1. Working with Interpreters in a Mental Health/Sensitive Context Dr Beverley Costa, CEO Mothertongue multi-ethnic counselling service www.mothertongue.org.uk beverley@mothertongue.org.uk

2. Mothertongue multi-ethnic counselling service Culturally and linguistically sensitive professional counselling service for people from black and minority ethnic communities Counsellors, patients and NHS professionals reported dissatisfaction from agency interpreters who were not trained and supervised to work in a Mental Health context Mothertongue responded by creating training for interpreters and clinicians in collaborative working, a training DVD and a dedicated Mental Health Interpreting Service which is funded by the local CCG and Health Trust

3. Outline working with interpreters The issues Some solutions Demonstration Tips for effectiveness Results of research

4. Clinicians and interpreters working together KEY ISSUES The nature of power in relationships The subsequent need for reflective attention to be given to this The importance of safety, quality and equity

5. Training to work effectively with an interpreter The importance of working collaboratively with an interpreter If professionals don’t feel confident they will find ways to avoid this work Consequences are that: 1.Clients who need an interpreter get pushed down the waiting list 2.Professionals expect the communication to be problematic 3.Professionals’ anxieties are left unresolved and reacted upon rather than understood and creative solutions found

6. Some fears of the interpreter Jargon Emotional overload Risk Role in the therapeutic relationship Lack of knowledge/context Clinician’s competence

7. Some fears of the clinician/worker Am I being translated accurately? Will there be enough time? Trust e.g.confidentiality,reliability,consistency Can I establish a rapport/connection with client? Staying in control of the session

8. Some fears of the client Will the interpreter know my family? Will they tell anyone else? Will the interpreter judge me as we are from the same community? Will we be political enemies? Will they translate me accurately?

9. Karpman’s Drama Triangle Persecutor Rescuer Victim VICTIM Even though only one is called victim, all three originate out of and end up back at the position of victim PERSECUTORRESCUER

10. Exercise Think of the triangular relationships you have been in over the course of your life from your earliest moments. Safety recommendation! What have been the patterns of inclusion and exclusion? What coping strategies have you developed to help you manage anxieties which can be elicited in triangular relationships? Only share your coping strategies with other members of the group

11. A client’s experience of using an interpreter You are telling something,….. You revolt at everything… You have problems … You want to tell them to the doctor… You know Turkish.. You can’t tell them in English … That’s number one... already enters into you like an arrow. Secondly...a second person…that person knows your language She is someone from your own culture, That is how you think.. You talk about what you have lived through… Wondering what she is thinking. That enters you as the second arrow. It makes you upset, of course it makes you upset.

12. The model for working with interpretation developed by Mothertongue multi-ethnic counselling service Conceptualises the therapeutic process as working within triangular relationships consisting of patient, therapist and interpreter - key features of the training and codes of conduct : (a) interpreters must have an appropriate command of the spoken languages in which they interpret, including dialects, current idioms and cultural background knowledge (b) therapists and interpreters need to work together before, during and after the therapy to establish the working alliance and to process the emotional impact on both (c) interpreters need to recognise boundaries between themselves and clients and to follow guidance about what to do, and what not to do in sessions (d) therapists’ responsibilities to assist interpreters with any strong emotional impact of the session is recognised

13. Clinicians/workers who are not trained to work with interpreters may defer all responsibility to the interpreters or try to undermine them by, for example: requiring interpreters to break bad news to clients expecting interpreters to manage the consequences of misjudged interventions wresting control from interpreters by discounting them or excluding them from the process being unclear about the extent of the interpreter’s role transferring the blame for an ineffective session wholly to the interpreter refusing to be available for the pre and post briefing meetings ignoring the needs of interpreters

14. These are very delicate situations for interpreters where they will need to be assertive and to remind professionals of the limits and responsibilities of both their roles. At the same time they need to be sensitive to the clinician’s/worker’s authority in the session.

15. What would you do? The interpreter doesn’t turn up The interpreter is late The client’s sister is in the waiting room and insists on interpreting for her sister Despite having briefed the receptionist last time, you find the interpreter and the client sitting chatting together in the waiting room

16. Working with interpreters – a few pointers Some Operational Tips Pre meeting/ training session –: establish ways of working together and your working relationship; role play tricky areas Think through with the interpreter how to approach beginnings and endings Ground rules – confidentiality and EVERYTHING in the room translated

17. Any input from interpreter only if essential. If not – hold on to it and share at end Speak in small chunks so that the interpreter can translate accurately Allow time for de briefing at end of session Work collaboratively together with interpreter to form a counselling/therapy team Provide support for interpreter – be aware of vicarious traumatisation

18. Clarify that you the counsellor/MH worker have ultimate responsibility for the session. It is necessary that the interpreter feels able to trust you to hold that responsibility Do not leave the interpreter on their own with the client before, during or after the session – what are the clinical implications if you do?

19. Some Organisational tips: Budget for a pre-session training meeting with the interpreter involved in clinical work. Even if you have to reduce the number of sessions with the client, the pre-session will prove invaluable Consistency of same interpreter – try to build up bank of your own – you will have no control if you have to use an agency Interpreter used for counselling /MH should only be used for those sessions.

