#61283: Using Interpreters in Health and Mental Health Settings

In many cases, the terms "interpreting" and "translating" are used interchangeably, but interpreting is specifically associated with oral communication while translating refers to written text. Interpreting involves analytical hearing and decoding of the original message into the targeted language. It involves much mental energy to hear, decode, and remember while taking and reading notes and then conveying the information [134]. As such, interpreting and translating require different skill sets. Translators must understand the source and target language, understand the culture, and have a good repertoire of vocabulary of the target language in order to convey the written information clearly, without losing any of the meaning [17]. They should also be proficient in using different reference materials [18]. On the other hand, interpreters must work on the spot, listening to both parties and communicating from the language of one party to the language of another party very quickly [17]. They should be well versed in idioms and colloquialisms. When interpreting in specific settings, like health or mental health, they must be familiar with the technical language as well.

There are several methods or strategies for interpretation. This section will outline a few of the most commonly used approaches, although others may also be used.

Interpretation can also be categorized by setting and proximity of the involved parties. If interpretation is done with all persons in the same room or setting, this is called proximate interpreting [23]. However, if it is not conducted in the same setting and/or the interpreter is linked in through some sort of telecommunication system, this is referred to as remote interpreting.

It is not clear if one interpretation setting is more effective than another, and research in this area is ongoing. In an experiment involving medical scripts to evaluate if one configuration of interpreting was more accurate than another, interpreters were randomly assigned to one of the four types of interpreting conditions: remote simultaneous medical interpreting (RSMI), remote consecutive medical interpreting (RCMI), proximate consecutive medical interpreting (PCMI), and proximate ad hoc interpreting [23]. The study found that RSMI was more accurate and was the quickest compared to the other three modes of interpreting. Although it was expected that simultaneous interpretation would be faster, the accuracy of RSMI was unexpected [23]. The researchers speculated that it may be because interpreters had less time to edit or advocate on behalf of the patient.

In an experimental study to evaluate whether patients are more satisfied with an RSMI model versus a hospital's "usual and customary" interpreting method, 735 Hispanic (Spanish-speaking) and Chinese (Cantonese- and Mandarin-speaking) patients presenting to an urgent care hospital were randomly assigned to one of the two interpretation groups [24]. In this study, the RSMI involved a commercial language service whereby the interpreter was off-site. The usual and customary method consisted of remote consecutive interpreting, proximate consecutive interpreting, or ad hoc interpreters (e.g., a family member, volunteers, untrained staff). Overall, the findings indicated that patients in the RSMI group were more satisfied than patients in the other group. The greater levels of satisfaction stemmed from the patients' perception that they were treated with more respect by the physician and that their privacy was better protected. However, in both groups, the patients reported low satisfaction regarding being understood by the physician, comprehending the physicians' explanations of results or procedures, and instructions for a follow-up care plan [24].

Another study assessed the use of dual-handset phones at the bedside that allowed patients to call for interpreting services. Research indicated that the readmission rate decreased among those with direct access to interpretation compared with no direct access [99].

As noted, interpreters acting as conduits of information fall on the "neutral" end of the continuum. In this perspective, interpreters are detached and neutral individuals who communicate information back and forth. This perspective views interpreters as tools to relay information and as the de facto voices of the clients [26; 27; 136]. Interpreters adhering to this model attempt to channel words verbatim while remaining outside the interaction [100]. Interpreters acting in this capacity may indicate they feel they are treated just as voices, representing both the professional and the patient. In other words, they may feel they must be invisible in order to reinforce the privacy of the provider-patient relationship [28]. Westermeyer has called this perspective the "black box model," and it has been the predominant traditional perspective held by practitioners and even interpreter training programs [21,26]. It is implicit in the assumptions of this model that interpreters should/can all be the same, with no individuality, and that the interpretation process and experience is universal [29].

The "interpreter as conduit" perspective has been widely criticized. It is impossible for interpreters to act like computers or robots, completely detached from human dynamics. In a qualitative study of 39 providers regarding the role of emotional support among interpreters, this perspective was dismissed as being unfeasible [30]. In a qualitative study conducted to understand the perspectives of interpreters and clinicians, interpreters reported tension between the ethical responsibility for speaking out and advocating for clients and being silent because clinicians and providers expect a "conduit" model. Clinicians indicated that they wanted an interpreter who can act as a cultural broker, but they were simultaneously concerned with power shifts [83].

This method also discounts the emotionality and physicality of communication. The simple presence of an interpreter, whether it is in person, on the phone, or via a video, can be comforting, as the bond of a common language can be an emotional support. When interpretation is done in person, body language, eye contact, and/or touch can offer patients reassurance and context [30].

