Case example

Gloria has recently joined a service as a CBT therapist. Gloria tries to book an interpreter for a session later in the week, but she is told that that the administration team is responsible for booking interpreters to make the booking process streamlined and effective for all. Gloria wonders: ‘Where do the interpreters come from? Have they been vetted/assessed/inducted into our code of practice?’.

Later at the session, when the Turkish-speaking interpreter Mustafa arrives, it soon becomes clear to Gloria, in the patient’s notes and in the pre-meeting, that her patient speaks Kurdish. Mustafa tries to reassure Gloria that the patient will be able to understand Turkish. During the session, Mustafa makes several asides to Gloria in which he expresses a negative opinion about the patient. The session does not go well, and Gloria makes a commitment to think about this carefully with her supervisor and to reflect on what she could have done differently. In the supervision session she identifies the need to stay active even before the interpreter-mediated session begins. She will try to take a systemic approach and consider all the elements of the system which are impacted before, during and after the session.

It is useful to liaise closely with the administration team if an interpreter is needed so that you can check that the correct language-matching has occurred and so that you can understand the criteria the administration staff are using to assess patients’ linguistic abilities and linguistic needs. Interpreting agencies are unregulated, so you may want to find out about the interpreting agency your service uses. You can ask about the interpreting agency’s codes of practice and its quality control measures. Many patients (although not all) prefer to have the same interpreter for their treatment, so that they do not have to repeat their story to multiple listeners. If that is a patient’s preference or need, can the interpreting agency accommodate that requirement? One solution to relying on unregulated agencies is to create an in-house team of interpreters. The following description of interpreters’ experiences of working directly with therapists within an Improving Access to Psychological Therapies (IAPT) service provides an example of service-wide good practice.

Case example

Usually, IAPT services work with interpreters from different agencies. The following example of a pilot scheme illustrates how interpreters can be incorporated into an IAPT service and the difference they can make for the therapeutic process. The pilot scheme lasted for 3 years. The small pool of interpreters representing different languages and trained in interpreting for mental health, became a part of a local IAPT service. The interpreters were employed directly by the NHS, but they were managed by the IAPT administration team. All the IAPT CBT therapists, counsellors and psychological wellbeing practitioners (PWPs) were given a list of interpreters with their spoken language, email address and telephone number. Usually, the whole booking process was done by the IAPT administration team. The therapists could also contact interpreters directly to find out their availability and/or discuss alternative dates and times. The direct contact between therapists and interpreters was very useful. It helped practitioners to have the same interpreter for the whole therapeutic process. It meant that both sides could develop a relationship and exchange CBT materials, questionnaire and booklets. From my point of view, as an interpreter, it was much easier to navigate the materials and interpret if we already knew what to expect. Sight or telephone translation of difficult questionnaires which are used in Step Three is very difficult, almost impossible without previous preparation. In briefings, therapists could discuss and explain to interpreters their methods of practice and their expectations. Interpreters could share their views and observations. All these procedures contributed to interpreters feeling like a key part of the therapeutic process and showed them that their work was being appreciated. This positive working relationship contributed to many successful, completed courses of therapy.

Example of the content of a pre-meeting

Charlie, a CBT therapist, has arranged to have a pre-meeting with an interpreter called Lamia. He has never worked with her before, so he sets himself an agenda for the type of things they are going to discuss. He wants to leave enough time for anything Lamia wants to ask or tell him. He plans to share his working methods with Lamia if she is new to CBT. He explains how some behaviours of a clinician, e.g. not rushing to comfort a patient who is crying, or allowing silences in the room, may seem strange. But Charlie explains they are clinical strategies, not signs of incompetence. Charlie has also, in advance, sent a sample of the forms that are going to be used to the interpreter and they have already addressed any linguistic problems. They agree that all the form-filling will be done together (with all three of them) in the room and with the interpreter translating all the questions and responses orally.

As Charlie is aiming to use guided exposure therapy, he asks Lamia not to step in to try to alleviate the emotional disturbance for the patient, even though it may be difficult to resist. Charlie asks if Lamia can interpret consecutively Footnote ⁴ and in first person so that he can feel more of a connection with the patient. They think about the logistics of role playing and chair work that Charlie plans to use. These are new concepts for the interpreter and may need some logistical planning together, e.g. how does the interpreter translate for a patient who is speaking from multiple roles?

