WikiJournal Preprints/Emotional and Psychological Impact of Interpreting-for Clients with Traumatic Histories- on interpreters

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Article information

Authors: Aasia Rajpoot[a], Salma Rehman, Parveen Ali

Rajpoot, A; Rehman, S; Ali, P. 




Abstract

Interpreters play a very important role in the health and social care system. The aim of this review is to synthesize available qualitative studies exploring experiences of interpreters when working with individuals and groups who have experienced DVA or other traumatic situations. A comprehensive literature searches of databases helped identify 18 studies including 3 quantitative and 15 qualitative studies published between 2003-2017. The studies were conducted in various countries and data analysis resulted in the development of 5 themes which included ‘role and impact of interpreter’, ‘psychological and emotional impact of interpreting’, ‘workplace challenges faced by interpreters’, ‘coping strategies used by interpreters’, and ‘interpreters’ support needs’. Themes are then discussed in relation to the available literature and gaps in the literature are identified.

INTRODUCTION[edit]

The context of health and social care and the population we provide health and social care services to is changing rapidly. Now it is perfectly normal to encounter someone in a professional setting unable to speak the common spoken language. We regularly provide care to individuals with limited English proficiency (LEP). Increased social and geographical mobility lets people move much frequently and easily within and between countries. While such internal and external migration creates many economic and personal opportunities, they also bring challenges, both for the migrants as well as the host society. One of the challenges is difficulty in speaking the same language as other members of the host country, as there is always more than one language spoken in any country. Increase in migration also means migration of nurses and other health care professionals from one place to the other and this does help, however, this also means that health care workforce as well as their clients or service users is much more diverse than ever before in the history. Having said that the number of health and social care practitioners and service users is not even and therefore it is impossible to linguistically match service users and health care providers. To ensure provision of appropriate care for those who cannot speak the common language of the country, use of interpreters and translators has become a necessity. However, the role of interpreters, especially with regards to their work experiences,  challenges and issues they face when supporting service users and practitioners understand each other is not clearly understood.

This paper aims to review available literature to explore experiences of interpreters or translators when working with clients (from now on referred to as service users) in health and social care settings. Particular emphasis is placed on service users with sensitive issues such as gender-based violence, violence and torture, mental health conditions etc. The impact of being exposed to such traumatic histories and their impact on the interpreters and the impact of interpreters on the practitioners and service users is explored. The word practitioner here is used to refer to health and social practitioners such as psychotherapist, psychologist, nurses, medical practitioners or other as involved in the selected studies included in this review.

BACKGROUND[edit]

Language plays a central role in ensuring people understand and consequently each other’s needs. When it comes to provision of health and social care services, practitioners and services users need to have appropriate communication channels, however, this requires practitioners and the service user to speak the same language.[1] This is not always possible in the present age where migration and immigration, within and outside countries is at its highest and where people speak varied languages. A quick google search reveals that there are 7117 living languages in the world at present.[2] Population in any country is becoming more and more diverse and there is no single country with only one spoken language. Though, it may be possible that a country has only one official language, number of languages spoken in any country are much more than one. There are many countries in the world where the number of spoken languages exceeds 200.[1]

If we take the example of the United Kingdom (UK) census conducted in 2011 suggests the use of more than 80 languages in England and Wales.[3] While English is the official language, other top ten languages used in the country include Polish, Panjabi, Urdu, Bengali (with Sylheti and Chatgaya), Gujarati, Arabic, French, Chinese, Portuguese and Spanish.[3] The results of the census also revealed that 4.2 million people (aged > 3 years) in England and Wales spoke a main language other than English. Among this group, approximately 20% indicated difficulty or inability in speaking English.[3] Such individuals or groups are identified as those who have Limited English Proficiency (LEP)  which means that they “… are not able to speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers”[4] (p. 728). Surely individuals who are not able to speak the predominant language of the country require health and social care services and therefore they need either a practitioner who can speak the same language or a person who could help bridge this gap between them and the practitioner and help them communicate better. Such individual is known as an interpreter. Interpreters, are individuals who intervene in such situation and help practitioner as well as the service user understand each other and communicate their needs effectively to each other.  It is also important to note that while, here, I have only used an example of the English language and UK as a country, the issue of language barriers and use of interpreters is not limited to the UK or English speaking countries. Even within one country, all of the members of the nation don’t speak or understand every language spoke or used in the country. Within country immigration and the fact that multiple languages are spoken in every country makes use of interpreter an international concern.

Interpreter and the need of interpreter[edit]

The word ‘interpreter’ is derived from a Latin word ‘interpres’ which means ‘expounder’, ‘person explaining what is obscure’. Some scholars believe that the second part of the word is derived from partes or pretium (meaning ‘price’, which fits the meaning of a ‘middleman’, ‘intermediary’ or ‘commercial go-between’), but others believe the word is from the Sanskrit language.[5] Interpretation is identified as a translational activity, but one that is done immediately on the spot. Interpretation is not a new concept and had existed for centuries as human being have travelled to far places and have needed to communicate with individuals who may not understand their language. Interpretation is different from translation as interpretation means interpreting spoken words of someone and presenting it in another language, whereas translation often refers to translation of written documents from one language to another.[5]

