Working with interpreters in healthcare settings

Dr Sharon Doherty Clinical Psychologist COMPASS team Asylum seeker and refugee mental health liaison service NHS Greater Glasgow and Clyde

Overview
Introductions
Why use interpreters?
The patient’s perspective
The clinician’s perspective
The interpreter’s perspective
Good practice when using interpreters

Why do we use interpreters in healthcare settings?
To enable effective communication between the patient and healthcare staff.
To ensure equitable access to services regardless of ethnicity or language spoken (Scotland Act 1998, Race Relations (amendment) Act 2000).
To increase the likelihood that treatment will be effective.

The patient’s perspective
That they place their trust in the interpreter as a broker of the communication between themselves and the health professional
That they adjust how much information they communicate at any one time so that the interpreter can remember it.
That they maintain the thread of the conversation whilst interpretation is taking place.

Specific patient concerns?
Trust
Confidentiality
Interpreter’s gender
Interpreter’s religion
Quality of interpreting (skill level, dialect)
Inappropriate manner
Shame/embarrassment/fear or being judged
Interpreter represents oppressor
Different interpreter at each consultation

How do patients generally feel about using interpreters?
Patients report that they feel understood (Kline, 1980).
Patients report that they feel more compatible with their therapist (Cox, 1977).
Patients are more likely to return after initial appointment (Hillier et al 1994).
Fits with feedback from COMPASS clients.

The therapist’s perspective (1)
Aim to make sense of the patient’s description of their feelings and inner life.
Aim to establish trust, reach a shared understanding of the patient’s difficulties, mobilise hope and agree a way forward.
All of this relies on paying attention to what the patient is saying and the meanings they are making.

This understanding is predominantly derived from what the patient communicates (form and content of speech).
Demeanour, tone and responsiveness of the therapist central to developing this relationship.
Not surprising that therapists feel concerned when a third person enters into this relationship.

Clinicians inexperienced in using interpreters are uncomfortable, uncertain and anxious (Tribe and Thompson, 2009).
Psychiatry resident doctors viewed clients as having had a poor experience of their service - same clients reported high rates of satisfaction with consultation (visit helpful, felt understood and wanted to come back, Kline et al 1980).
Concerns centre around: not knowing what the interpreter is communicating, impact on the relationship, feeling that non-verbal aspects of communication is being lost, concerns about the assumptions/understanding of the interpreter.
Does effective mental health interpreting require the interpreter to mirror the attributes of the therapist?

Added value (1)?
With experience, discomfort settles and experience of using interpreters viewed as enjoyable (Miller et al 2005).
Interpreter often enhances therapeutic work -“added value” (Tribe and Thompson, 2009).
Clinicians more aware of non-verbal aspects of client communication (Holder, 2002)
Clinicians reporting simplifying their language, reassessing the assumptions behind jargon, and increased use of the client’s own words (Holder, 2002).

Added value (2)?
Clinicians report enjoying a more flexible and open approach to therapy.
Clinicians report a joint struggle between all three parties to find the right words – a shared search for meaning (“co-construction”).
Clinicians find cultural information provided by interpreter helpful

The interpreter’s perspective (1)
Are required to interpret across a range of health and social care settings and to undertake a range of different jobs in one day (dentist, labour ward, pain clinic).
May have little formal training.
Often work with very little if any briefing about the purpose of the appointment.
Are required to establish a relationship with a patient, sometimes over an extended time frame, and to communicate often distressing material.

Are required to interpret complex ideas through a process of “co-construction”.
Are required to bridge cultural and linguistic misunderstandings between patient and therapist.
Are required to tolerate patient distress and communicate it in the first person.

“ How does it feel for you? The emotional impact and specific challenges of mental health interpreting?” (Doherty et al, Mental Health Review 2010).
Surveyed interpreters from Glasgow translating and Interpreting service (GTIS).
157 surveyed, 20 returned, 18 analysed (qualitative and quantitative analyses).

Results - Challenges of mental health interpreting (1)?
Interpreter –client relationship
- Establishing rapport
- Displaying sensitivity
- Maintaining a non-judgemental stance
Interpreter – mental health professional relationship
- Staff poor understanding of interpreter role
- Failure to brief interpreter
- Poor technique
Linguistic, paralinguistic and cognitive demands of the role
- Listening attentively to the client
- Remembering content
- Fully understanding the client
- Conveying non-verbal aspects of communication
- Accurately conveying meaning, content and feeling
- Facilitating a sense of direct communication

Results - Challenges of mental health interpreting (2)?
Emotional demands of the role
- Client distress
- Personal resonance of session content
- Containing own response
- Having to block out feelings
- No outlet for own emotional distress
5. Maintaining boundaries
6. Perceived risk
- Violence risk
- Child protection issues

Results - Emotional impact (1)
56% reported having been emotionally affected by mental health interpreting at some point
22% emotionally upset over past week
67% sometimes found it hard to put clients out of their mind
56% sometimes thought about client for up to 30 mins after the session
23% sometimes thought about client for hours/days
Anger, sadness, powerless, guilt, hopeless, anger towards client.

Results - Emotional impact (2)
33% said work had had a personal impact
28% sometimes had difficulty moving onto next job because upset, in turmoil, weary.
28% sometimes avoided accepting mental health interpreting work:
Work too intensive vs. other types of interpreting and poorly remunerated.
No capacity to hear problems of others due to own life circumstances
Because the work was impacting on physical health of interpreter
Due to belief that clients are misleading the therapist

Rewarding aspects of mental health interpreting
Clients and staff showing appreciation of interpreter
Knowing that helped the client be understood and communicate.
The relationship with the client
Seeing clients get better
Knowing interpreted well
Seeing client’s anxiety reduce with interpreter’s presence
Learning about effective mental health treatments
Being asked to return
Observing a increase in client rapport
Learning about different cultures
Job completion

Pause for thought

Good practice (1)
Always book an interpreter for a patient whose first language is not English unless referral information says otherwise.
GGHB partnership agreement with Glasgow Translation and Interpreting Services (0141 – 276 6850).
Give consideration to interpreter gender, (religion and country of origin).
Never use a family member to interpret.
Give advance thought to the seating arrangements
Always brief the interpreter as to the context and purpose of session (treatment approach, what is required of the interpreter).

Good practice (2)
Introduce your patient to their interpreter – establish they are comfortable before proceeding.
Speak directly to the client.
Work with the interpreter to make sense of the communication (where neccessary, be active in checking and clarifying what has been communicated).
If so wish, request the same interpreter for continuity.
Where appropriate, spend a short while de-briefing interpreter if session has been distressing.

Contact
Dr Sharon Doherty
COMPASS Team
Unit 34, 60 Mollinsburn Street
Glasgow G21 4SF
0141 6304985
[email_address]

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Working with interpreters in healthcare settings

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