In the more active approach to interpretation, the interpreter is a participator or co-diagnostician, negotiating between two cultures and assisting in promoting culturally competent communication and practice [25,28]. It involves continual negotiation of the meaning of the information conveyed by the parties. Furthermore, the construction and communication of meaning are influenced by social, institutional, and interpersonal factors [136]. This type of interpretation has been referred to as an "embedded interpreter" or the "triangle model." In a qualitative study with 27 healthcare interpreters conducted to obtain an inside perspective about interpreting work, participants summarized their work as "a complex mental and social activity that went beyond linguistic transformation and included deciphering body language, establishing trust with multiple stakeholders, and brokering cultural concepts and frameworks" [31]. In another qualitative study with interpreters working in a mental health setting with migrants, interpreters discussed the difficulty being neutral and invisible. They reported being expected to discern hidden meanings, serve as a cultural broker, and express opinions about treatment [84]. As co-diagnosticians, interpreters determine which medical information is valuable, seek illness-related information outside of the provider's questions, and participate in the diagnostic process by identifying symptoms the provider may not have directly asked about [28].

Some interpreters report having altered the tone or framing of a statement to clarify intent or to advocate for the patient. Most who reported this behavior realized they were blurring the established role boundaries [101]. However, some interpreters felt that it was necessary in order to improve the relationship and communication between the patient and provider [100]. In this more active role, the interpreter's behavior is also influenced by a host of cultural variables, such as gender, class, religion, educational differences, and power/authority perceptions of the patient [25]. Interpreters in this model can help practitioners determine whether certain concepts are equivalent between languages and offer insight about the client's cultural background to inform and guide the implementation of culturally sensitive assessment and interventions [78,85]. These interpreters perceive themselves as cultural brokers [131]. Beyond the mere conduit role, some interpreters also view themselves as clarifiers, particularly when they independently sense that further explanation of the information is necessary. Other interpreters see themselves as advocates and mediators who may intervene on the patient's behalf to ensure they can access services [137]. Some will also serve to monitor and shape the affective climate and tone of the therapeutic environment [137]. Consequently, an intricate, triangular relationship develops between all three parties.

Interpreters in the approximate or ad-hoc model often are family members, although they may be any available person (e.g., friends, bilingual staff who were not hired to be interpreters) [102]. The ease of accessibility, the low (or no) cost, and the patient's familiarity and comfort with the interpreter are advantages of using this model [33]. In some cases, patients prefer to have a family member or friend serve the role of interpreter because they are viewed as more trustworthy and helpful [103]. In terms of logistics, family interpreters can provide additional insights to the patient's illness and medications, particularly if they are involved in caregiving for the patient [86,103]. Family interpreters can be particularly beneficial if family interventions (e.g., multisystemic therapy) are being used [87]. However, some may not want to disclose sensitive information to an "outsider" due to cultural norms about privacy [34]. Because family members have intimate knowledge of the dynamics of the family structure, having a family member serve as an interpreter can help the practitioner establish a good rapport and clinical relationship with the patient and the entire family [34]. They can also obtain services for the patient by exaggerating symptoms, ultimately becoming advocates [86]. In addition, if the patient is unable to remember an important point, a family member may be able to assist [35]. This is particularly advantageous in cultures that emphasize collectivism.

However, employing a patient's family member as an interpreter also has its disadvantages and unique challenges regarding boundaries and role confusion. Family members may feel embarrassed or uncomfortable in having to convey potentially intimate and private information [36]. Consequently, they may unconsciously or consciously screen out or summarize information, to the point that they alter the original content or intent [34,36,86,104]. For example, the family member may exaggerate symptoms in order to advocate obtaining a particular procedure or intervention [105]. In a study with 28 caregiving relatives, participants reported selectively interpreting information for the patient based on a personal assessment of the patient's emotional status [88]. This method of interpretation does not promote the patient's confidentiality and privacy, and the interpreter is not bound to uphold confidentiality [35,37]. Family members may decide to limit information provided to the patient due to family loyalties and/or power dynamics [38]. Because family members are so close to the patient's situation, they may include their own views and opinions in the interpretation [39]. If the family member acting as interpreter has his/her own agenda, there may be three competing agendas in the clinical process—the practitioner's, the patient's, and the family member interpreter's—which can be time-consuming and render the communication process more complex [34,105]. Family members or friends are also limited in their knowledge of medical, psychiatric, or other clinical terms compared to professional interpreters.

In a qualitative study of the complexities of culture and interpreting with Russian patients, a focus group discussed the challenges of using family members as interpreters in situations in which bad news must be delivered [40]. One participant stated:

In a 2020 study, the perspective of 69 healthcare providers from neonatal and pediatric departments in an Australian hospital were asked how and when they decide to use family members for interpreting [138]. Generally, these healthcare providers felt that using family interpreters was appropriate when interpretation of basic and non-medical information was necessary. They also felt that in emergency and time-sensitive situations in which a professional interpreter was not immediately available, family members were a viable option. Finally, they did take into consideration the family member's age, level of English proficiency, and the nature of the relationship to the patient [138].

Using a child to help interpret is strongly discouraged [104]. When a child serves as an interpreter, the boundaries of the parent-child roles are crossed, and the child carries the unnecessary burden of learning information that may not be beneficial to him/her [36,139]. Practitioners may also feel more inhibited to raise certain issues when a child is interpreting. Consider, for example, issues of domestic violence, sexuality, abuse, mortality, and other sensitive matters for which employing a child interpreter would be uncomfortable and inappropriate [33,89,139].

