Is three a crowd or not? Working with Interpreters in CAT

Emilion, J., 2011. Is three a crowd or not? Working with Interpreters in CAT. Reformulation, Summer, p.9.


Introduction

Working as a CAT therapist and understanding the concept of reciprocal roles led me to understand further how the presence of the interpreter influences the therapeutic process and the therapeutic alliance.

The idea of working with an interpreter and providing therapy through interpreters still raises anxiety and questions in many of us. CAT offers a new perspective particularly in understanding the unconscious process within this triad relationship. It also offers us the language to discuss these unconscious processes in a non-blaming way with the interpreter, thereby strengthening the containing function of therapy and leading to early identification of possible therapeutic ruptures that are likely to occur in this matrix. I am hoping that this article enables us to look at the complexity of working with the interpreter through the lens of CAT.

I am a trained interpreter and a bi-lingual therapist who has worked extensively with interpreters in therapeutic situations for the last twenty years. I am convinced that using interpreters in therapy is much more than just acquiring the translation of words and language. It requires a skilful therapist who is extra vigilant and is able to weave in and out of the complex mosaic of language, culture, gender, history, inter-subjective experiences, multiple dialogues and role positions.

Whilst in training as a CAT psychotherapist, I researched and interviewed several interpreters, who are not trained clinicians, on their experiences of working with psychological therapists. Several key themes that affect the therapeutic process and relationship emerged from this research. I will be sharing some of these themes in the article.

Clinical Case Discussion:

Ana was a Turkish client with whom I worked with in Primary Care through an interpreter. She has kindly given her permission for me to write about our work.

This was a brief 8 session CAT in Primary Care with a very brief verbal reformulation. The focus was on Target Problems and Procedures and reciprocal roles.

Brief history and presenting problem:

Ana was referred to me for depression by her GP. She had recently been divorced and was struggling to cope with the loss of her marriage after 10 years together. Her husband had left her 6 months ago for another woman with whom he had been having a relationship for 18 months. He told her that he was divorcing her because she was overweight and unable to have a child. He became violent and abusive towards her, and she believed this led to her losing control and comfort eating. She was now size 30. Ana did not speak any English and had not worked since coming to the UK 4 years ago.

Early stages:

Ana came to the first session but the interpreter went to the wrong GP surgery and hence I had to see her without the interpreter. Ana spoke very little English but somehow managed to tell me her story and I was able to get a sense of her difficulties. In the session she was mostly calm with occasional tears. The following session we worked through an interpreter. She was extremely upset and was crying quite loudly when describing the loss in Turkish. Expressing her painful experience in her own language to another native speaker had a different meaning for Ana. It put her in touch with feelings of anger, shame and sadness, which she was able to express and articulate in Turkish. This session was ‘lively’ compared to the previous one. This reaffirmed my belief that therapy needs to be provided in one’s first language, highlighting the connection between affect, experience and language.

In the sessions that followed Ana told us how she had never had much nurturing or care from her own parents when growing up and she had hoped that she would have been looked after in her marriage. I sensed her as a hungry baby who was never satisfied. At the end of this session I gave her the psychotherapy file that was in English and asked her to complete it for the next session. The interpreter volunteered to stay behind and spent an hour helping her with the file.

It was interesting to note my feelings in relation to Ana. I could almost understand and even accept on a strange level why her husband had abandoned her. Recognising my responses in relation to her neediness I was conscious of the roles of ‘withholding’ and ‘rejecting’ being evoked in me.

Ana informed me that the Psychotherapy file, though in English, did help her to recognise some of her procedures. Ana was not fluent in written Turkish, which made things even more complex. She had just met the interpreter and I was not clear whether she was able to trust or be open with the interpreter when completing the file. I did not trust this process entirely as I was not present when the file was completed. Trust and control were some of the issues I was struggling to manage as a therapist initially.

Following this session there was a cancellation. Inevitably the interpreter had to speak to Ana to rebook. Ana was not well physically but had also felt very upset following her second session but she requested us to rebook. Again I was conscious that the interpreter and Ana were speaking on the phone and judging by the tone of the interpreter’s voice I thought that she was being firm with Ana for cancelling at the last minute. Discussing this with the interpreter she told me that she was not being firm but told Ana to give us enough notice if she was to cancel again. She also told me that she thought that Ana was not too keen on therapy and that I had to rethink about offering her more sessions. I was more sympathetic, feeling that Ana had cancelled as she had felt the session was overwhelming. It was interesting to note the change in our roles. I was now more ‘accepting’ and the interpreter had taken on my former role of ‘withholding’.