Together, Charlie and Lamia discuss the frame for the work. Charlie explains that the therapeutic frame refers to the micro and the macro levels of structures which enable anxieties to be contained and worked with productively in mental health settings. Charlie proposes that he will probably set the ground rule that ‘everything everyone says in the room will be translated out loud’. They agree that it will be Charlie, rather than Lamia, who sets the ground rules. They want to give a clear message to the patient about who is leading the sessions. It can be tempting to leave the setting of communication guidelines to the interpreter. But it can be confusing for a patient. Creating a safe psychological space (the therapeutic frame) is the responsibility of the clinician. If a clinician adopts a passive position in relation to this responsibility, giving the more active role of establishing the psychological safety to the interpreter, it is quite possible that a patient may start to have doubts about the clinician’s competence to contain the session safely. It is therefore also agreed that Charlie will lead on the introductions, but he will invite Lamia to introduce herself so that she can reassure the patient that whatever she hears in the session she will treat as strictly confidential.

After this discussion there is time for Lamia to ask Charlie one thing. She asks him if he can remember to speak in small chunks and allow time for her to translate.

During Charlie’s and Lamia’s pre-meeting, Charlie had also mentioned that sometimes, if the patient understands and prefers to speak some of the time in English, the therapist, interpreter and patient will negotiate together how much needs to be translated in order for everyone to understand everything.

The following case example, written from an interpreter’s perspective, illustrates how this can happen.

Case example

Shazia is an experienced Urdu interpreter. She’s interpreting for a CBT therapist, called Laura, with whom she has worked on other occasions. Neither have worked with the patient before. During the triage session the assessor had felt that the patient didn’t fully understand what was being said. The patient had dismissed the offer of an interpreter, but Shazia had still been booked. When the patient arrived at the CBT session, he said ‘I have been in this country for over 25 years, and I speak English at work all the time. I don’t need an interpreter’. However, Laura was able to reach an agreement with the patient that Shazia would only translate in the case that one of them didn’t fully understand the other. Shazia was aware of the patient’s need to be self-sufficient, and the session went ahead without any further issues.

Working together as a team, Laura and Shazia were able to manage a delicate situation. However, the following example, again, from an interpreter’s perspective, illustrates what can happen when the opportunity for a pre-meeting has not been provided.

Case example

Simran, an interpreter, is booked in for a telephone interpreter-mediated CBT session with a Punjabi-speaking patient. It is a half an hour slot during which the therapist goes through the compulsory PHQ-9, GAD-7, Phobia Scales and Work and Social Adjustment Scale. It takes 10 minutes to explain the purpose of the call to the patient, who just wants to tell her story/explain her situation. After each question Simran has to remind the patient to rate her problems/feelings with a number as the therapist keeps insisting upon it. This takes up the full 20 minutes with the final questions being rushed through.

If only they had allowed a double slot both the patient and the therapist would have got to the point they hoped to reach. They were all disappointed with the outcome as a second session had to be booked to complete what should have been done in one.

A therapist may also want to consider allowing time for the interpreter to share issues of cultural sensitivity.

The following example, told from an interpreter’s perspective, illustrates how important cultural sensitivity can be for effective therapy to occur.

Case example

Danielle is carrying out an assessment session with Marta, a Portuguese patient. For this session Danielle has booked a Portuguese interpreter, Isabel. The session is proceeding well, and the communication and flow of conversation are working to everyone’s advantage until Danielle asks Marta ‘Now that I have all the relevant information, and I have explained the various ways in which we can support you, I was wondering what type of therapy you feel would be best for you?’. At this point, Marta looks at Isabel with a very baffled look on her face. ‘What does she mean? I thought that as she is the professional, she would be the one telling me what the best form of treatment would be to help me. I don’t know what to say’. Marta bursts into tears. Danielle is confused. What could she have said that has upset Marta so much?

Patients may come from cultures that adopt different approaches to healthcare. They may not be familiar with an approach to treatment which involves tentative questioning or an invitation to collaborate in their own treatment. Had Danielle been aware of this, she may have thought of a different way to put this question. In the briefing session, Isabel could have mentioned that some patients from Marta’s cultural background find a tentative approach from a clinician unsettling initially.

Case example

Maria came for her first counselling session. Paramjit, her therapist, went to collect her from the waiting room, where she was sitting with her sister, Ana. In the waiting room, Ana explained to Paramjit that she would be interpreting for Maria. She said that she always did this and that this is what Maria wanted. Paramjit took them both into the therapy room where an interpreter was waiting. Via the interpreter (so that Maria would be included), she thanked Ana, the sister, for her support and explained that organisational policy meant that she would not be able to accept her kind offer. She asked Maria if she would be prepared to have one trial therapy session with the interpreter. They could then review together, afterwards, to see if Maria felt able to continue working in this way. Paramjit also asked Ana if later on, when the therapy had progressed, she could ask for her support, if relevant issues emerged in the sessions. This could include for example, asking Ana to accompany Maria to different, new activities. Maria and Ana agreed to give it a try.