Although many discourage the use of children as interpreters, the reality is that practitioners often resort to using children to help with interpreting, particularly in emergency situations, and it may be too simplistic to label this practice wrong or right [139]. In some cases, parents may prefer children to interpret, and to stop them from doing so could be more harmful. A 2017 study found that children and parents often work together as a team in medical interpreting situations [140].

Using the approximate (ad hoc) interpreting model, staff persons (e.g., receptionist, in-take worker) may also step in as interpreters. The advantage to this approach is that the interpreters are familiar with the agency and setting [90]. However, one of the problems with using staff who happen to be able to speak the patient's language is that it interrupts the workflow [41,90]. Consistently eliciting interpreting assistance from staff persons who are not hired to do so can cause additional stress (because they are not professionally trained) and can trigger anger and resentment over time, affecting staff morale [41,42,43]. In a case study of a community health center that was training and utilizing staff members to do interpreting, these ad-hoc interpreters reported high levels of work pressure [44]. One of the main reasons was because interpreting was not their sole job responsibility; they were also doing their other tasks.

Overall, this model is the most convenient, particularly for agencies that are fiscally constrained. The approximate or ad-hoc model of interpreting has many limitations, however, such as the higher levels of communication errors and higher levels of dissatisfaction among patients [44]. Family members and untrained staff members are viewed as being conduits of information under this model, and it does not take into account that communication involves a host of nuanced verbal and nonverbal cues.

Another method of providing interpreting services involves using the tele-active model or video remote model. For video remote interpreting, all parties are on a video conferencing platform, allowing for visual as well as verbal communication [102]. A smartphone or laptop with camera, microphone, and Internet service is required [106]. Similar to telephone interpreting, video remote interpreting typically involves a shared network of interpreters who are dispersed geographically but who can interpret within minutes using a video monitor [107]. It offers the benefit of real-time interpretation and potentially good quality video images and audio. Of course, as with any technology, there can be technologic challenges. Video remote interpreting can be somewhat less expensive than in-person interpreting. For example, remote video interpreting can cost $1.95–$3.49 per minute and in-person interpreting can cost $45–$150 per hour [106].

The tele-active model consists of a telephone program from which the patient can select from a menu of different languages/dialect. This service might be offered in house or through a commercial organization [43]. There are also national organizations that provide interpreting services via telephone to providers at any geographic location.

With the tele-active model, there is no human interaction, and it is often used after hours, when an interpreter is not available on-site. Systems are installed to allow healthcare professionals to use one handset and patients to use another. An interpreter is then called and provides interpretation in real-time [45]. Or, software may be programmed to ask initial questions in the patient's language and then connect the provider and patient to a live interpreter [46]. Within the healthcare context, administrative and routine follow-ups are more amenable to this type of interpreting [102].

Interpreting services offered through phones are particularly beneficial in crisis or emergency situation [43]. These types of interpreting services can also offer a wider range of language options, as it is not often feasible for agencies to employ multiple interpreters who can speak a host of languages. Other data have indicated that the quality of communication in interpreting by a trained interpreter through the tele-active model is comparable to an in-person interpreter [91]. Studies indicate that although clinicians tend to prefer on-site interpreters, patients may prefer phone interpreters, feeling that this method is more confidential [85,141].

Some argue that the interpreter in the tele-active model has more difficulty establishing rapport with the patient and cannot evaluate nonverbal communication cues [90,141]. The downsides to the tele-active model are that it is expensive and the agency has to ensure that the most up-to-date equipment is used [43].

In a systematic review comparing in-person, telephone, and video interpreting, patient satisfaction was comparable among the three models [108]. However, in general, there are more interpreting inaccuracies, omissions, additions and clarity in remote interpreting done via telephone or video compared with in-person interpreting [109].

The bilingual worker model relies on a staff person who is specifically hired to work with a practitioner or who sees patients under close supervision. This model is different from the ad-hoc model in that the agency has specifically hired the staff member to act as an interpreter. In many ways, this is the ideal model, assuming the bilingual worker is professionally trained to be an interpreter. It is beneficial to have staff members specifically allocated in terms of resources and time spent on interpreting and working with practitioners [43]. The problem is that this model is often not realistically attainable, as patient populations are typically diverse, with more than one target language.

It is important to keep in mind that, even using the bilingual worker model, the designated interpreter may or may not be professionally trained; often, they are not. An agency may hire a bilingual staff person to help with interpreting but not require that the individual have any formal training. In such cases, the staff member may be more suited to interpret using the conduit model [21]. One study found that non-professionally trained bilingual workers usually ultimately serve as cultural advocates [25]. This can be risky when the interpreter is not qualified and may not feel comfortable with this level of involvement. In an online survey of 55 bilingual graduate social work students, more than half (54%) of the participants stated that they were asked to help interpret for other staff members at least once a week [47]. More than 80% of the students felt that working with patients with limited English proficiency was much more complex than working with English-speaking patients. It was assumed by staff in the agencies that the students could easily translate their language competencies into the clinical setting without formal training [47].

The volunteer interpreter pool model relies on a group of individuals who can provide interpreting services when needed. As with many other models, the volunteers are not professionally trained. Many of the limitations identified in the section regarding bilingual worker interpreters are also applicable in the model. Essentially, the lack of formal training can both hinder the process and be a liability.

