Emotional and Psychological Impact of Interpreting for Clients with Traumatic Histories on interpreters: a review of qualitative articles

Interpreters play an important role in the health and social care system. The aim of this review is to synthesize available qualitative studies exploring experiences of interpreters when working with individuals and groups who have experienced domestic violence and abuse or other traumatic situations. A comprehensive literature search of databases helped identify 18 studies including 3 quantitative and 15 qualitative studies published between 2003-2017. The studies were conducted in various countries and data analysis resulted in the development of 5 themes which included: (cid:494)role and impact of interpreter(cid:495)(cid:482) (cid:494)psych ological and emotional impact of interpreting(cid:495)(cid:482) (cid:494)workplace challenges faced by interpreters(cid:495)(cid:482) (cid:494)coping strategies used by interpreters(cid:495)(cid:482) and (cid:494)interpreters(cid:495) support needs(cid:495)(cid:484) Themes are discussed in relation to the available literature and gaps in the literature are identified.


Introduction
Language plays a central role in making people under stand and consequently meet each other s needs When it comes to provision of health and social care services practitioners and services users need to have appropri ate communication channels however this requires practitioners and the service user to speak the same language This is not always possible in the present age where migration and immigration within and out side countries is historically high and where people speak varied languages A Google search reveals that there are presently living languages in the world and the number of spoken languages exceeds in some countries The population in many countries is becoming increasingly diverse and there is no single country with only one spoken language While a coun try may have only one official language several lan guages may be spoken The United Kingdom UK census of suggests the use of more than languages in England and Wales While English is the official language of the UK the other top ten languages include Polish Panjabi Urdu Bengali with Sylheti and Chatgaya Gujarati Arabic French Chinese Portuguese and Spanish The results of the census also revealed that million people aged years in England and Wales spoke a main language other than English Among this group approximately indicated an inability or difficulty in speaking Eng lish Such individuals or groups are identified as those who have limited English proficiency LEP which means that they are not able to speak read write or understand the English language at a level that per mits them to interact effectively with health care pro viders p )ndividuals who are unable to speak the predominant language of a country require health and social care services and therefore they need either a practitioner who can speak the same language or a person who could help bridge this gap and help them communicate for example an interpreter )nterpreters are individuals who intervene in such situations and help practitioners and service users to understand each other and communicate effectively The issue of lan guage barriers and use of interpreters is not limited to the UK or English speaking countries )ncreasing immi gration and the use of multiple languages in most coun tries makes the use of interpreters an international con cern