It is easy for therapists to feel pulled into accepting a family member’s generous offer to interpret. But as therapists, we need to think carefully about this kind of pull. It can feel counter-intuitive and persecutory not to accept a relative’s offer of support (especially if this seems to be a patient’s preference). Therapists can feel anxious about appearing culturally insensitive, ignoring families’ preferences, values and systems. It is important to remember why you make a decision. Do you actively want to involve a family member in the treatment? Is this part of your therapeutic plan? Or did you just slide into accepting the offer of help? Even though the incorporation of family members is appropriate in some CBT treatments, it is acknowledged that: ‘Without a clear framework, the involvement of family members in therapy can feel unstructured, unpredictable, and challenging’ (Lobban and Barrowclough, Reference Lobban and Barrowclough2016; p. 198)

Paramjit demonstrates that she is making a conscious decision, not just reacting to a difficult situation. She uses the organisational policy to move the discussion away from personal preferences. Family members are, of course, involved in some formal CBT treatments, but in a reflectively organised way, not as a reactive response (Lobban and Barrowclough, Reference Lobban and Barrowclough2016; Renshaw et al., Reference Renshaw, Steketee and Chambless2005; Thirlwall et al., Reference Thirlwall, Cooper and Creswell2017).

Although Paramjit took the decision to respectfully invite Ana into the room, no therapeutic conversation took place, and no personal material was discussed. By treating Ana’s offer with respect – by giving some of the power back to Ana (asking, rather than telling her, if she could contact her in the future), by valuing Ana’s relationship with Maria, and by not rejecting her completely – Paramjit is able to build enough trust for the session to go ahead appropriately.

Another relational dilemma may be posed by professional interpreters who have worked with patients before, in other settings. Some interpreters have established long-term relationships with their patients (even though it may be advised against in interpreters’ codes of practice). This can be problematic. It may make it difficult for a therapist to form a rapport with the patient. However, rather than declining to work with an interpreter outright (indeed, there may not be an alternative interpreter available), the therapist could explain why having an interpreter with whom the patient has a prior relationship could impede the therapy. The therapist could mention that for therapeutic work, it is important to create a therapeutic space where it is possible for the patient to remove herself from external influences in order to view and review the influences of the external world in multiple ways. The therapeutic space might be likened to the controlled space of a laboratory where people can experiment and try out new behaviours and responses. For this reason, it is usually helpful if all the people involved in the therapy do not have relationships outside of the therapy room. However, if the patient is still hesitant about bringing in an unknown interpreter, the therapist might suggest that they try a couple of sessions with the patient’s preferred professional interpreter and then evaluate together how the therapy is progressing. They can then decide whether it is viable to continue as they are, or whether a different interpreter is needed and can be tolerated by the patient. Through the regular review structure, the therapist retains control of the session while remaining flexible. A therapist needs to be confident in their decision-making processes about this complex ethical issue. If the patient’s safety may be compromised by having an over-involved interpreter in the therapy sessions, then a final option may be that the treatment does not go ahead. The therapeutic frame and ethical guidelines can be flexible but there need to be limits if the therapy is to stay within the domain of safe practice.

Case example

Saira is an interpreter. She has had a pre-meeting with the CBT therapist, Ann. Ann has explained that she will set down all the ground rules about the communication. Saira waits patiently at the beginning of the session for Ann to explain that everything that everyone says will be interpreted, but Ann seems to have forgotten to mention this. Saira thinks this is too important to neglect and so she intervenes and explains the ground rule in both the languages of the therapist and the patient. Ann is cross with herself for forgetting to set the ground rule, and she is cross with Saira for interrupting.

This case example and the next case are illustrations of how quickly clinical authority can slip away, and of how anxieties can be elicited and acted upon when mistakes are made, even when everyone’s intentions are benign.