In this model, a paid, formally trained staff person is employed to provide interpreting services. Studies have shown that professionally trained interpreters ultimately reduce the risk of miscommunication and decrease the likelihood of misdiagnosis [48]. It is important to remember that untrained bilingual staff do not have all of the tools and skills as a professional trained interpreter [102].

The training that professional interpreters attend includes aspects of ethics, impartiality, accuracy, and completeness [49]. These individuals are well-versed in interpreting both the overt and latent content of information without changing any meanings and without interjecting biases and opinions. Professionally trained interpreters are familiar with the different types of interpretation (i.e., word-for-word interpreting, concurrent interpreting, summary interpreting, consecutive interpreting, culture-relevant interpreting, and culture-expert interpreting), and they are cognizant of each's merits and limitations [19]. Differences between the denotation and connotation of words can be ascertained [19]. Interpretation of a message's denoted meaning requires the interpreter to have an excellent grasp of the two languages involved, while interpretation of the connotation, or underlying emotional meaning of a message, requires biculturality, or an understanding of the patient's culture and the culture of the helping professional [19]. These interpreters can construct a "third culture" involving the interaction of the practitioner and the patient [34]. Unfortunately, the main barrier in providers hiring professional interpreters is limited financial resources [90].

Generally, professionally trained interpreters make fewer errors than non-trained interpreters. One study found that the proportion of errors was lowest for trained interpreters (12%) compared with no interpreter (20%) or ad-hoc interpreters (22%) [110]. Professional interpreters with more than 100 hours of training made the fewest errors, regardless of the amount of experience. A study analyzing 11 peer-reviewed articles examined the cost-effectiveness of using professional interpreters [142]. The researchers concluded that with minimal additional costs for a professionally trained interpreter, medical care and treatment outcomes were improved.

Not surprisingly, employing untrained interpreters is the most common model used. In a study involving 348 physicians, researchers found that 75% of the physicians who worked with limited-English-proficient patients had used untrained interpreters within the last 12 months [50]. Slightly more than 20% had used a remote interpreter service via the telephone, and 42% had employed professionally trained interpreters. Of the non-professionally trained interpreters used, 86% were family members or friends [50]. The findings of this study, indicating that practitioners are overusing ad hoc interpreters, have been supported by other research. Overall, the choice of whether to employ professionally trained or ad hoc interpreters is affected by three predominant factors: availability of bilingual staff, views of the quality of interpreting, and financial cost [76].

Many agencies' and organizations' budgets do not allow for either professionally trained interpreters on staff or easy access to remote professional interpreter services. In a 2010 survey of physicians, participants cited cost as a leading barrier in the use of interpretation services [50; 143]. In a 2021 systematic review, cost was one of the major barriers identified [144]. Because of the weak enforcement of the language-access mandate, financial concerns took precedence in the decision-making process. Demographics and practice type may also be factors, as 62% of the physicians had small or solo practices. Time constraints have also been noted as a significant barrier to the use of professional interpreters, with the act referred to as a "luxury" or "interruption" [90]. In a survey study, more than 30% of participants indicated that they resorted to using an ad-hoc interpreter due to the wait time for trained interpreters [111]. Similarly, providers cited the urgency of a situation and/or a busy workload as motivators for ad-hoc interpreter use [112].

Within an ethnic group, there are often multiple dialects and regional differences in language and terminology [48]. This would require a diverse bank of interpreters, which can exacerbate the issues of cost and availability of interpreters. Consequently, providers resort to ad-hoc interpreters such as family members and available staff [143].

In general, practitioners are not accustomed to having a third party involved in patient care. Consequently, they may perceive they are being scrutinized or that their relationship with the patient is being threatened. Many are concerned about information being filtered in and/or out without their knowledge and about interpreters' competency in conveying complex medical ideas or terms [48; 145]. Undoubtedly, having a third person in the clinical environment affects the dynamics, which can impact trust and rapport building. This can make it more difficult for the practitioner to engage with the patient. These points can combine to result in a devaluation of the interpreter's contributions to the clinical encounter.

In a study of Spanish-speaking mothers seeking pediatric services, participants were assigned either to a "control" group for routine care (with ad hoc interpreting services or no interpreting) or to the intervention group for routine care and telephonic interpreting services via headsets [53]. Nearly 95% of the women in the intervention group found the telephonic interpreting services very helpful and felt that the medical encounter would be much more difficult without it. They stated they understood all the information that the physician communicated, and 96% wanted the telephone interpreting services for subsequent visits. Interestingly, only 33% of physicians in the study believed their patients would opt to use telephonic interpreting services in the future. In a 2017 study, a number of healthcare providers acknowledged that they underutilized interpreters and used heuristics to evaluate if an interpreter is really needed [113].

Confusion stemming from blurred role boundaries on the part of the practitioner and/or interpreter can affect the clinical encounter. Interpreters may experience tension between being advocates for the patient and working on behalf of their employer [19]. The interpreter is often viewed by the patient as a listener, interpreter, gatekeeper, interviewer, and advocate for change, which can cause stress and confusion for all involved parties [25].