The need of interpretation services in the UK was first identified on 1980s and 1990s, when a series of serious court cases were conducted using untrained interpreters with limited proficiency in the language they have been interpreting.[6] The famous case of Iqbal Begum, a woman from Pakistan who was tried for the murder of her husband and was sentenced to life imprisonment. Mrs Begum suffered years of domestic violence and abuse (DVA) from her husband. Following sentencing, four years into her imprisonment, serious problems with the interpretation provided for Mrs Iqbal during the trial process were identified. Specifically, the issue was the interpreter provided was not a trained interpreter and though he spoke similar languages to Mrs. Begum, he didn’t speak the same dialect as Mrs Begum. As a consequence, he failed to provide clear instruction to Mrs Begum and she didn’t understand the difference between the charges of murder and manslaughter when she was charged and could not clarify her position.  Her case review resulted in nullifying the charges and she was subsequently released in 1985 though she committed suicide after a few years.[6] Another high profile case was of Victoria Climbie, a 7 years old girl from Ivory Coast who came to the UK in 1999 with her aunt and legal guardian. Her Aunt began a relationship with a Bus Driver Carl Manning and she moved in to Manning’s home in London in July 1999. Soon Manning began to abuse Victoria resulting in Victoria’s visit to hospitals for injuries. Victoria died soon and her post mortem revealed a total of 128 injuries and scars.[6] The case review highlighted the failure of health and social care and police services to provide Victoria and her family with appropriate professional interpreters at least at two occasions before her death. A family member (her aunt) was used as an interpreter. She herself struggled to communicate in English and was later found jointly responsible for Victoria’s death.[7]

As mentioned previously, an interpreter ensures that the message is understood by the service user as well as a service provider. Evidence suggests that services use informal interpreters (family and friends of the service user) or formal or professional interpreters, though it is always better to use professional interpreters to ensure bias, appropriate interpretation, and the risk of other problems is minimised.[8] An interpreter may use three processes to interpret the information. The first type is simultaneous interpretations (where the speaker and the interpreter speak at the same time and the interpreter has less time to work). Second form in consecutive interpretation in which the speakers say something and then pauses for the interpreter to interpret in another language. The third form is whispered interpretation in which the speaker whispers the message to the interpreter who then interprets it and shares with the audience.  In the health and social care setting, consecutive interpretation is used often.[8]

Interpretation can be done through various ways including face to face interpretation, telephone interpretation and video interpretation. As the name suggests face to face interpreting requires the person and the interpreter to be available at the same place, whereas for telephone and video interpreting, the interpreter does not need to be physically present in the same place as the service user requiring the use of interpreters. As far as the health care system in the UK is concerned, use of telephone interpreting is much common.[8]

While interpretation is clearly an important task, the field of interpretation has not really developed as a profession, yet and therefore the qualification and preparation of interpretive vary significantly. In the UK, there is a voluntary register of the interpreters which is called National Register of Public Service Interpreters (NRPSI). It is a public register of professional, qualified and accountable interpreters accessible online and free of charge. According to the NRPSI, by the end of 2018 there were 1730 registered interpreters who could offer interpretation for 104 languages (54 of which are registered at Rare Language status) in the UK.[9] Interpreters appear in a wide variety of settings and are unlikely to be employed by a single organisation. Interpreters can be employed by public sector organisations, privately funded, self-employed and/ or registered with a telephone interpreting agency. Despite NRPSI, and due to the fact that a majority of public service interpreter work across settings, mostly on a freelance basis, there appears to be a lack of professional regulation for interpreters. The fact that NRPSI is a voluntary register, it is not necessary for all the interpreters to be registered with NRPSI or have completed a specific course in interpreting. Interpreters work in a range of settings, including courts, police stations, hospital, health care settings, conferences, with international delegations etc. At the same time, there are sign language interpreters who interpret for people with hearing disabilities.[10] In the UK, interpreters are known as public service interpreters as they work with professionals in public services. In that context, an interpreter is one who possess and recognised nationally credited qualification, is registered as a public service interpreter, comply with the code of professional conduct for interpreters and is associated with a recognised and identifiable profession.[6] Regardless of the work setting, the goal of interpreters is to ensure the information is communicated appropriately between the service user and service provider/ practitioner.

Within their day of work, interpreters may have to regularly interpret for individual with traumatic experiences such as those who have experienced sexual abuse,[11] [12] torture and DVA[13] [14] or other similar traumatic experiences.[15] We were interested in exploring issues of using interpreters in the context of provision of services to victims of DVA. We were interested in exploring issues with regards to provision of health and social care services where interpreters work in a range of situations. For instance, an interpreter may help a mother communicate information about fever her child is suffering from, or it could be about disclosing experiences of DVA a service user has endured from their partner or other family member. It could be a case of sexual abuse, a robbery or something more serious than that. This means that interpreters are exposed to emotionally demanding and burdensome situations that may make them prone to vicarious trauma resulting from clinical and emphatic engagement with service users with traumatic experiences.

Interpreters and Vicarious Trauma[edit]

As mentioned earlier, interpreters' job is very challenging as they can be exposed to emotionally demanding and stressful situations that they may experience directly or indirectly by listening to the experiences of other they provide services too. Such experiences result in the development of vicarious trauma which refers to the situation where “the [practitioner] is vulnerable through his or her empathetic openness to the emotional and spiritual effects of vicarious traumatization. These effects are cumulative and permanent, and evident in both...professional and personal life” (p.151).[16] Experiencing vicarious trauma have psychological consequences such as post-traumatic stress disorder (PTSD) whereby the practitioner may experience concentration difficulties, nightmare, anxiety, depression, self-doubt etc. Practitioners may also experience secondary traumatic disorders, compassion fatigue, burnout symptoms. Most of these conditions are similar and result from being exposed to traumatic situations either by self or by indirect exposure as though listening to or supporting those affected by such issues. Dealing with such situation and prevention of vicarious trauma requires appropriate opportunities to verbalise feelings and clinical supervision so that the impact of such situations on the individuals can be minimised.[17] However, interpreters are generally self-employed individuals who do not have appropriate organisational support. While there is a growing interest in this topic, we still do not understand the issues around the interpretation and interpreters.[17][18][19] There is limited understanding about how interpreters see their role in supporting individuals with traumatic histories, the impact of such exposure on health and wellbeing of interpreters and ways through which they cope with such situations. There is also a need to understand the positive and negative impact of interpreters on service user’s ability to share their views and how interpreters share their stories to the practitioners.