Mid stages:

As this was brief therapy (6-8) we did not do a written reformulation but discussed the procedures linking them to Ana’s history as a brief verbal reformulation. The interpreter translated this for us. Ana acknowledged what I had said but did not appear convinced. She said that she was unclear as to how early life experiences affected her way of thinking, behaving and feeling in the present.
As we continued our work we mapped the Target Problem Procedures. They were very simple partly because of Ana’s difficulties with written Turkish. The target problem procedure was mapped as different stages:

Feeling hungry and needy → longing for love → giving up hope of being loved → stuff myself with food.

2) Feeling deprived and unprotected as child → don’t know how to protect myself → trusting anyone → risk being abused → put up with abuse → any attention is better than no attention.

The reciprocal roles were simply mapped just to help Ana recognise them in relation to self and others.

Depriving, neglectful ↔ empty and hungry

Absent, unavailable ↔ unprotected and frightened child

Abusive, attacking ↔ worthless, helpless, furious and rubbished

Ana came back to say that she really recognised the second TPP and how she does this with everyone she meets. I was really pleased that Ana was able to recognise something, as she did not come across as really being able to reflect or think. In the de-briefing the interpreter was however quite critical of the session. She said that just recognising was not really going to change anything in the client’s behavior and she herself personally recognises things in her life but has not been able to change them. She was quite dismissive of the session and its benefits.

Final stages:

In the sessions that followed Ana was set some simple tasks such as visiting the local Turkish organisation. Ana however came back after every session to say that though meetings with us were helpful she felt unable to try out any of the set tasks. At session 5 Ana talked about the issue of ‘trust and need’ and how her friends have often abused her trust as they have recognised her as needy. This discussion along with identifying the TPP had enabled Ana to recognise some of her procedures. As a result in the following session she informed us that she had decided to attend some of her other hospital appointments without relying on her friend. This I saw as the first step to her independence and self-reliance. She even talked about how language acts as a barrier to her accessing services, leaving her isolated, particularly living in the UK where values and beliefs were not so traditional. We soon started exploring her feelings around the ending of the therapy. Ana appeared neither happy nor unhappy but just nodded acceptingly. In session 7 she came back really furious. She had come up in severe rashes and was furious with me and the doctors for not really listening to her and making her feel better. We explored if her anger was linked to us finishing the therapy but Ana could not recognise it and hence dismissed it. She did not want to offend me but she strongly felt that she did not want to attend her last session. She was however given details of the other organisations she could get help from and her file was closed. I thought this was in some respects positive, as she was finally being able to express anger, but in doing so she deprived herself of the final session, and it was questionable whether she understood her own rage when she could not have everything she wanted.

Interpreter’s experience of using the file with the client:

The interpreter told me at the de-briefing that this was the most difficult of the forms she had had to translate in a therapy session for a client. Some of the words such as ‘being a martyr’ had a completely different meaning in the Turkish religion and culture. Some words such as ‘traps, zombie and depression’ were really difficult to translate, as there were no similar words in Turkish and hence these had to be broken down and explained through symptoms. I was told that the client was much calmer and quite thoughtful when completing the file with the interpreter. After completing the file for some reason the interpreter felt that she had to look after the file for the client until the next session and offered to keep it with her. The client was happy with this and left the surgery without the file. Here the interpreter had taken on the role of mothering this client right from the start, which perhaps was an unconscious response to the client’s needs.

Therapist’s Experience:

Working with this client I realised that the interpreter was experienced and had worked with other clinicians in similar settings. The issues around seating arrangements, confidentiality and de-briefing were explicitly discussed prior to starting therapy. I felt supported by the interpreter as it felt as if we were coming together as a couple to help this client at her time of distress. I did struggle with her strong views particularly after the session where the client had recognised her TPP. Reflecting on the ‘shadow aspect’, that is the interpreter not being able to express feelings of envy that were evoked in her because she believed that she had to be professional at all times and the super-addressee positions, helped me not to get drawn into this process.

In session seven when the client came in angry, the interpreter appeared genuinely shaken up. She informed me later that the client’s rashes and scratching in the session were almost beginning to make her feel sick. On reflecting on the reasons as to why this therapy ended in session seven instead of eight I was also aware of how I had reacted to the interpreters feelings of fear and became quite pacifying in the session rather than exploring and naming the client’s anger in relation to our limited sessions.

Discussions/Reflections:

In the work with Ana it was as if the therapist holds one part of the therapeutic process i.e. all my skills as the clinician, and the interpreter holds the other aspects of therapy, that is information about the cultural norms, and language, which I needed for therapy to begin. Translations take longer at times and it is easy to feel disconnected to the process. Therapists can manage this disconnection by constantly making eye contact with the client and addressing the client by first name when speaking to her or asking her a question.

In Ana’s case the interpreter also offered me some understanding of the meaning of feeling depressed in the Turkish culture and explained how sometimes it was understood as being ‘mad’. The client herself was able to acknowledge this and informed us that her cancellations were linked to feelings of overwhelming pain and fear of being labelled as ‘mad’ for seeing a therapist. Here the interpreter acted as a ‘cultural broker’ as defined by Raval (2002).