As discussed, if an interpreter is viewed as a conduit, then the practitioner will expect that he or she will only interpret the spoken word. If this is the case, the interpreter will most likely be expected to avoid acting as an advocate or cultural broker [37]. Many interpreters report feeling as though they should be invisible; all of their experience and intelligence are expected to be omitted from their work [146]. However, because a new set of dynamics is introduced when a third party is involved in the clinical process, it is not always feasible for the interpreter to remain completely neutral. Interpreters can form powerful therapeutic connections with patients, particularly if they are from the same racial/ethnic background or the same community [19,54]. This can then lead to role exchange, whereby the interpreter becomes the counselor in the eyes of the patient and the practitioner is relegated to the role of an outsider. Because the practitioner is not familiar with the patient's language and culture, it is also possible for the practitioner to become overly dependent on the interpreter [19]. The interpreter also has to negotiate professional and ethical boundaries. If interpreters are from the patient's community, the ethical mandates of confidentiality and privacy can be compromised. Interpreters may be confused by organizational policies and may not always feel supported as they encounter blurred boundaries [147]. In one study, practitioners described being wary of interpreters providing emotional support to patients because it can cloud roles. Often, as one relationship (e.g., patient and interpreter) grows, the other relationship (e.g., patient and practitioner) becomes weaker. So, while practitioners acknowledge that the emotional support offered by interpreters can be beneficial to patients, they are simultaneously concerned about the rapport between the practitioner and patient being threatened [30]. This is further exacerbated if the practitioner and interpreter do not discuss role exchange and confusion prior to meeting with the patient [54].

This theme of power was reinforced in a 2015 study with interpreters and clinicians who worked in a multicultural setting [83]. When an interpreter and clinician had no prior working relationship and rapport, the power struggle was more obvious. In these cases, interpreters experienced the clinician's authority and their control for this authority in the session, and clinicians tended to feel threatened when interpreters took the initiative in expanding their role and tasks. Interpreters often report feeling that practitioners do not understand their work and its emotional toll [148]. If they feel caught between the patient and the practitioner, tension results [146]. This is particularly the case when the practitioner is a novice, as they may have limited experience working with interpreters [146].

The opposite can also transpire, with the patient rejecting the interpreter due to fears regarding privacy and confidentiality, particularly if the interpreter is known or is from the same community. The patient and interpreter may also be from different ethnic groups, in which case historical and political differences may result in tension [19].

The issue of accountability is a factor in role confusion. Before beginning work, it is important to resolve questions such as: Who does the interpreter work for? Who does the patient believe the interpreter works for? What is the practitioner's position on the role of the interpreter in the clinical encounter? If interpreters do not assume that they work for the agency, then they may step out of the bounds of what the agency can offer in terms of services. The patient or the provider may also assume that the interpreter will perform additional tasks that are not within their professional purview [37]. For example, if the provider requests the interpreter obtain informed consent, this could compromise patient safety, ethical validity, and professional roles [101]. These roles should be clarified before problems arise.

Cultural values and norms can also result in role confusion. Norms about gender roles, for example, are extremely powerful in some cultures [48]. If an elderly Korean male patient is not very acculturated, he may be uncomfortable and embarrassed disclosing information to a young Korean female interpreter, because in many Asian cultures, social hierarchy and etiquette are based on age and gender. Cultural taboos may also impede an interpreter from adequately optimally performing their job because a particular topic may be viewed as unacceptable or inappropriate [114]. Cultural values regarding disclosing bad news can impact roles as well. A practitioner who adheres to the Western biomedical model and the associated tenets of individualism and autonomy will feel ethically obligated to disclose bad news or a poor prognosis, but the interpreter may know that it is not culturally sensitive to do so. How and where does the interpreter draw the boundaries [55]? Again, these questions should be discussed before interacting with the patient.

There are few nationally certified programs for interpreters in the medical and mental health fields, and not all states certify or license language interpreters [9]. In part, the lack of professionally trained and qualified interpreters stems from this lack of standardized, locally and federally recognized training and certification interpreting programs, particularly in the area of mental health [56,144].

However, even if not certified, there are basic competencies that all interpreters should possess. Professionally trained interpreters should be skilled and competent in six main areas: the field in which they are interpreting, communication and interpersonal skills, content interpretation, interviewing, cultural background(s), and the expectations of the employing organization. Interpreters who limit their practice to a specific content area should have knowledge of specific technical terms and how to facilitate the flow of communication [115].

The issue of trust is at the heart of therapeutic process. There are several layers of trust when a third party is introduced in the clinical encounter—trust between the practitioner and the patient, trust between the interpreter and the patient, and trust between the practitioner and the interpreter. Few studies have examined how the presence of an interpreter affects the therapeutic alliance. In a 2016 study with 458 Spanish-speaking patients in Arkansas, there did not appear to be any differences in participants' self-reported therapeutic alliance whether there was a trained interpreter or a bilingual clinician in the session [93]. However, interviews revealed that patients preferred a bilingual clinician, feeling it was more efficient and confidential [93].

Patients are often asked to share their stories as part of any health or mental health care. If their trust has already been violated through traumatization, such as rape or victimization, then their story may have components of shame and humiliation. When an interpreter is necessary, the patient must retell the traumatic events with two different people [57]. If the patient perceives anyone in the clinical process as being cold and/or judgmental, then the trust is adversely affected and the therapeutic alliance and the healing process are also negatively impacted [57]. So, it is vital that the patient trusts his/her interpreter and feels as comfortable as possible.

