility and authority.

Mental Health interpreting via Skype: proposals from a training initiative.


Interpreting through the medium of Skype (or a similar web based form of video communication) magnifies all of these dynamics. The technology is currently faulty but it is improving rapidly. It is not the intention to address the technological issues here but rather to consider the human aspects of the clinical process over which we can exert some control.
The following issues of interpreting in a mental health context have already been addressed earlier in this paper:

  • The need for all the professionals to be fully attentive and connected emotionally

  • The impact of the transference

  • The potential for splitting

  • The need to maintain a transparent and collaborative working relationship as interpreter and therapist, constantly reassessing and renegotiating ways of working together

An attempt is now made to show the particular way in which these issues need to be addressed when interpreting via Skype in this context. Mothertongue runs training workshops on Mental Health interpreting via Skype. These workshops have developed from an initial attempt to try to resolve the practical problems of limited availability of interpreters of minority languages and managing interpreters’ travel costs. Initially the possibility of Mental Health interpreting via the telephone was explored. The conclusion drawn from this exploration was that it had not been possible to find a way where this form of interpreting could work effectively. It is widely understood that body language plays an important part in human communication. (Gregory 2004). The feedback from interpreters was that they felt unable to establish a relationship with more than one person at a time without the visual clues. Both clinicians and interpreters commented that they found it more difficult to build up a relationship of trust with each other over the telephone. Interpreters reported that they felt out of control when, for example, a client was very distressed. They were not able to read any visual cues that the clinician was able to manage the situation and so they were more likely to step in and intervene themselves. Because of the nature of mental health consultations, the dual disadvantages of remoteness and of having no visual communication between the three parties made the effectiveness of any meaningful clinical intervention problematic.

The advantage of Skype is that all the parties can see each other. One other advantage that should not be underestimated is that it is free.


From the workshops trialled so far the following checklist has been developed for the pre-meeting:


  • Arrange for the client to try out the technology before the actual session so that he is familiar with how it will work

  • Arrange for a pre meeting between the clinician and the interpreter over Skype - before the client comes into the room. This will cover the usual issues, plus:




  1. The clinician should lead the session and maintain overall control

  2. Unlike in face-to-face interpreting, the interpreter may have to intervene more than is customary in a clinical interpreting situation to manage the communication flow e.g. slowing down the pace etc. This is because the natural rapport which the interpreter and the clinician may have developed together may be disrupted by e.g. delayed images and sound; lack of clarity of the image so that the clinician, client and interpreter are less likely to pick up on body language

  3. A protocol should be established if Skype breaks down, e.g. the clinician will call the interpreter in 10 minutes on a conference call. All phone numbers should be exchanged in advance to avoid delay

  4. Seating should be arranged so that the webcam can pick up everyone involved

  5. The clinician should look at the client, for the benefit of the therapeutic alliance. It will be very tempting to look at the interpreter on the screen. This will require practice

  6. The clinician should start the session by bringing in the client and by introducing everyone. The clinician should deliver the agreed ground rules, reminding people to speak one at a time. This is vital as the communication can get confused far more easily via three way Skype than via face-to-face interpreting

  7. The clinician should repeat people’s names each time he addresses them. Otherwise there may be confusion over who is addressing whom. The communication needs to be more clearly signalled over three way Skype


  8. The clinician should agree that the interpreter might have to remind people of these points in the session if communication is being affected by people forgetting these guidelines.



Conclusion

Despite the problems with this method of working it is worth putting in the effort to explore its viability and to improve its effectiveness. The main drivers for this assertion are practical: there is often no one local available to interpret for minority languages; the cost including travel from out of area can be prohibitive. Models for face-to-face mental health interpreting are already being used to great effect, despite initial reservations and resistance. Training and preparing to interpret for Mental Health consultations using an alternative method like Skype means that we will be ready to provide an effective service when the technology has caught up with us.
APPENDIX

Working with interpreters in a Mental Health context –summary guidelines for Clinicians and Interpreters working together


  • Pre meeting/ training session: establish ways of working together and your working relationship; role play tricky areas e.g. the client in distress or angry with the practitioner, endings, collusion, not interpreting parts of conversation

  • Think through with the interpreter how to approach beginnings and endings

  • Ground rules – confidentiality and everything in the room to be translated

  • Input from the interpreter should be made during the session only if it is essential If not – hold on to it and share it at the debriefing

  • Speak in small chunks so that the interpreter can translate accurately


  • The Clinician should address the client directly, not the interpreter, even when the interpreter is speaking

  • Allow for 5 to 10 minutes debriefing at the end of the session

  • Work collaboratively together with the interpreter to form a counselling/therapy team

  • Clarify that the clinician has the ultimate responsibility for the session. It is necessary that the interpreter feels able to trust the clinician to hold that responsibility

  • The interpreter should not be left on their own with the client at the end of the session – what are the clinical implications if this happens?

  • Ensure that there are processes to provide emotional support/supervision for interpreters so that they are supported appropriately

  • Aim for consistency of the same interpreter with each client

  • The interpreter used for mental health interpreting should only be used for those sessions. If an interpreter is needed for other interviews e.g. legal, benefits, medical, a different one should be used. This is for the client’s sense of safety in the counselling session and also for the clinician to have a realistic chance of establishing a therapeutic relationship with the client

  • Check the language of the interpreter and the client are compatible. Also be sensitive to the possibility of the interpreter being from a political faction, community or religious group alien to the client

  • Check if there are gender issues for the client



References

Bradford, D.T. & Munoz. A. (1993) Translation in Bilingual Therapy in Professional Psychology: Research and Practice. Vol24. No.1, 52-61

Fernando, S. (2003) Cultural diversity, mental health and psychiatry. Hove: Brunner-Routledge

Gregory, R.L. (2004) The Oxford Companion to the Mind. Oxford, New York: Oxford University Press

Muriel, P. & Smith, H.C. (2009) Talking Therapy in The Linguist. Vol48 No.2.The Chartered Institute of Linguists

Perez Foster, R. (1998) The Power of Language in the Clinical Process: Assessing and treating the bilingual person. New Jersey: Aronson

Sue, D. W., & Sue, D. (1999) Counselling the culturally different: Theory and practice (3rd edition). New York: John Wiley & Sons

The Medical Foundation for the Care of Victims of Torture (2005) Code of Practice and Ethics for Interpreters and Practitioners in Joint Work

Tribe, R. & Raval, H. (2003) Working with Interpreters in Mental Health. London: Brunner- Routledge

Tribe, R. & Thompson, K. (2008) Working with Interpreters in Health Settings: Guidelines for Psychologists. Leicester: The British Psychological Society

Tribe, R. & Thompson, K. (2009a) Opportunity for Development or Necessary Nuisance? The Case for Viewing Working with Interpreters as a Bonus in Therapeutic Work in International Journal of Migration, Health and Social Care. Vol5. Issue 2



Tribe, R. & Thompson, K. (2009) Exploring the Three-Way Relationship in Therapeutic Work with Interpreters in International Journal of Migration, Health and Social Care. Vol5. Issue 2




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