Working through an interpreter is both positive and negative. The negative experience is often due to the lack of trust and relationship between the therapist and the interpreter. It is evident from my research that what occurs between the therapist and the interpreter is at times a parallel process to what the client is discussing in therapy.

At times the triadic relationship simply does not work. This is because the client is unable to relate to the interpreter. Gender, ethnicity and political backgrounds are identified in some cases as the reasons as to why this occurs.

The triad relationship between the interpreter and the therapist becomes strengthened as trust develops. De-briefing after every session helps this process. Interpreters are able to express any feelings or thoughts they have about the session. It is noticeable that almost in every de-briefing session interpreters discuss some topics that were similar to what the client had discussed in the session. For example, in one session a client talked about the death of her father and his ill health. In the de- briefing the interpreter talked about the death of a client with whom she worked and how this death had affected the client’s family. It was as if the feelings evoked in the interpreter in the session about the loss of her previous client were projected out during the debriefing, in order for her to be able to manage them. However, this particular interpreter informed me several times how she has never had any experiences similar to that of this client. Though this may have been true it also indicated to me that the interpreter perhaps wanted to distance herself from the experience and the feelings the client was holding and to deny any identification. These feelings are sometimes owned and linked to personal experiences or sometimes projected out as someone else’s experiences. When interpreter’s feelings are becoming involved I have to be very clear and just offer a containing space and recognise the fact that I am not their therapist.

The discussions during de-briefing can be interpreted and understood as the interpreter taking on a different voice to me in relation to the client and the session. It was as if the hidden internalised voices of the client are sometimes heard through the interpreter, as a response to the client’s speech. Understanding this in dialogic terms it is clear that within the therapeutic process the interpreter is always present though some times silent, but always taking on a role unconsciously and at times reciprocating or taking on the voice of ‘super-addressee’. As a therapist, holding this in mind enables me to keep my role as therapist with the client clear, and not be drawn into challenging the views of the interpreter shared openly with me in the de-briefing.

Power Dynamics and Reciprocation

Powerful feelings were evoked in the interpreters during their work with the clients. All the participants described feelings of helplessness or at times feeling in control. The impact of this on the therapist will be discussed later.

Understanding this subjective experience in CAT terms, the roles of powerfully controlling to powerless or feeling out of control operated between therapists and interpreters, and at times between clients and therapists. All interpreters talked about being blindly led in the sessions, as they are often unaware of the therapeutic process. What was fascinating was that when being pushed into the “powerless” role, they often felt vulnerable and helpless but only seemed to feel furious when they wanted to move out of this role into the powerfully controlling positions. However, they felt that their professional role as an interpreter did not allow this to be expressed or explored and to change their role positions.

For example, one interpreter talked about how she felt that the therapist did not understand the cultural issues and as a result decided to intervene during the session by giving information directly to the client. This action pushed the therapist into a ‘controlled role’ leaving her /him feeling powerless and the interpreter in the controlling and rescuing position.

From my own experience of working with interpreters I have noticed that at times the interpreters do ask the clients certain information that is not asked by the therapist. Though it’s easy to become critical of such queries as an intrusion into the therapeutic process, one has to keep in mind that powerful feelings evoked in the interpreters invite them into certain roles which they often end up reciprocating.

There were many reasons for such ‘joining in’. Discussions with interpreters highlighted that though powerful feelings were evoked in them, not all reciprocated or joined in the sessions. It was only when the interpreters had a similar experiences or roles to that of the client that they got hooked into the process to reciprocate. This was evident from the de-briefing discussions. This could be understood as a reciprocal role enactment or projective identification where the interpreter wanting to make connections/ identification with the client reciprocates in an attempt to ease the client’s feelings and perhaps manage their own. This is because the content within the sessions often put them in touch with their own experiences and feelings.

What CAT offers is an understanding of this process in a non-blaming way as reciprocal role enactments for both the therapist and the interpreters. Hence I prefer to use the term ‘joining in’ therapy rather than ‘acting in’ therapy, as it is less blaming and more collaborative and the power balance is shared with all concerned. This is quite different to the analytic perspective, where only the therapist is assumed to have an understanding of the unconscious acting out. This ‘joining in’ process can be explored using the reciprocal roles in order to strengthen the working alliance not only between the client and the therapist but also between the interpreter and the therapist.

CAT offers the luxury of translating the inter- subjective unconscious process into conscious behaviors and actions through the concept of reciprocal roles. The enactments make the idea of working with interpreters containing and less threatening to the professionals involved.