There should also be trust established between the practitioner and the interpreter. The practitioner must entrust his/her voice to the interpreter with confidence that concrete information, identity, and emotions are conveyed accurately [29,151]. Four components have been identified as vital to building trust between the practitioner and interpreter. First is the interpreter's competence, as practitioners should be certain information will be relayed to and from patients accurately. Second are shared goals between the practitioner and interpreter. Trust is enhanced when everyone knows they share a common goal and are part of a team. This is reinforced when interpreters feel they are respected as professionals. The third component involves professional boundaries. When interpreters remain within their professional boundaries and these boundaries are clearly defined, the relationship is strengthened. Finally, trust is increased when practitioners and interpreters build a collaborative relationship, becoming accustomed to each other's communication style and anticipating each other's needs [29]. The patient is embedded in the triadic relationship, and when patients feel tension emanating from power differentials, they may feel fearful and powerless if trust has not been established [151].

Studies indicate that untrained interpreters have inaccuracies 23% to 52% of the time [35]. In a study conducted by Flores, even trained interpreters, in this case Spanish interpreters in a pediatric emergency department, made an average of 31 errors per clinical encounter [58]. An estimated 63% of these errors subsequently affected diagnosis and treatment. The error rates are highest when dealing with untrained interpreters compared to full-time hospital interpreters (77% vs. 53%) [59]. In a 2019 study involving 10 clinical encounters that were audiotaped with ad hoc interpreters and emergency room physicians, there were 704 ad hoc interpreter speech turns [152]. Accurate interpretation occurred in as few of 19% of these speech turns. The most frequent types of errors were answering for the patient and omitting information [152]. In a 2018 study, some providers relayed feeling that interpreters were not attentive listeners or skipped words [116]. For example, an open-ended question might be translated to a closed-ended question [114]. According to Luk, there are three common errors made during the interpreting process: omission, addition, and inaccuracy [19]. With omission of or minimizing information, content is purposely or inadvertently deleted or skipped. In some cases, this is unconscious, but in others, it is intentional in order to save time, minimize perceived embarrassment, or eliminate information that is perceived to be irrelevant or unimportant. Some interpreters omit information to help control the flow of conversation in order to keep the conversation on track or because they believe the information was not important [153]. Some interpreters will act to protect patients from shame or embarrassment they have not adhered to instructions. In a 2017 study examining transcripts of interpreted health consultations, 25% of healthcare providers' affective utterances (i.e., words that give emotional expression) and 21.5% of all instrumental utterances (i.e., explicit, directive, or factual information) were actually interpreted [117]. Another study found that about 20% of patients' emotional and informational cues were interpreted [118]. Interpreters may minimize issues such as child abuse, family violence, or sexual dysfunction because they want to "protect" the patient, but this can result in delays in diagnosis, missed services, and improper care [60].

The opposite of this error is adding or exaggerating information. In these cases, the interpreter, again either unconsciously or purposely, adds or expands on information based on their value systems, experiences, and/or worldviews. This can inject bias into the diagnosis and treatment planning processes.

Problematic condensation and substitution are also possible and can lead to problems with diagnosis. Condensation is basically defined as paraphrasing and simplifying patients' lengthy and/or complicated responses. For example, in mental health, failing to convey a patients' disordered thought process can result in missed or delayed diagnosis [94].

The last type of error stems from inaccurate translation of words. For example, certain terms may have multiple meanings. In Chinese, the word for "noise" and "voices" is the same. A patient might answer "yes" to a question about hearing voices, but the question might have actually been interpreted as about hearing noises. This becomes even more difficult when regional and dialect differences are present, as a term may have a completely different meaning in another dialect or region [54]. The complexities of language will affect the accurate translation of terms.

Interjecting a third person into a counseling dyad introduces a new set of dynamics. Even suggesting use of an interpreter can have significant meaning for the patient. For example, a patient who feels extremely vulnerable may feel rejected by the practitioner, which can negatively affect rapport and the therapeutic alliance [119]. Practitioners should also be aware of transference issues that may emerge between the interpreter and the patient. For example, a patient may project feelings of insecurity and inadequacy to the interpreter, or a patient and interpreter may direct transference reactions toward the practitioner, further distancing themselves [120,121]. Some even argue that the terms transference and countertransference as used in therapy have different meanings in a triadic encounter. Instead, numerous interactions are occurring and should be addressed [119].