20. Check the language of the interpreter and the client are compatible! Also be sensitive to the possibility of the interpreter being from a political faction, community or religious group alien to the client Check if there are gender issues for the client. Further reading: Tribe and Raval(2003) Working with Interpreters in Mental Health, Brunner Routledge Costa (2011) When three is not a crowd. Professional preparation for interpreters working with therapists, ITI Bulletin, January-February, 2011 Managing the demands of mental health interpreting: why training, supervision and support are not luxuries, ITI Bulletin, March 2011 Interpreting in mental Health contexts via Skype. Paper produced for the conference: The Future in the Present: Public Service Interpreting and Translation in the Wild Wired World – University of Alcala. Madrid, April 2011

21. Supervision of Mental Health Interpreters 1.Managerial supervision 2.Professional support and mentoring e.g. The interpreter describes a situation where the clinician leaves the room and leaves the interpreter on her own with the client 3.Case management e.g. The clinician invites a family member into the room and allows her to interpret informally from time to time 4.Personal/pastoral support e.g. An interpreter has been interpreting for a woman whose father recently died from cancer. She is very distressed and is suffering from depression. The interpreter is finding it very hard to stop thinking about her after the sessions 5.Clinical supervision e.g. An interpreter is worried because the practitioner seems to be annoyed with her. The client keeps looking at the interpreter and not at the practitioner. In the de-brief with the interpreter, the practitioner asks the interpreter to stop looking at the client as it is disrupting his ability to achieve a rapport with the client. The interpreter is worried about the impact it might have on the client if she avoids her gaze but appreciates that the practitioner is finding it difficult to form a working relationship with the client.

22. Recommendations from research on patients’ experiences of IAPT therapy via an interpreter Communication flow Collaboration, respect and trust Containment and support Attention to the level of the patient’s vulnerability in the relationship “Try again. Fail again. Fail better.” (Samuel Beckett 1983)

23. Speaking like falling …. The problem with English is this: You usually can’t open your mouth and it comes out just like that – first you have to think what you want to say. Then you have to carefully arrange those words in your head. Then you have to say the words quietly to yourself, to make sure you got them okay. And finally, the last step, which is to say the words out loud and have them sound just right. But then, because you have to do all this, when you get to the final step, something strange has happened to you and you speak the way a drunk walks. And because you are speaking like falling, it’s as if you are an idiot, when the truth is that it’s the language and the whole process that’s messed up. And then the problem with those who speak only English is this: they don’t know how to listen; they are busy looking at your falling instead of paying attention to what you are saying. (p.194) We need new names, by No Violet Bulawayo, Chatto and Windus 2013

24. A play about languages and relationships Mothertongue presents a new play, The Session, at The Soho Theatre London, about how couples communicate across different languages and the impact this has on their family lives. It will be on at the Soho Theatre, London during the month of November, 2015. There will be an after-show discussion on November 10 th. Here is the link for more details. Please come along and support us! http://sohotheatre.com/whats-on/the-session/

25. Suggested Reading Burck, C. (2004). Living in several languages: implications for therapy. Journal of Family Therapy, 26, 314-339. Burck, C. (2005). Multilingual Living: Explorations of Language and Subjectivity. London: Palgrave Amati-Mehler, J. Argentieri, S. & Canestri, J. (1993). The Babel of the Unconscious, Mother Tongue and Foreign Tradition. Madison: International Universities Press. Perez Foster, R. (1996). The bilingual self: duet in two voices. Psychoanalytic Dialogues, 3, 69-121. Hoffman, E.(1989).Lost in translation: A life in a new language. New York: Penguin Books. Dewaele, J.-M. (2010) Emotions in Multiple Languages. Basingstoke: Palgrave Macmillan. De Zulueta,F. ( 1984) "The implications of Bilingualism in the study and treatment of psychiatric disorders: A Review", Psychological Medicine 14:541- 57. De Zulueta,F. (1990) "Bilingualism and Family Therapy", Journal of Family Therapy 12: 255-65. Costa B. A working model of a community based, culturally sensitive counselling service, in Psychotherapy and Culture by Zack Eleftheriadou, Karnac Books 2010 Costa, B. & Dewaele, J.M. (2012) Psychotherapy across Languages: beliefs, attitudes and practices of monolingual and multilingual therapists with their multilingual patients, Language and Psychoanalysis: http://www.language-and-psychoanalysis.com/ http://www.language-and-psychoanalysis.com/ Costa, B. & Briggs, S. (2015) Service-users’ experiences of interpreters in psychological therapy: a pilot study DOI 10.1108/IJMHSC-12-2013-0044. Costa, B. (2014) Counselling in many tongues. Therapy Today Vol. 25/4, 20 -23 Dewaele, J-M., Costa, B. (2013) Multilingual Clients’ Experience of Psychotherapy Language and Psychoanalysis, 2013, 2 (2), 31-50 http://dx.doi.org/10.7565/landp.2013.0005

26. Training DVD For more information about the Mothertongue Mental Health Interpreting training DVD and the training package, please contact: Mothertongue multi-ethnic counselling service: www.mothertongue.org.uk info@mothertongue.org.uk T: 0118 957 6393