Case example

Jenny is a CBT therapist working with a patient called Bushra, mediated through an interpreter called Sameera. Jenny wants to introduce the concept of obsessive compulsive disorder (OCD) to Bushra and asks her how much she knows about OCD. Sameera is pretty sure that Bushra won’t understand the concept of OCD so she decides to ‘translate’ the concept into something Bushra can relate to. She says to Bushra, ‘Do you keep washing your hands all the time?’, and Bushra replies that she does not. Sameera ‘translates’ to Jenny that Bushra says she doesn’t have a problem with this issue. Jenny leaves the line of questioning about OCD and doesn’t discover that it takes Bushra 30 minutes to leave her house because she has to keep checking that the door is locked.

Succumbing to the temptation to solve troubling interpersonal communication between the participants in the system may result in ironic (or unintended) consequences (Dallos and Vetere, Reference Dallos and Vetere2012). What seems like a facilitative intervention by the interpreter is, in fact, obstructive of the treatment.

This series of (lack of) decisions and actions illustrates how easily clinicians can become passive when they don’t understand an interaction. It is not infrequent for a clinician to be so grateful to the interpreter for taking control that they forget the importance of their own therapeutic alliance and communication with the patient. Consequently, they lose their therapeutic footing. How can this be avoided? The prevention is better than cure approach can help a clinician to stay active. (This approach can also help interpreters manage their own professional and self-care needs; Bontempo and Malcolm, Reference Bontempo, Malcolm, Malcolm and Swabey2012.) In the pre-meeting the clinician can establish with the interpreter that they need everything translated. If the interpreter lets the clinician know that the patient doesn’t understand something it is then the clinician’s job to find the words that will reach the patient. If the clinician leaves paraphrasing to the interpreter, the clinician loses the clinical control of the message and, consequently, of the session. By engaging with the meta communication, talking about the talking – agreeing together with the interpreter the communicative strategy – this potentially harmful situation could have been avoided.

Case example

Tom has just conducted a risk assessment with a new patient called Wanda. He needs to leave the room for a moment to collect a form. When he returns to the room, he can see that the interpreter, Pawel, looks uncomfortable. In the debrief, after the session, Pawel tells Tom that Wanda disclosed that she has been having suicidal thoughts. She asked Pawel not to tell Tom when he came back into the room. Pawel says he feels terrible because Wanda clearly felt she could trust him. He doesn’t think Wanda will trust him any longer as she thought Pawel would keep her secret. But Pawel feels he has to tell Tom because of the potential risk. Tom wishes he had thought about the implications of leaving the interpreter and the patient alone together. He decides that the next time he needs to leave the room he will take the interpreter with him. Although the ground rule about risk and confidentiality had been set, it may be tempting for a patient to believe the rule need only apply if the clinician is present.

Systemic preparation, by therapists, includes thinking about how interpreters arrive and leave appointments without being left on their own to manage unfacilitated conversations with patients. Although a pre-meeting and a post-meeting debrief may be planned, patients and interpreters can still encounter each other in unplanned situations outside of the therapy room. One solution is for a clinician to have a conversation with the receptionist to ask them to seat interpreters, on arrival, in the staff room, away from patients. Also, as part of the ‘talking about the talking’ clinicians may want to discuss with patients the rationale for not continuing the conversation with the interpreter if they are left on their own together. This explanation for the patient (and for the interpreter) can make transparent why it is preferable if the interpreter does not interact with the patient beyond the clinician-facilitated therapy session.

Case example

Prudence has agreed to try cognitive restructuring to address her tendency to over-generalise some of her beliefs about the safety/lack of safety of travelling by bus. Prudence is from Cameroon and her therapy is mediated by a male French-speaking interpreter called Dominic. The CBT therapist is called Will. Prudence trusts Dominic, and Prudence and Dominic seem to have a good rapport together. Will feels that he needs to gain Prudence’s trust so that she will engage fully in the cognitive restructuring work. Will has carefully laid out the seating in the room in an equilateral triangle. But despite Will’s efforts Prudence does not look at him. Prudence is happy to make eye contact with Dominic but not with Will. Will understands that this is probably because Dominic speaks her language, but Will still finds that he feels annoyed with Dominic. Will blames Dominic for the lack of his own rapport with Prudence. Will starts to see Dominic as an opponent. Dominic notices that Will is angry and starts to experience Will as persecutory. Before long Will and Dominic both feel like victims, and Prudence doesn’t know whether to try to rescue the situation or just go home.

Self-reflexivity on the part of the therapist and the interpreter can help to bring these complexities into the light. What are one’s default behaviours and (sometimes unhelpful) coping strategies when one feels excluded? Is a different response needed in the interpreter-mediated triad? With awareness, these relational dynamics [also exemplified by Karpman’s (Reference Karpman1968) Drama Triangle] can be reflected on in supervision, not reacted to in the session (Costa, Reference Costa2017). It is probably useful to discuss eye contact with the interpreter in the pre-meeting and to think together about how to manage the potential dynamic illustrated in the previous case example.