Because some interpreters work with patients who have experienced trauma, victimization, and/or abuse, it is possible that interpreters may experience secondary traumatization, secondary victimization, vicarious traumatization, or compassion fatigue. These terms all refer to the psychologic trauma experienced by those in close contact with trauma victims [61]. Secondary traumatic stress is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" [61]. Secondary trauma can affect practitioners' beliefs about the world, others, and self, including concepts of safety, trust, control, and intimacy [62]. It has been argued that trauma caused by another person (e.g., abuse) may be more difficult for practitioners to deal with because it brings up the issue of human evilness. This may affect existing beliefs and ideals more than trauma caused by natural events (e.g., natural disasters) [62]. Seven psychologic areas are negatively affected by trauma or secondary trauma [63]:

Much empirical work has been conducted regarding secondary or vicarious trauma in health and mental health professionals but less is available on interpreters. Interpreters listen to emotionally charged stories and must repeat this information back to the practitioner, so it is inevitable that stories of trauma, loss, victimization, and separation will affect interpreters [57,131]. At times, interpreters can overidentify with patients' stories (particularly those who share cultural or ethnic histories) and become overwhelmed with the pain and distress [64,114]. In a 2019 study, interpreters who worked with patients with emotionally charged stories frequently reported feeling mentally exhausted [122]. In a 2021 systematic review, interpreters reported negative emotions related to their work, including distress, hyperarousal, anxiety, mental exhaustion, and sadness [148]. Interpreters' use of first person in the interpreting process can add to the risk of vicarious traumatization. For example, an interpreter who interprets "I have been sexually abused" or "I have been raped" may feel and experience the devastation, sense of helplessness, and horror [95,120]. It is important to remember that interpreters are not necessarily trained to recognize or address vicarious traumatization and countertransference issues [131].

Interpreters should debrief with the practitioner after every session to resolve any issues that came up [85]. Other strategies for avoiding vicarious trauma and burnout include distracting oneself with other tasks after work, focusing on the importance of the work, and seeking and obtaining emotional support from family and friends [57].

In a qualitative study with eight interpreters regarding vicarious traumatization, interpreters discussed how the process of interpreting can impede one's ability to ensure emotional distance from a patient's story [65]. When translating patients' emotionally distressing and traumatic stories verbatim, there is increased involvement and identification. To cope with the intense emotions related to their work, the interpreters noted the importance of having a good social support network, peer supervision, opportunities to debrief, and other personal coping methods like exercising, meditating, watching movies, using avoidance strategies, and general life balance [65]. One interpreter who worked with rape victims described her personal strategy of coping: "If I have something that really bothers me, I write it on a piece of paper after the session and then throw it away before I go home" [66]. Organizational infrastructure that promotes incorporating supervision as a part of the workflow is crucial. Systems and administrators should consider how interpreters' value is conveyed. For example, consider if interpreters are reimbursed for travel time or overtime [122]. Ultimately, vicarious traumatization can lead to existential growth and resilience [122].

Although it may seem basic, practitioners should not automatically assume a patient wants an interpreter. Some may decline the use of an interpreter because they feel that it is important for them to converse in English, or they may perceive having an interpreter as a sign that their English is not good enough, which can be embarrassing [21]. Keep in mind that the patient can also change his/her mind during the clinical encounter. Therefore, practitioners should always be mindful of signs that indicate discomfort or difficulties conversing in English and offer services when appropriate.

It is very important that interpreters are treated as part of the healthcare team. Unfortunately, in many cases tension between providers and interpreters results in a misalignment and miscommunication of professional roles, goals, working styles, and interpersonal dynamics [137]. Providers fear losing control of the therapeutic alliance between themselves and patients. Simultaneously, interpreters feel that providers hold institutional control over their jobs. These tensions in the power dynamics have resulted in a mistrust and misalignment [137].

It is highly recommended for the practitioner and interpreter to meet prior to the clinical encounter to discuss the case (e.g., background of the patient, presenting problem), objectives of the meeting, how interpretation will affect the clinical process, and the logistics of working together [37,83,131]. Roles and tasks should be clarified [123]. In general, the patient's role is to seek and accept help; interpreters should not assume this role even if there is a common shared experience. The interpreter's role is to provide his/her interpreting expertise and to help empower the client. Finally, the provider's role is to provide a framework for the session and to facilitate it in such a manner that recognizes the difference between the therapeutic and interpreter roles. This is particularly important when there are sensitive or difficult topics that need to be addressed (e.g., bad news) to avoid either party being caught by surprise [67]. When working with an interpreter, it is important for practitioners to discuss whether they expect strict interpreting or whether the interpreter can take on other roles, like being a cultural broker [67]. The practitioner and interpreter should discuss and agree on communication logistics (including type of communication style, the mode of interpreting to be used, and frequency of communication) before the start of the therapeutic encounter [95; 131; 149].

It is also important to meet with the interpreter after the session to debrief [9]. The practitioner may simply ask the interpreter his/her thoughts and observations about the session and the patient. This is a good time for the practitioner and interpreter to discuss any cultural issues that may have affected the clinical process [9]. Furthermore, the practitioner should check in with the interpreter about how he/she is feeling and responding to emotionally difficult topics that may have been raised [131,149]. When possible, the agency and practitioner should provide on-going support for interpreters after working with difficult patients or patients who are grappling with emotionally difficult issues [37].