While some research is conducted to determine the effectiveness or the importance of provision of language concordant care through interpreters,[20][21][22][4] research exploring the use of interpreters in the context of DVA or the experiences of interpreters when providing interpretation services to clients with difficult and traumatic histories is scarce. Generally, research related to health and well being of interpreters is limited. We do not know much about how interpreters cope with the difficult situations they often encounter and what coping strategies they use to protect themselves from trauma. The initial aim of this review was to explore the role of interpreters with regards to service provision of victims of gender based violence. However, research on this specific aspect does not exist. Most of the research exploring interpreters’ experiences or perspectives in qualitative, however, no serious attempt has been made to aggregate studies to generate conclusions to then develop future review questions. An extensive search of common databases including MEDLINE, CINAHL, Cochrane and Joanna Briggs Library of Systematic Reviews, did not identify any review conducted to explore interpreters’ experiences of providing services to individuals and communities with traumatic histories. No review exploring coping mechanisms of interpreters providing services to vulnerable groups such as those experiences violence and abuse could be identified. It was felt important to explore this area to aggregate available literature, to identify gaps in the literature and to improve our understanding of not only the role of interpreters when providing services to vulnerable groups but also about interpreters coping strategies to ensure the development of appropriate support mechanisms for interpreters. Findings from this review may also help identify research questions to be explored through future research.

Aims of Review[edit]

The aim of this review is to synthesize available qualitative studies exploring experiences of interpreters when working with individuals and groups who have experienced DVA or other traumatic situations. The aims and review question were developed using PICO (Patient, intervention, Comparison and Outcome) framework and the specific review questions were:

·       What are the interpreters’ experiences of dealing with individuals and groups with traumatic histories?

·       What impact such encounters have on health and wellbeing of interpreters?

·       What coping strategies interpreters use to protect themselves from the negative?

METHODS[edit]

Eligible Studies[edit]

Empirical studies interpreters experience of working with clients with traumatic situations/ histories and studies exploring the emotional and psychological impact on interpreters were considered for inclusion. For the studies to be included, had to be: exploring the experiences spoken language interpreters; empirical (quantitative; qualitative; literature review/ systematic review); written in English; published in peer reviewed journal during 2000-2019). Studies that explored experiences of bilingual workers, sign language interpreters, informal interpreters were not included. Studies that did not explore the emotional or psychological impact of interpreting, case reports, case studies, scholarly or theoretical papers, opinion pieces and commentaries were excluded. The initial focus of the review was interpreters and their experiences of working with victims of gender based violence, however, no studies were available on this particular issue and therefore the scope has broadened to include participants with traumatic histories and sensitive issues.

Searching Process[edit]

A comprehensive literature search using search engines including engines MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychInfo, Excerpta Medica Database (EMBASE), SCOPUS, web of science, the Cochrane Library and Joanna Briggs Library was performed. Keywords including ‘interpreter’, ‘vicarious trauma’, ‘secondary trauma’, emotional impact’, ‘psychological impact’ were used. Various combinations of search terms and Boolean operators (‘AND’, ‘OR’, and ‘*’) were used to help specify the search. A search was also conducted using Google and Google Scholar to identify studies not published in indexed journals. In addition, reference list of each article was reviewed to identify studies not listed in the searched databases.

Study selection[edit]

This firgure provides a flowchart of the literature search strategy.

The initial search identified 3018 potentially relevant studies. Following removal of duplicated studies 2452 studies remained. A scan of title helped in narrowing down this to 193 potentially relevant articles. A careful review of the abstract and a scan of papers resulted in exclusion of further 151 articles which didn’t meet the inclusion and exclusion criteria resulting in remaining 42 articles. Full text of all 42 articles were printed for further reading and assessment. However, only 18 studies that met full inclusion criteria and therefore included in the review. Figure 1 provides a flowchart of the literature search strategy.

Quality Examination[edit]

To explore the quality of qualitative studies and to perform a robust analysis, the Critical Appraisal Skills Programme (CASP) checklists for qualitative study was used. To review quantitative study and qualitative studies respective checklists were used. As there is no CASP checklist for quantitative studies, checklist for cohort studies were used.

Data Extraction[edit]

To extract relevant data from included studies, a data extraction form was developed and utilised. Appropriate information, including, authors detail, country of study, purpose, research design related information such as sampling, sample characteristics, data collection and data analysis method, study findings, limitations and recommendations were extracted. Appropriate information is summarised and presented in relevant tables and figures in the upcoming sessions. The findings of qualitative studies are synthesised and analysed using Noblit and Hare's method of meta-ethnography.[23] Table 1 shows this process and how these papers contributed to the synthesis.

Findings[edit]

All together 18 studies were finally included in the review. Among these there were 3 quantitative studies and remaining all were qualitative studies. Studies were published between 2003 and 2017. In the following various aspects of studies are explored.

