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Chapter: Essentials of Psychiatry: The Cultural Context of Clinical Assessment

Working with Interpreters and Culture-brokers

A key skill which has not been addressed in many training pro-grams concerns how to work with interpreters.

Working with Interpreters and Culture-brokers


A key skill which has not been addressed in many training pro-grams concerns how to work with interpreters (Table 2.4). In the absence of familiarity with this technique and quality assur-ance standards insisting on appropriate use of interpreters, many clinicians simply try to avoid the situation, relying on patients’ sometimes limited command of the clinician’s language. This is unfortunate and may lead to errors in diagnosis and management as well as the failure to engage and help many patients.


There are several models of working with interpreters (Westermeyer, 1989). Medical interpreters have adopted a code of ethics and model of working that owes much to forensic and political interpreting. Their goal is to provide accurate, complete and literal translation of the statements of patient and physician. This model tends to portray the interpreter as providing a trans-parent window or conduit of communication between clinician and patient. In this approach, the clinician addresses the patient directly as though the interpreter is not present. The interpreter may speak in the first person for the patient and for the clinician alternately. The model assumes that it is possible to achieve com-plete and accurate translation of message in both directions and treats the interpersonal triad of doctor–interpreter–patient as if it was a dyad. To do so assumes that the interpreter does not have an independent relationship with patient or clinician. Of course, this is certainly not the case in any clinical encounter that goes on for a time or involves repeated meetings. Indeed, at the level of transference it is never the case because the mere presence of another person immediately evokes distinctive thoughts, feelings



Table 2.4 Guidelines for Working with Interpreters and Culture-Brokers

Before the Interview

·            Explain the goals of the interview to the interpreter

·            Clarify the roles of interpreter and clinician, and the conduct of the interview

·            Discuss the interpreter’s social position in country of origin and local community as it may influence the relationship with the patient

·            Explain the need for literal translation in the Mental Status Examination (e.g., to ascertain thought disorder, emotional range and appropriateness, and suicidality)

·            Ask for feedback when something is hard to translate

·            Discuss etiquette and cultural expectations

After the Interview

·            Debrief the interpreter to address any of their own emotional reactions and concerns

·            Discuss the process of the interview, any significant communication that was not translated, including paralanguage

·            Assess the patient’s degree of openness or disclosure

·            Consider translation difficulties, misunderstandings

·            Plan future interviews

·            Work with same interpreter/culture-broker for the same case whenever possible


and fantasies. Then too, the presence of the interpreter inevitably changes a dyad into a triadic social system with its own complex interpersonal dynamics. These dynamics are complicated by the ethnocultural background of the interpreter and his or her own cultural assumptions.


The very idea of literal translation is also problematic. Across languages, words and phrases with similar denotation often have different sets of connotations. Every translation, there-fore, is an interpretation that emphasizes some potential mean-ings while muting or eliding others. Interpreters tend to smoothe out fragmentary, incomplete, or incoherent statements and so may mask thought disorder or other idiosyncrasies of speech with diagnostic relevance. The clinician needs to understand the choice of alternatives made by the interpreter in order to appre-ciate the connotations of the patient’s words and to convey his or her own nuanced meanings. These requirements place much higher demands on interpreting in mental health setting than in other medical or legal settings.


A slightly different model views the interpreter as a “go-between”. In this approach, the interpreter takes turns interact-ing with clinician and patient to clarify what is being said and to find a means of conveying it. This model acknowledges the interpreter as an active intermediary and allows the interpreter some autonomy. The sequential dyadic interaction puts greater time and distance between clinician and patient. This demands that the interpreter have a high degree of clinical knowledge and interpersonal skill, which is possible when the interpreter has been trained as a clinician. Taking this autonomy further, the in-terpreter may be viewed as a cotherapist. In this approach, the interpreter with clinical skills develops his or her own working alliance with the patient. The interpreter may respond independ-ently to the patient and initiate interventions. This sometimes happens because of language barriers, when patients may contact the interpreter to ask for help with practical issues.


Given the complexities of interpreting, we prefer to view the interpreter as a culture-broker who works to provide both the patient and the clinician with the cultural context needed to understand each other’s meanings. To do this, the interpreter must understand something of the perspectives, cultural back-ground and social positions of both patient and clinician and appreciate the goals of the clinical task. Based on this knowl-edge, the culture-broker can enhance patient and clinician un-derstanding of each other and can help negotiate compromises when there are widely divergent understandings of a problem and its solutions.


Despite increasing recognition of the importance of ad-equate interpretation, many clinicians or institutions use lay in-terpreters who are directly available at no cost, usually family members (even children) or other workers within the institution. Except in emergency situations, this practice should be avoided because it exerts a strong censorship on what may be disclosed in the encounter and because it may damage relationships that are very important to the patient by transgressing certain social and familial taboos.


Both interpreters and culture brokers need training to per-form competently, and clinicians need training, in turn, to work with these allied professionals. The clinician must take a sys-temic approach, understanding the other people in the room as part of an interactional system. Clinicians must also understand the interpreter’s position in the larger community. Some of this training can go on when clinicians have an opportunity to work repeatedly with the same interpreters, who thus become part of a treatment team.


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