Interpreter and the need for an interpreter
The word interpreter is derived from the Latin inter pres which means expounder or person explaining what is obscure Some scholars believe that the second part of the word is derived from partes or pretium meaning price which fits the meaning of a middle man intermediary or commercial go between but others believe the word is from the Sanskrit language )nterpretation is identified as a translational activity but one that is done immediately on the spot )nterpre tation is not a new concept and has existed for centuries as humans have travelled and needed to communicate with individuals who may not understand their lan guage )nterpretation is different from translation as it means interpreting the spoken words of someone and presenting it in another language whereas translation often refers to translation of written documents from one language to another The need for interpretation services in the UK was first identified in the s and s when a series of seri ous court cases were conducted using untrained inter preters with limited proficiency in the language they were interpreting For example the case of )qbal Begum a woman from Pakistan who was tried for the murder of her husband and was sentenced to life im prisonment Mrs Begum suffered years of domestic vi olence and abuse DVA from her husband Following sentencing four years into her imprisonment serious problems with the interpretation provided for Mrs Begum during the trial process were identified Specifi cally the interpreter provided was not trained and alt hough he spoke a similar language to Mrs Begum he did not speak the same dialect Consequently he failed to provide clear instructions to Mrs Begum who did not understand the difference between the charges of a murder and manslaughter and could not clarify her po sition (er case review resulted in nullifying the charges and she was subsequently released in though she committed suicide a few years later Another high profile case was that of Victoria Climbie a year old girl from the )vory Coast who came to the UK in with her aunt and legal guardian (er Aunt be gan a relationship with Carl Manning and moved to Manning s home in London in July Manning abused Victoria resulting in her visit to hospitals for in juries Victoria died soon and her post mortem revealed a total of injuries and scars The case review high lighted a failure of health and social care and police ser vices to provide Victoria and her family with appropri ate professional interpreters on at least two occasions before her death A family member her aunt was used as an interpreter She herself struggled to communicate in English and was later found jointly responsible for Victoria s death An interpreter ensures that a message is understood by a service user and a service provider Evidence suggests that services use informal interpreters family and friends of service users and formal or professional in terpreters although it is always better to use profes sional interpreters to avoid bias provide appropriate in terpretation and minimise the risk of misunderstand ing An interpreter may use three processes simulta neous interpretations where the speaker and the inter preter speak at the same time and the interpreter has less time to work consecutive interpretation where the speaker says something and pauses for the interpreter to interpret and whispered interpretation where the speaker whispers the message to the interpreter who then interprets it and shares with the audience )n the health and social care setting consecutive interpreta tion is often used )nterpretation can be done in various ways including face to face telephone and video interpretation Face to face interpreting requires the person and the inter preter to be available at the same place whereas for telephone and video interpreting the interpreter does not need to be physically present in the same place as the service user )n the UK s health care system the use of telephone interpreting is common While interpretation is clearly an important task it has not really developed as a profession therefore the qualifications and preparation of interpreters vary )n the UK there is a voluntary National Register of Public Service )nterpreters NRPS) )t is a public register of professional qualified and accountable interpreters ac cessible online and free of charge According to the NRPS) by the end of there were registered interpreters who could offer interpretation for lan guages of which are registered as Rare Language status in the UK )nterpreters appear in a wide variety of settings and are unlikely to be employed by a single organisation They may be employed by public sector organisations privately funded self employed and or registered with a telephone interpreting agency As most public service interpreters work across settings mostly on a freelance basis there appears to be a lack of professional regulation for interpreters The NRPS) is a voluntary register and it is not necessary for interpret ers to register with NRPS) or complete a specific course in interpreting )nterpreters work in a range of settings including courts police stations health care settings conferences and with international delegations )n ad dition there are sign language interpreters who inter pret for people with hearing disabilities )n the UK in terpreters are known as public service interpreters as they work with professionals in the public services )n that context an interpreter is one who possess a nation ally accredited qualification is registered as a public service interpreter complies with the code of profes sional conduct for interpreters and is associated with a recognised and identifiable profession

Interpreters and Vicarious Trauma
)nterpreters may have to interpret regularly for individ uals with traumatic experiences such as those who have experienced sexual abuse torture DVA or similar traumatic experiences This means that inter preters are exposed to emotionally demanding and bur densome situations that may make them prone to vi carious trauma which refers to the situation where the practitioner is vulnerable through his or her empa thetic openness to the emotional and spiritual effects of vicarious traumatization These effects are cumulative and permanent and evident in both professional and personal life p Experiencing vicarious trauma can have psychological consequences such as posttrau matic stress disorder PTSD whereby the practitioner may experience concentration difficulties nightmares anxiety depression and self doubt Practitioners may also experience secondary traumatic disorders com passion fatigue and burnout symptoms Most of these conditions are similar and result from being exposed to traumatic situations either to self or by indirect expo sure such as through listening to or supporting those affected by such issues Dealing with such situations and prevention of vicarious trauma requires appropri ate opportunities to express feelings and clinical super vision (owever interpreters are generally self em ployed and do not have appropriate organisational sup port While there is a growing interest in this topic we still do not understand the related issues around the in terpretation and interpreters There is limited understanding about how interpreters see their role in supporting individuals with traumatic histories the im pact of such exposure on the health and well being of interpreters and ways whereby they cope with such sit uations There is also a need to understand the positive and negative impact of interpreters on service users ability to share their views and how interpreters share their stories with the practitioners While some research is conducted to determine the ef fectiveness or the importance of provision of language concordant care through interpreters re search exploring the use of interpreters in the context of DVA or the experiences of interpreters when provid ing interpretation services to clients with difficult and traumatic histories is scarce We do not know much about how interpreters cope with the difficult situations they often encounter and what coping strategies they use to protect themselves from trauma The initial aim of this review was to explore the role of interpreters with regards to service provision of victims of gender based violence (owever research on this specific as pect does not exist Most of the research exploring in terpreters experiences or perspectives is qualitative however no serious attempt has been made to aggre gate studies to generate conclusions to then develop future research questions An extensive search of com mon databases including MEDL)NE C)NA(L Cochrane and Joanna Briggs Library of Systematic Reviews did not identify any review conducted to explore interpret ers experiences of providing services to individuals and communities with traumatic histories No review ex ploring coping mechanisms of interpreters providing services to vulnerable groups such as those experienc ing violence and abuse could be identified )t was con sidered important to explore this area to aggregate available literature to identify gaps in the literature and to improve our understanding of the role of interpret ers Findings from this review may also help identify re search questions to be explored through future re search