Purpose of the included studies[edit]

Among included studies, four studies explored the role and experiences of interpreters working in different settings.[24][25][26][27][28] A few studies explored professionals experiences of working with interpreters[27][29][30][31][32] and interpreters’ impact on the process of psychotherapy.[27][33][34] Few other studies explored the psychological and emotional impact of interpreting.[27][33][34] Few other studies explored the psychological and emotional impact of interpreting.[25][35][27][36][37][38]

Geographical location of the included studies[edit]

The majority of the studies originated from western and developed countries, including Australia,[25][14] Denmark, [38] UK, [35][28][30][31][37][39][40] USA. [33][27][36][34][32][41]

Study designs used included studies[edit]

The majority of the included studies used a qualitative approach with only few studies using a quantitative approach.[35][36][31] In addition to qualitative exploratory approaches,[14][28][39] other commonly used methodologies included grounded theory,[38][24][39] ethnography,[33] phenomenology,[37][29][32] interpretive phenomenological analysis (IPA)[40][25][26][30] narrative methods,[24] [27] and practice based evidence methodology.[34]

Study setting of the included studies[edit]

Included studies were conducted in various settings including community settings,[24][32][42] health centres,[27][38] torture treatment centres,[27][33][34] rehabilitation centres, [29] mental health clinics,[26][27] sexual health clinics,[40] translating and interpreting services,[35][36][43] or other therapeutic[37] and criminal justice system related settings.[14]

Sampling approaches used in the included studies[edit]

The majority of the included studies used a purposive sampling approach, with only few studies using convenience,[35][39] snowball[24][36] or random sampling approaches.[44]

Study participants in the included studies[edit]

The focus of all of the studies were interpreters, therefore most of them included professional interpreters in their sample, however, some studies also included psychotherapists,[27][32] mental health professionals[30][33] or other professionals such as police officers.[14] In most studies, the main focus was to explore role or impact of interpreter on the therapeutic process, though the interpreters were specifically questioned about the impact of interpreting on their mental and emotional well being. The sample size of the studies ranged from 3- to 30 in qualitative studies and 119-271 participants in quantitative research studies. Taken together the number of participants contributing to the studies were 618 which included 534 interpreters, 68 other professionals and 16 refugees. This sample included 188 male and 455 females and 2 other participants. Some studies did not provide information about the gender composition of the sample.[28][35] The participants spoke had different ethnicities and spoke various languages.

Data collection in included studies[edit]

As mentioned previously, the majority of the studies used a qualitative approach and therefore, face to face interview was a common data collection method. Only a few studies used focus group discussion [14][25][39] one study opted for telephone interviews[32] as a sole data collection method and another used it in combination with face to face interviews.[14] A semi structured interview guide was reported to be used in all qualitative research studies. The quantitative studies used questionnaires as methods of data collection.[35][36][44] Only one quantitative study[36] reported the use of a validated instrument to assess the degree of secondary traumatic stress, burnout and compassion satisfaction. The study also looked at the impact of other factors, including gender, history of trauma and refugee status of the participants. Remaining quantitative studies did not report use of validated measures.[35][44]

Data analysis in included studies[edit]

Various data analysis methods were used in the included studies. As mentioned previously majority of the studies (n=16) used a qualitative approach, the specific data analysis approaches included interpretive phenomenological analysis,[25][26][37] grounded theory,[38], thematic analysis[28] and narrative analysis.[24][27] In quantitative studies, data were analysed using descriptive and inferential statistics.[35][36] Table 2 present detailed information about the data collection and analysis methods used in each study. This section presented information about study characteristics and the next section aims to present findings of the review with regard to the issue under study.


KEY THEMES EMERGING FROM THE STUDY

Five themes emerged from the thematic analysis of the findings of the included studies and these included ‘role and impact of interpreter’, ‘psychological and emotional impact of interpreting’, ‘workplace challenges faced by interpreters’, ‘coping strategies used by interpreters’, and ‘interpreters’ support needs’.  These themes are presented in the following section and appropriate quotes from the included studies are used to illustrate the points clearly. Table 3 presents the process of developing these themes and the contribution of various included papers to each theme.

Role of Interpreter    [edit]

This theme describes how interpreters themselves and other professionals perceived and understood the role of interpreters. It explores the concepts related to ‘self-perception of the interpreter’s role’, ‘professional’s perception of role of interpreters’ and the impact of interpreter on the therapeutic process. As all of these concepts are very interlinked, the analysis is presented as one. The majority of studies explored interpreter’s self-perceptions about their role. Findings suggest that interpreters felt that their broader role or job was to facilitate and enhance communication between the service user and practitioner, who don’t speak the same language, by conveying their message and information to each other. They become a voice of their service user and practitioners and try to convey their message as accurately as possible. This is illustrated in the following quote from Resera et al:[39] 'You are just an interpreter there and you are… we say ‘tongue’ of that person because you’re going to speak on behalf of that person, cause you’re going to translate everything from that language to the counsellor’s language. … In a way, you’re just a language between two people, because you are the communicator, you are the one who passes one information from one to another. We are messengers… '(p. 198).

While it may seem to be a simple act of translating messages from one language to another, in reality, it is not easy and that their role is quite complex. They felt that to become a ‘voice’, they may also have to act as a service user’s advocate to ensure that the practitioner and services meet their service related support needs as effectively as possible. Interpreters felt that they also play a role of a ‘cultural broker’ as languages and the process of communication is affected by culture and norms of the speaker. At the same time, understanding or interpretation of a message also is affected by culture and orientation of the listener. So the interpreter’s role becomes even more important as they not only have to make sense of the message and associated verbal and nonverbal cues and expressions (which can also have very different meaning in different cultures) and convey it to the practitioner in a way that they get a comprehensive understanding of the issue.[25][28] This is illustrated in the following quote from one study:[25] '...to make sure both sides understand each other... for the patient to understand everything and of course for the healthcare provider to understand what the patient is suffering and to make the right decision to help this patient' …(P.8). Another example where the interpreter has to take a role of cultural broker for the service user as well as a practitioner[25] ‘I mean to the patients (it) is... critical because in our culture it is really cruel to tell the patient that he is or she is diagnosed with cancer...maybe it can cause him to be depressed or maybe diminish his ability or willingness to survive. So we ... can find some code word, like instead of saying you have cancer, we can use the word tumour... and we’re going to ... treat you for that tumour, but knowing that a tumour will be treated the same way as cancer would be treated. So we can get around that and use code words just to, you know, just to make it easier...just to alleviate the situation and make it acceptable, more acceptable’ (P.10)