Consider seating arrangements prior to the session. Seating arrangements can implicitly convey power and position between the practitioner and interpreter and affect the ability to establish rapport [68]. Should the interpreter be seated a bit off to the side? Or should the patient and interpreter sit side-by-side facing the practitioner? The practitioner and the interpreter should determine which arrangement is most conducive for the clinical encounter; there are no definitive rules. If the interpreter sits beside but slightly behind the patient, he or she may not catch all of the nonverbal cues. However, this type of arrangement conveys the message that the practitioner-patient relationship is the center of focus [9,124]. A triangular seating arrangement, whereby every party can maintain eye contact, may be necessary and is most recommended [124]. With this approach, the practitioner and patient can look at each other directly and the interpreter is then perceived as being objective and neutral [39,68]. In a 2015 study, the interpreters conveyed the importance of the sitting position in order to promote eye contact to facilitate trust with the patient and the practitioner [84]. Triangular seating implies that the patient is the focal point and conveys equality of all parties [9,125].

Before beginning a session, the interpreter must decide whether to use first or third person. Some argue for the use of first person, because this allows for more accurate (literal) translation of words and emotions being conveyed [37]. However, others have differed. Using first person may be distressing for some patients if it is too personal [57]. In some languages, verb conjugation depends on the gender of the subject of the sentence, which can be confused in interpretation [78]. Consequently, it is crucial that the practitioner and interpreter discuss the merits and limitations of using first or third person prior to meeting with the patient.

The practitioner should talk directly to the patient (e.g., "Mrs. L, how are you feeling today?") rather than asking the interpreter to inquire with the patient (e.g., "Please ask Mrs. L how she feels.") [9,39,154]. By speaking through the interpreter rather than to the patient, the practitioner may jeopardize establishing rapport and trust [19]. The practitioner should continually check whether the patient comprehends the information being conveyed [39]. Furthermore, the practitioner should be attentive and respond to non-verbal cues, pause frequently, and be in control of the clinical encounter [39]. Again, it is vital that the practitioner and interpreter meet prior to the session to review how reflections or affirmations should be handled [126].

When possible, the gender of the patient and the interpreter should be matched. There are often cultural norms regarding gender roles, and some patients will feel uncomfortable disclosing embarrassing or sensitive information to an interpreter of the opposite sex [41]. It is also important to take into account any spiritual, sociopolitical, and regional nuances between the ethnicity of the patient and the interpreter [85]. Careful consideration to whether it is prudent to have an interpreter from the same community as the patient is necessary. A shared community experience could promote rapport, or it could make the patient feel that his/her confidentiality and privacy are compromised. However, it is important not to assume that a same or similar racial/ethnic background equates to shared cultural experiences [85].

When possible, practitioners should attempt to use the same interpreter with the same patient. The connections between interpreters and patients are strong, particularly if the relationship is given time to develop. If a new interpreter is used with each clinical contact, this discounts the importance of having the same trained interpreter develop rapport and a safe therapeutic environment for the patient [56].

Language is complex; however, when cultural differences are added, it can be even more complicated, with layers of nuances. As a result, practitioners should avoid using proverbs or colloquialisms that are confusing or nonsensical when translated literally [37,102,154]. Practitioners should also realize that not all concepts common in a health or mental health setting can be easily translated [95]. Humor and jokes should be carefully considered, as they can be easily misunderstood in a different cultural context [67,102]. Finally, technical jargon is difficult to interpret and should be avoided whenever possible.

Practitioner should avoid asking compound questions that may require more than one answer. In addition, it is important to wait for a response before proceeding to the next question [96]. Speaking in long sentences and digressing can result in a confusing session [126]. Skilled interpreters may be able to convey to the practitioner that slowing or pausing is necessary. As much as practitioners can, they should attempt to unpack the information and speak in a simplified manner [154].

Hand gestures and nonverbal communication are culturally bound. A hand gesture, for example, may be benign in one culture but interpreted as insulting or sexually suggestive in another [69]. A smile can also have different cultural connotations. In Chinese culture, a smile does not always mean happiness, but can convey disagreement or even lack of understanding [127]. Therefore, practitioners should be careful with their physical expressiveness. The practitioner should focus on maintaining eye contact with the patient rather than the interpreter [95].

Practitioners should keep attuned to any incongruence. For example, if the patient provides a lengthy response but the interpreter conveys a brief response, this may be an indication that the interpreter is condensing the information [96]. Alternatively, if the patient's body language appears to be dissonant with the message being communicated back, it is best to pause and check in with the patient [96].

It is important to recognize that every subpopulation has different needs, and interpreters working with children require a different set of competencies. Skills necessary for interpreters working with children and their families include [60]:

Practitioners should keep in mind that using an interpreter does not mean that they may abandon their responsibility of cultural competence. The practitioner cannot rely solely on the interpreter to be the cultural broker and expert [19]. Because cultural competence is an ongoing process, practitioners should seek out education on cultural and racial issues in health and mental health care. If a clinician's patient population is predominantly one culture/ethnicity, this should be a focus of additional research.

Interpreters are bound to a code of professional conduct and ethical principles as well. Similar to the codes of ethics that practitioners operate under, interpreters have a responsibility to maintain confidentiality, accuracy (in order to promote beneficence), and impartiality and objectivity. They are also required to promote the patient's welfare and dignity [74]. A sense of self-awareness is extremely crucial when it comes to professional conduct and ethics. Interpreters should be continually cognizant of their role and the limitations of the process of interpreting [67]. The National Council on Interpreting in Health Care Code of Ethics may be accessed online at https://www.ncihc.org/ethics-and-standards-of-practice.