Aims of Review
The aim of this review is to synthesise available qualita tive studies exploring experiences of interpreters when working with individuals and groups who have experi enced DVA or other traumatic situations The aims and review question were developed using the P)CO Pa tient intervention Comparison and Outcome frame work and the specific review questions were

Eligible Studies
Empirical studies on the interpreter s experience of working with clients with traumatic situations histories and studies exploring the emotional and psychological impact on interpreters were considered for inclusion For studies to be included they had to explore the ex periences of spoken language interpreters empirical quantitative qualitative literature review systematic review written in English and published in peer re viewed journals during Studies that ex plored experiences of bilingual workers sign language interpreters and informal interpreters were excluded Studies that did not explore the emotional or psycho logical impact of interpreting case reports case stud ies scholarly or theoretical papers opinion pieces and commentaries were also excluded The initial focus of the review was interpreters and their experiences of working with victims of gender based violence how ever no studies were available on this particular issue therefore the scope was broadened to include partici pants with traumatic histories and sensitive issues

Search Process
A comprehensive literature search using search engines including engines MEDL)NE Cumulative )ndex to Nurs ing and Allied (ealth Literature C)NA(L Psych)NFO Excerpta Medica Database Embase Scopus Web of Science the Cochrane Library and The Joanna Briggs )nstitute was performed Keywords including inter preter vicarious trauma secondary trauma emo tional impact and psychological impact were used Various combinations of search terms and Boolean op erators AND OR and were used to help specify the search A search was also conducted using Google and Google Scholar to identify studies not published in indexed journals )n addition the reference list of each article was reviewed to identify studies not listed in the searched databases

Study selection
The initial search identified potentially relevant studies Following removal of duplicates studies remained A scan of titles helped reduce this to po tentially relevant articles A careful review of abstracts and a scan of papers resulted in excluding a further articles which did not meet the inclusion criteria result ing in articles The full texts of all articles were printed for further reading and assessment (owever only studies that met full inclusion criteria were fi nally included in the review Figure provides a flowchart of the literature search strategy

Quality Examination
To explore the quality of qualitative studies and to per form a robust analysis the Critical Appraisal Skills Pro gramme CASP checklist for qualitative study was used For quantitative studies the CASP checklist for cohort studies was used

Data Extraction
A data extraction form was devel oped and used Appropriate infor mation including author details country of study purpose re search design related information such as sampling sample charac teristics data collection and data analysis study findings limita tions and recommendations were recorded Appropriate infor mation is summarised and pre

Figure
Flowchart of the literature search strategy

Purpose of the studies
Five studies explored the role and experiences of inter preters working in different settings Some studies explored professionals experiences of working with interpreters and interpret ers impact on the process of psychotherapy Other studies explored the psychological and emo tional impact of interpreting

Geographical location
Most studies originated from western and developed countries including Australia Denmark UK and the USA

Study designs
Most studies used a qualitative approach with only few studies using a quantitative approach )n addi tion to qualitative exploratory approaches other commonly used methodologies included grounded theory ethnography phenome nology interpretative phenomenological anal ysis )PA narrative methods and prac tice based evidence methodology

Study settings
Studies were conducted in community settings health centres torture treatment centres rehabilitation centres mental health clinics sexual health clinics translating and interpreting ser vices or other therapeutic and criminal jus tice system related settings

Sampling approaches
Most studies used a purposive sampling approach with only few studies using convenience snowball or random sampling approaches

Participants
The focus of all studies was interpreters therefore most of them included professional interpreters in their sample however some studies also included psycho therapists mental health professionals or other professionals such as police officers )n most studies the main focus was to explore the role or im pact of interpreters on the therapeutic process alt hough the interpreters were specifically questioned about the impact of interpreting on their mental and emotional well being The sample size of the studies ranged from in qualitative studies and in quantitative studies )n total the number of partici pants contributing to the studies was which in cluded interpreters other professionals and refugees This sample included male and fe males and other participants where gender was un specified Some studies did not provide information about the gender composition of the sample