Conclusion

It is clear from the above points that feelings are evoked in the interpreters when working within a therapy context, which affect the therapeutic relationship and the processes. Interpreters, like therapists, experience counter-transferential reactions. They, however, do not have the skills to understand or manage the powerful feelings evoked in them. Sometimes these feelings are managed by reciprocating to the client’s roles. Having an understanding of the concept of reciprocity will enable the therapist to feel empowered to work with interpreters and manage the therapeutic process and the various alliances in a triadic relationship effectively.

The educational alliance allows the interpreter to take on the role of a co-worker (Patel 2003) with the therapist and to work in partnership to alleviate distress, and to develop an observing eye and internalise positive reciprocal roles. Having an interpreter who comes from the same community and speaks the language can at times be experienced as a positive role model, especially when a good alliance between the three people is established and the client begins to experience the therapist and the interpreter as nurturing and supportive. The therapist however needs to be extra vigilant about the roles that could be set up along with feelings of envy, guilt and shame experienced by any of the parties in the triadic relationship, and alert to the risk of boundary violations if the interpreter and client are from the same community.

The concept of reciprocal roles allows all three parties to be able to have a dialogue about the process of therapy in an open and non-blaming manner. The relational aspect of CAT also allows the possibility of having a 3-way conversation about the roles being enacted in the session.
The power the therapist holds with knowledge of the unconscious process is shared with the client and this is unique to CAT. The client with this knowledge learns to self observe and recognise the processes as they occur in the therapy and outside, feeling more in control and empowered. This concept can also be used in discussion with the interpreter especially when the interpreter has reciprocated or feels that the client needs to be rescued, or colludes with the client or the therapist, enabling the interpreter to understand and become aware of the ‘joining in process’ occurring within therapy.

Mudarkiri (2003) describes a similar model where the interpreter, clinician and the client are all empowered to play an active and equal role in the therapeutic encounter. He goes on to explain that it is dangerous to hold the view that the interpreter just has a mechanical role in the work. He describes the interpreter as an active participant in therapy whereby they bring personhood, life experience and work experience to the therapy encounter. “Embracing the personal qualities of the interpreter into the work can have an enhancing effect rather than becoming a problem to overcome” He also adds however, “To utilise the interpreter effectively requires training on the part of the clinician.”

As with most dyadic relationships in therapy, the therapist often gets ‘hooked’ into the reciprocal role or becomes paralysed by projective identification especially when similar roles or procedures are present within the therapist’s psyche or mental processes. Hence there is strong emphasis on personal therapy throughout CAT training to develop an observing eye. Self-awareness and self-reflexivity are essential for clinicians to be able to manage the therapeutic process effectively. This understanding comes from having worked as a therapist for many years. It may be that the interpreters who respond and reciprocate to the client’s roles /procedures have experiences themselves which are similar to those of the particular client, as it is notable that not all interpreters reciprocate during a consultation.

Powerful feelings are evoked in interpreters during translation and if they are not explored and understood they can influence the process of therapy and therapeutic relationship.

In summary, working through an interpreter works well if one is able to have a dialogue both in relation to self and with the interpreter, constantly exploring the explicit and implicit meanings in what is being discussed. At the same time it is crucial to reflect on the feelings evoked in the therapist and the interpreters and to conceptualise them in the form of reciprocal roles and dialogic voices in order for the therapy not to rupture.

Giving voice to the silenced words and feelings of the client, be it through an interpreter, can only be empowering to the client. Similarly, giving voice to the feelings evoked in the interpreter can only be supportive and strengthen this complex triadic process. I conclude with a Czech proverb,

“Learn a new language and get a new soul” (Burck, 1997)

Author

I am employed by South London and Maudsley NHS Foundation Trust as Head of Counselling and Diversity Lead IAPT Lewisham, Primary Care Psychological Therapies Service. In my role as Diversity lead I train the psychologists and counsellors within SLAM on how to work with Interpreters. It is a trust wide programme. I also train the interpreters on how to work with psychological therapists.
I am also employed by Custom House Teaching Pactice in East London as Practice counsellor and supervisor. I am a CAT Psychotherapist and supervisor.

References

Burck,C.(1997). “Language and Narrative: Learning from bilingualism”, in Multiple Voices, (Eds) Papadopoulos,R, Byng-Hall,J. Duckworth, p 64.

Patel, N. (2003). “Speaking with the silent: addressing issues of disempowerment when working with refugee people”, Chapter 14, Working with Interpreters in Mental Health, Bruner-Routledge, England: p 228.

Raval, H. (2003), “An overview of the issues in the work with interpreters”, Chapter 1, Bruner-Routledge, England: p 9.

Mudarikiri, M. (2003). “Working with Interpreters in adult mental health”, Chapter 12, Working with Interpreters in Mental Health, Bruner-Routledge, England: p 190.

Full Reference

Emilion, J., 2011. Is three a crowd or not? Working with Interpreters in CAT. Reformulation, Summer, p.9.

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