Interpreters felt that their work, while ‘invisible’, requires a wide range of complex linguistic, critical thinking and processing skills,[27] however, it is often seen as ‘invisible’ work. The findings of the included studies stress that interpreter’s role is demanding as it requires concentration on the message provided by both service users as well as a service provider. As indicated above, they essentially have to not only share the message, but the ‘intent of the message’. [24] This suggest that it requires much more from the interpreters than only simple understanding the two languages. This is explained by the following quote taken from Butow et al's study:[25] ‘In translating, it’s not just saying the literal [equivalent of] what they’re saying. Interpreting is making some sense of it. . . . Those are two different things’.

Interpreters as well as professionals felt that interpreters need to be able to multitask as unlike conference interpreting (which requires only one-way interpretation), they need to be attentive to both service user and practitioner and should have the skills to be able to switch between both languages promptly and accurately. They have to keep a fine balance between convening accurate translation or interpretation and accurate translation of the meaning of the message. It is possible that interpreters may they are unaware of many different technical terms that they come across and therefore have to quickly ascertain ways of communicating and capturing the underlying meaning of the words[24][25] as indicated in the following quote[24]:

‘… You’ve got to have your resources as available as possible. There have been times I have said, “All right. I am just really stuck on this one. Hang on just one second, I will go ask somebody or try to look it up." It used to be that without a computer, you would have to sit there and have a glossary. . . and actually leaf through it to find [a word]. . . . I would have two copies of the glossary— one sorted by Spanish, the other sorted by English. . . .But with the computer . . . you can find it within about five seconds. . . . And also, of course, being in a medical facility, [to] be on top of all the medical terminology, all the patient rights, all the protections that you [and] the provider needs and the patient needs ( p. 140).

Interpreters felt that at times, they have to play a role of neutral conduit and have to actively engage in the discussion as one interpreter mentioned:[24] ‘asking questions that are difficult or too open-ended makes it difficult for the client to answer. And also by being open-ended, then I’ve got to sit there and write a lot of things on paper and then hope I remember them all. What I often do when open-ended questions are asked is to say, “Could we just go with that one at a time?” For example, if it is a dietician saying, “How many portions of starches are you serving?” and that sort of thing, I’ll suggest: “Let’s go over the specific kind one by one’ ( p. 41).

This work, while important, can cause a tension between the interpreter and the practitioner who may see this as an interference or inappropriate interjection of opinion on the interpreter’s part. These issues will be discussed later in ‘impact of interpretative theme. While practitioners generally valued the role of interpreters, there were occasions when they felt angry, frustrated due to interpreter’s inappropriate interference as exemplified by Miller et al.[27] ‘there [were] a few times when I was working with an interpreter and I was asking about a particularly sensitive topic, and the interpreter stopped me and said, “Please don’t ask her about that, that is going too far, you are going too deep, she is not ready for that,” and I said essentially, “well you are going to have to trust me as the therapist here that I will handle this in a delicate way, but I think it is important that we take this to the next level.” And I had to convince the interpreter to actually do what I thought was therapeutically indicated’ (p. 33).

Practitioners also felt that at times, interpreters do not always interpret accurately and at times, in a desire to help the service user they either give wrong information or incomplete information. They also articulated that at times, service user may not want to disclose issues to an interpreter as they share their culture and this can be a problem. Overall, both interpreters as well as practitioners perceived interpreter’s role as positive and recognised their contribution.

Psychological and emotional impact of interpreting[edit]

This theme aims to illustrate the psychological and emotional impact of interpreting on the interpreters. All included studies described significant emotional and psychological impact on interpreters, resulting in the development of emotional distress and burnout.[38] Findings suggest that such issues often could become unbearable and overwhelming for the interpreters[24][26] and may result from listening to the traumatic stories armed attack, assaults, torture, persecution or other traumatic experiences of the service users or breaking bad news during health care encounters.[24][25][28] While interpreters found such instances, at times, ‘intense’[37] or ‘too difficult to handle’[26] situations, they were required to not only listen, but to absorb these stories and relay it back to the practitioner. A participant in a study[37] stated: ↵ ‘You have to visualize you know, when you do the interpreting, the interpreting process is not just about words. When you’re telling a story, it’s complex, it’s set in a place and you have to process all that. So you’re hearing the story but you’re also saying the story and imagin[ing] what it was like for the person. You know the emotions, they can never be as strong as what the client feels, but you get a sense of the way they might have felt’ (p. 1709). ↵

Such emotions heighten when the interpreters themselves had a traumatic history and interpreting for the service user has reminded them of their emotions and past experiences[26][27] or it may have made them worried about their family members living in the affected country. However, Mehus and Becher[36] found no relationship between trauma history or refugee status with secondary traumatic stress, burnout or compassion satisfaction. ↵Such impacts reported to have a variable length as interpreters continue to work in demanding environments. The included studies reported that the emotional and psychological impact was not limited to work or professional life of interpreters but also affected their personal life. Interpreters often felt it hard to move on to the next job.[35] The studies used terms such as vicarious trauma, PTSD and secondary PTSD. Box 3.1 describes various psychological and emotional reactions reported. ↵The following quote[37] also illustrates some of the manifestations as experienced by an interpreter: ↵ ‘I would perhaps, you know, miss my stop, or [be] forever checking where are the car keys, and keep waking up and feeling still tired. Maybe I was taking my emotions outside with my own emotions and I found no answer to it. I went to bed with it and wake up and they’re still there’(p.1710).↵