Case example

Ivana is a Romanian interpreter. She received an email from the booking coordinator with a request for a video call assignment for four consecutive weeks and accepted it. On the booking confirmation she received a Microsoft Teams link. She thought that everything was fine, and she was not expecting any problems.

On the day of the first appointment, she used the link to join the meeting and was waiting for a practitioner to invite her into the room. But there was nobody there. Nobody contacted her by phone either. After 20 minutes of waiting, she contacted her agency who tried to reach the service but still it was unsuccessful. The same situation happened on the second and third week.

What went wrong? When booking an interpreter for a video or telephone call it is important to give the contact details of the interpreter, such as an email address and telephone number to the administration team/clinician. If possible, the interpreter should also be given a contact telephone number to be able to reach the service if something goes wrong. Using technology is a helpful alternative to face-to-face appointments. However, it is not always reliable. Thinking ahead and having a back-up plan, in this case having a telephone number or the interpreter’s email address, is always good, to avoid the situation described in the case example.

The Royal College of Speech and Language Therapists has also produced guidelines for working with interpreters remotely which include useful guidance about the communication process: https://3959e25e-b3e4-4cf0-92ed-b4c50fc1442d.filesusr.com/ugd/7f9695_e2618d3af15c43d5ab5057ad54e5cd97.pdf

The following case example illustrates what can happen if communicative issues, when working with interpreters remotely, are not addressed.

Case example

A therapist, Ben, has an interpreter-mediated telephone session booked with a Mandarin-speaking patient, Pearl. Although a video call might have been better, for logistical reasons this hasn’t been possible. But Ben has been working via the telephone with Pearl for two months and he feels the sessions have gone well. Their regular interpreter is on leave and so a different interpreter, called Huang, has been booked. When Huang joins the call, he seems keen to get started. Ben is pleased that there are no delays. Ben quickly reiterates the ground rule that everything will be translated, and they begin the session. As the call progresses, Pearl starts to explain why she was unable to complete the action plan/homework she and Ben had agreed she would do. She describes a serious incident that she witnessed near her house. Pearl is beginning to get distressed. At the same time, Ben can hear several noises in the background – running water and pans banging. It soon becomes clear that Huang is cooking a meal while interpreting. Ben is very cross and starts to get distracted from Pearl’s narrative.

It is easy to forget that even on the telephone or on a video call a pre-meeting and a debrief with the interpreter is essential. This needs to be planned into the booking request. In this way the interpreter would have met (via the telephone) with Ben prior to the patient joining the call so that expectations about behaviour could have been clarified, together with the usual items on a pre-meeting agenda. Even if the session is short, or the therapist has worked with the patient before, it is important on a remote call to slow down introductions and ground rules so that everyone understands them. It is even more vital for the therapist to stay active and to find ways to engage directly with the patient. One way of doing that is to use people’s names (more frequently than you would if you were all in a room together) to make a connection. Finally, immediately after the session, it is helpful to write down the issues and to make a plan for how to resolve them next time, together with the interpreter. If the sessions move between remote sessions and in-person sessions it is useful to re-contract for the new context at each transition.

Case example

‘Thank you. The session went well. Do I have to sign your form?’. Once the form was signed, the CBT therapist shut the door. I stood there; the only sound the tap tap of a keyboard somewhere along the corridor. I turned to leave. I felt very strange, as if walking in another life. Something in that session had touched a raw nerve. I’d felt it, but in the sequence of interpreting I had not given it much thought. I could now feel the wave of emotions bubbling up inside me. I had to get out quickly before that feeling took over.

Often something within interpreting sessions leaves unresolved emotions in the interpreter. Spending a few minutes allowing the interpreter and the therapist to restabilise after the impact of the session should be part of the overall work of the CBT therapist/interpreter team.

This section finishes with a compilation of interpreters’ own words about the impact the work can have on them.

Without 5 to 10 minutes at the beginning and end of a session, interpreters can be left ‘emotionally naked’ to enter or leave a therapy session. It seems only fair to give interpreters information about the session if it is available, so that they can prepare themselves for a distressing situation. Even in very busy contexts, briefing and debriefing is highly recommended so that there is space to think and learn, and so that burn-out can be avoided. Where possible, supervision groups can also be set up for interpreters (Costa, Reference Costa2017; Costa, Reference Costa2020).