Another very powerful illustration was described as:[24] ↵ ‘getting drawn into it. Wishing I could do something. You want to say, “Well, just come home with me.” . . . You can’t do something for all of them . . . you do have to maintain your distance and be professional . . . but . . . you want to pick those kids up and hug ’em. You have to worry because those kids are terrified of you, too. . .. That kind of makes you feel bad’ (p. 143). ↵

The fact that they have to keep this confidential and there is usually no other support available, the impact is even greater. In addition, unlike other health and social care practitioners such as doctors, nurses or other professionals, interpreters are not trained in dealing with emotional issues. Other factors at work place such as the feeling of not being valued or recognised by practitioners and employing organisations manifested by not being allowed to have breaks, restricted or no access to appropriate notes, etc., lack of acknowledgement of the role and underestimation of the impact of the work of interpreters. ↵All of these issues generally contributed to physical, psychological and emotional impact on interpreters. However, a couple of studies also identified positive impacts of such experiences resulting post traumatic growth where interpreters felt that they became more empathetic towards service users, improved self-understanding and understanding of the world around them.[26][37]

Workplace Challenges[edit]

This theme explains the findings of the study with regards to workplace challenges that interpreters face on a daily basis and consequently experience the negative impact on their health and wellbeing. Nearly all included studies explored or addresses concerns related to workplace challenges and these included heavy workloads, unrealistic expectations and lack of appreciation, lack of appropriate organisational support. Interpreters stated that their workload was too much and sometimes they had to work up to 14 hours without appropriate breaks. The issue of long hours is expressed by one of the participants in a stud:[24] ‘If we have to do an all-day conference, two people working, they switch off and on all day. We can’t do that when we’re interpreting in the medical setting. . . . We complain about the hours we work . . . the amount of concentration. . . . You get to the point where you just physically cannot do it anymore. . . . I’ve had so many calls at 2:00 or 3:00 in the morning from interpreters who have been [at the hospital Emergency Department] all night, and they’re like, “You have to come in and take over. I’m sorry to wake you up, but I just can’t do it anymore. My brain’s just not working.” It’s because we keep switching languages. . . . I have to work Spanish English, English-Spanish. So it skips back and forth, back and forth, back and forth. . . . When you’re doing medical interpreting you keep switching languages all the time. It gets confusing, and it gets to the point that . . . you speak English to the Hispanic patient and Spanish to the doctor because you are so tired . . . or you paraphrase’ (p.143).

The above quote highlights the issues interpreters face with regards to the demands of working long hours, but due to other issues such as need of constant language switching and attentiveness. Some studies also reported that the interpreters had to travel for outside assignment and that added to the pressure.[38] In addition, long waiting times and connection difficulties and delays added to the pressure contributing to physical and psychological stress on interpreters.[38] More recently, the majority of the services are moving towards telephone interpretation and this contributes to additional challenges as a participant’s in one of the study states: ‘It’s harder because you can’t see the person face to face. You’re telling somebody something really bad on the phone and they can’t even handle [it] face to face’( p. 240).[25]

Interpreters also articulated a concern that there are too many expectations from too many people, including the practitioners, the service user and their family and the organisations that they work for and that it is ‘too difficult to keep everyone happy’[24] and it’s difficult to be aware of every term used by the practitioner and the service user. Interpreters also felt that they are not valued by their colleagues and often seen as a technical tool or a ‘translation machine’ with no feelings or views. Interpreters felt that they are often not invited to team meetings or events and decisions made at home. This then has an impact on interpreters’ feelings of integration. In addition, they are often spoken to degrading tone. They felt that their needs for information about the clients are often ignored and as a result, they don’t feel fully prepared for an assignment resulting in apprehension and stress for the interpreters. For instance, one interpreter stated:[26] ‘I think it would also be better if for all mental health cases… to have five minutes with the professional before you go into the interview room’ (p. 233).

In the absence of formal training for interpreters (relevant for many interpreters) interpreters’ frustration and lack of trust on organisations can be easily understood. In addition, lack of provision for appropriate supervision opportunities for interpreters also conveys a lack of recognition for interpreters.

Coping strategies[edit]

This theme explains the coping strategies that interpreters used to cope with the psychological and emotional impact of interpreting.[35][37][38] Interpreters felt that they really needed various strategies to be able to continue to work effectively and to be normal in life as well. As a participant in one of the included studies[37] reports:↵ ‘Because they are so emotionally charged, these sessions, you have to find your own ways of dealing with it, and if you don’t have a way, you don’t have this protection, then I don’t know how you can do interpreting in those context[s] really. I think it would be hard because I would be crying every session’ (P.171)

Most common strategies included self-control,[37][38] self-medication,[38] Detachment,[26][37][38][40] accessing social support.[24][26][38][40] With regards to self-control, interpreter reported to use various strategies to basically regulate themselves and ensuring that the emotional impact of interpreting is limited. Examples included negotiating and taking a break from interpreting activities, getting involved in a different activity as mentioned by one of the interpreters in a study:[38] ↵ ‘I tried to swallow it and keep it down’; ‘After work, I went into the countryside. I concentrated on something quite different, like fishing; sometimes when I felt sick, I just drove around in my car’ (p. 26).↵

The same study[38] also reported use of self-medication as a coping strategy as a participant reported: ↵ ‘When I get headaches while interpreting. I take some medicine right away. When I can’t stand it anymore, then I need some headache pills’ (p. 26). ↵ Avery common strategy reported in most studies was the act of detaching/ distancing or distracting themselves from the issue. Participants in another study[37] reported: ‘I try to find something that can distract me or move me on to something else’ (p. 1711).

Another participant from Holmgren et al. (2003) reported: ‘While interpreting I had to tell myself: This is just work, remember! I have not been exposed to this. One has to switch off part of the brain and look at it as work’ (p. 26). Such strategies were used as a defence mechanism and to help themselves to not to think about traumatic and distressing experiences encountered while interpreting. Accessing appropriate social support was another common strategy used by many interpreters. They felt that it helps them share their feelings with colleagues or friends and consequently helps to take it out of mind. One participant in Holmgreen’s study[38] stated:↵ ‘I spent many evenings together with my Albanian friends; we talked about our worries; our situation was the same; many of my friends had no idea where their families were or if they were still alive; we found strength in one another’ (p. 26)↵ Use of various coping strategies helped interpreters to carry on with their daily personal and professional life.

Interpreters support needs[edit]

This theme aims to present interpreters views about the existing support system available and recommendation to improve support system. Nearly all of the included studies explored the interpreters view about available support system and commented on the lack of appropriate structures.[24][25] Interpreters in many studies reported a need to have debriefing sessions to talk about the impact of interpreting traumatic stories as these often shocked interpreters.[28] Interpreters felt that there were no appropriate provision for debriefing and support sessions. Due to the fact that interpreters, mostly work on self-employed basis, formal arrangement of clinical supervision if often unavailable. Another important aspect raised by interpreters was a lack of appropriate training and preparation as suggested by Butler[40] "it’s all supposed to be a certain way when you study interpreting, then when you are in the field it’s not at all as thorough as that because of time constraints or people just can’t be bothered or they just don’t know" (p..9) The majority of the interpreters did not have any training or had very minimal training for their job. In contrast, they had to deal with a variety of traumatic and difficult situations which require not only an understanding of how to translate or interpret, but how to support vulnerable and distressed people, deal with difficult situation and protect themselves from emotional and psychological impact of the traumatic stories. All of these aspects are often missing and there is no or minimal provision of education and training for interpreters during their career. As one of the interpreters in a study:[24] "The most difficult things—I would think emotionally. We don’t have the training like nurses or other health care personnel have. How to deal with the very intense situ- ations you’re in as far as life/death situations, [like] having to tell parents that their child has a terminal disease or something like that. So that . . . we have these debriefing sessions back in the office . . . very informally . . . within [the guidelines of] obeying HIPAA. But it makes it very difficult because you know . . . legally someone can’t go tell their husband this is what happened today. . . . So we have to have these sessions where basically sometimes you come in that office and you just have to vent because this or that happens. So that is one major problem. ."(P.143) Interpreters in the included studies believed that appropriate peer support,[35] clinical supervision opportunities,[27] briefing as well debriefing sessions.[26] An interpreter from a study[25] stated: 'Unfortunately that is a problem that we all have that there is no debriefing for interpreters. So I can walk out of an appointment feeling very, very bad and there is no one that you can talk to. In all the years that I have been working as an interpreter only once have I been offered debriefing and that was at the Coroner’s Court. Never in any other situation.”( P.15)

Interpreters also thought that training on coping strategies will also be useful.[25] Other suggestions to improve working conditions of interpreters included shorter working hours, improve wages, observance of breaks[24]: "I think it’s very difficult for interpreters to interpret for hours at a time. . . . I’ve had a call as long as two and a half hours, and that’s very difficult on an interpreter’s voice physically, because you’re saying everything twice. And it takes a lot longer so it tires you out. . . . It’s very draining. Doing it for hours can be very draining.. . . I’ve been called at home. I’ve been called on the weekends. I’ve been called on a holiday, after hours."(P. 143) In addition, interpreters felt that working with same professionals may help increase familiarity with each other and therefore would help make interpreters work easier.

To sum up, the findings of the studies included in this review suggest that while the role of interpreters is important in helping service users and practitioners communicate with each other effectively, it has its own challenges. The interpreters may themselves have experienced difficult situations in their life and working as interpreter means that they have interpreted and relay traumatic stories of service users who they work with and this may make them remember their own traumatic experiences. The findings of the studies revealed that interpreting for people with traumatic histories can have serious emotional and psychological impact on them. However, there appears to be a lack of appropriate support system to help interpreters to not only perform their job effectively, but to protect them from the negative impacts of their job.

DISCUSSION[edit]

The need of interpretation and interpreters is increasing day by day owing to internal and external migration within and between countries.[17] Health and social care professionals and other professionals such as those working in, for example, criminal justice system or other professions cannot provide appropriate services to those unable to communicate in the mainstream language of the country. It is important to recognise that interpretation or language barriers are not only relevant to an English speaking country, but to any country where there is a problem with provision of language concordant services to service users. The role of interpreters is a very important one as without their help service users as well as practitioners could not understand each other appropriately. Their role often seen as integral is not always acknowledged and recognised appropriately. While research related to interpreters and their needs is an emerging field, there are many areas that have not been explored as yet. For instance, the impact of interpreters on women’s ability to disclose their domestic violence experiences, preparedness or interpreters in supporting women (and men) to disclose their experiences of gender bases violence and or domestic violence and abuse, perceptions of men and women with domestic violence histories, about the role and impact of interpreters on the process. One of the reasons to embark on this project was to identify available literature on this particular topic, however, I did not manage to find any single study on the topic and therefore broadened the topic area to look at interpreters and their work with people traumatic histories and emotional and psychological impact of such exposure on interpreters and their health and wellbeing. The narrative analysis of the concept discussed in the studies is presented in five main themes and these included ‘role and impact of interpreter’, ‘psychological and emotional impact of interpreting’, ‘workplace challenges faced by interpreters’, ‘coping strategies used by interpreters’, and ‘interpreters’ support needs’. The first theme explored the role of interpreters as perceived by themselves and by other professionals. Interpreters as well as other professionals agreed that interpreters play very diverse and important role when helping service users and professionals to communicate with each other. Many studies have explored this particular aspect and various roles identified included of communicator, voice box, cultural broker, advocate and a neutral conduit.[24][29][40] The findings of the study reveal that though, the role of an interpreter appears simple, but it’s very complex and demanding. An interpreter is required to pay attention to both parties in an attempt to communicate and requires multitasking. Professionals while recognised the role of interpreters, also articulated their frustration as they felt that interpreters do not always interpret all information relayed by the professional to the service user or vice versa or that they interject inappropriately. There appear to be issues with the development of trust and rapport with the service user and many a times, professionals felt that their position was not maintained. Interpreters on the other hand, feel that professionals and others do not always understand the role of an interpreter. This finding is consistent with many studies conducted on this topic.[45][46][47] The next theme explored the psychological and emotional impact of interpreting on the interpreter. The findings of the review suggest that interpreters are required to interpret traumatic experiences of those they are interpreting for. This is a complex task and requires interpreters to not listen to the experiences, but to relay it back to the professional and to so they have to imagine that experiences. Nevertheless, repeated listening to articulating to traumatic situation can produce negative emotional and psychological symptoms. Symptoms reported include sadness, anger, feeling upset, insomnia, depression and anxiety.[26][37][38][48][49] Such symptoms are reported in previous research. The findings of the review suggest that interpreters felt that such experience had a very negative impact on interpreters and that there is not much support available to help interpreters cope with the such negative impacts. In addition to exposure to traumatic situations, included studies also explored workplace challenges faced by interpreters. Interpreters identified many different workplace stressors such as a feeling that they are not treated as equal of their professional colleagues, they are not invited to meetings and are not involved in decisions made at the workplace. They also felt that working conditions for interpreters are not good as they are required to work long hours, often don’t get breaks during work, and their requests for change in work are not listened to.[24][29] The next themes identified in the review explored coping strategies used by interpreters to deal with the negative impacts of interpreting. Various strategies used by interpreters included detaching themselves from the situation, self-regulation, self-medication and accessing social support.[25][29][38]Cite error: The opening <ref> tag is malformed or has a bad name Included studies also explored the interpreter’s views about their support needs and how these can be met. Interpreters suggested various ways that may help them cope with the negative impact of interpreting and improve working conditions for them. These included provision of peer support, the opportunity to have briefing and debriefing session, opportunities to talk to counsellors and professionals, availability of clinical supervision sessions, shorter working hours etc. To sum up, this review has identified many different important issues with regard to interpreting and interpreters. While most studies conducted on this topic, there are many different aspects that still need to be explored. For instance, research needs to be conducted on the role of interpreters with regards to provision of services to victims of gender based violence. Views of women, men, professionals as well as interpreters could be explored. Preparedness of interpreters with regards to provision of services to such vulnerable groups should be explored.

IMPLICATIONS[edit]

The findings of the study have implications for professionals, clinical practice, and future research. Present findings clearly highlight that interpreter’s role need to be recognised by organisations as well as professionals. With regards to interpreters, better education and training opportunities should be made available for interpreters to better prepare them for their roles and specially to provide appropriate services to those with traumatic histories. Interpreters should also have education and development opportunities to learn about coping strategies to enable them to cope with negative impacts of interpreting. There appears to be a lack of clear boundaries and role definitions among interpreters as well as professionals. Further work involving interpreters as well as professionals is required to develop a clear understanding of the role boundaries and the role of each other (professionals and interpreters). This may help reduce tensions between interpreters and professionals. It is also important to help interpreter prepare for their assignments beforehand by providing them with some information about the service user they are going to provide services to. Workplace conditions for interpreters need to be improved, so that interpreters feel valued and not alienated in their workplace. Appropriate service structures, etc. should be developed for interpreters for progression into their roles and for better job satisfaction. Research exploring the role of interpreters, impact of qualification and accreditation on service provision by interpreters and factors affecting interpreters’ performance should be conducted. Research should also be conducted to explore similar issues among sign language interpreters. Further research should be conducted, validated measures to explore psychological and emotional impacts of interpreting. Finally, further research to explore the impact of telephone interpreting or online interpreting should be explored

CONCLUSION[edit]

Interpreting is an important part of the provision of appropriate health and social care services to those with limited language proficiency in the mainstream language. However, research related to psychological and emotional aspects of interpreting is scarce. This review was conducted to explore the psychological and emotional impact of interpreting. The findings revealed that interpreting has significant impact on interpreters’ personal and professional life. Interpreters develop and use various strategies to cope with the impacts of psychological and emotional impacts of trauma. Further work needs to be done to improve working conditions for interpreters and to support them to provide appropriate services to those affected.

References[edit]

Additional information[edit]

Acknowledgements[edit]

Any people, organisations, or funding sources that you would like to thank.

Competing interests[edit]

Any conflicts of interest that you would like to declare. Otherwise, a statement that the authors have no competing interest.

Ethics statement[edit]

An ethics statement, if appropriate, on any animal or human research performed should be included here or in the methods section.

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