Data collection
Most studies used a qualitative approach therefore face to face interview was a common data collection method Only a few studies used focus group discus sion One study used telephone interviews as a sole data collection method and another used it in combination with face to face interviews A semi structured interview guide was reported to be used in all qualitative studies and the quantitative studies used questionnaires Only one quantitative study reported the use of a validated instrument to assess the degree of secondary traumatic stress burnout and compassion satisfaction The study also looked at the impact of other factors including gender history of trauma and refugee status of the participants The re maining quantitative studies did not report using vali dated measures

Data analysis used in studies
Most studies n used a qualitative approach the specific data analysis approaches included interpretive phenomenological analysis grounded the ory thematic analysis and narrative analysis )n quantitative studies data were analysed using de scriptive and statistics Table presents detailed information about the data collection and analysis methods used in each study Key themes emerging from the study Five themes emerged including role and impact of in terpreter psychological and emotional impact of in terpreting workplace challenges faced by interpret ers coping strategies used by interpreters and inter preters support needs These themes are presented in the following section and appropriate quotes are used to illustrate the points Table presents the process of developing these themes and the contribution of in cluded papers to each theme

Role of the Interpreter
This theme describes how interpreters and other pro fessionals perceived and understood the role of inter preters )t explores the concepts related to self percep tion of the interpreter s role professional s perception of role of interpreters and the impact of interpreter on the therapeutic process As all of these concepts are in terrelated the analysis is presented as one Most studies explored interpreters self perceptions about their role )nterpreters considered their broader role or job was to facilitate and enhance communica tion between the service user and practitioner who did not speak the same language by conveying their mes sages information to each other They considered they were a voice of their service user and practitioners and tried to convey their message as accurately as possible This is illustrated in the following quote from Resera et al You are just an interpreter there and you are we say tongue of that person because you re going to speak on behalf of that person cause you re going to translate everything from that language to the counsel lor s language )n a way you re just a language be tween two people because you are the communicator you are the one who passes one information from one to another We are messengers p While it may seem a simple act of translating messages from one language to another in reality it is not easy and the role is quite complex They considered that to become a voice they may also have to act as a service user s advocate to ensure that the practitioner and ser vices meet their service related support needs as effec tively as possible )nterpreters considered that they also play the role of a cultural broker as languages and the process of com munication are affected by the culture and norms of the speaker Simultaneously understanding or interpreta tion of a message is also affected by culture and orien tation of the listener Therefore the interpreter not only must make sense of the message and associated verbal and nonverbal cues and expressions which can also have very different meaning in different cultures but to convey it to the practitioner in a way that they get a comprehensive understanding of the issue as illustrated in the following quote to make sure both sides understand each other for the patient to understand everything and of course for the healthcare provider to understand what the patient is suffering and to make the right decision to help this patient p Another example is where the interpreter has to take a role of cultural broker for the service user as well as a practitioner ) mean to the patients it is critical because in our culture it is really cruel to tell the patient that he is or she is diagnosed with cancer maybe it can cause him to be depressed or maybe diminish his ability or willingness to survive So we can find some code word like instead of saying you have cancer we can use the word tumour and we re going to treat you for that tumour but knowing that a tumour will be treated the same way as cancer would be treated So we can get around that and use code words just to you know just to make it easier just to alleviate the situation and make it acceptable more acceptable p )nterpreters considered that their work while seen as invisible requires a wide range of complex linguistic critical thinking and processing skills The findings stress that the interpreter s role is demanding as it re quires concentration on the message provided by both service users and service provider They essentially have to share the message and the intent of the message which requires more from the interpreters than simply understanding the two languages This is ex plained by the following quote )n translating it s not )nterpreters and professionals considered that inter preters need to be able to multitask as unlike confer ence interpreting which requires only one way inter pretation they need to be attentive to both service user and practitioner and should have the skills to be able to switch between both languages promptly and accurately They have to balance between conveying accurate translation or interpretation and accurate translation of the meaning of the message )t is possible that interpreters may be unaware of many technical terms that they encounter and therefore have to ascer tain quickly ways of communicating and capturing the underlying meaning of the words as indicated in the following quote You ve got to have your resources as available as possible There have been times ) have said All right ) am just really stuck on this one (ang on just one sec ond ) will go ask somebody or try to look it up )t used to be that without a computer you would have to sit there and have a glossary and actually leaf through it to find a word ) would have two copies of the glos sary one sorted by Spanish the other sorted by Eng lish But with the computer you can find it within about five seconds And also of course being in a medical facility to be on top of all the medical termi nology all the patient rights all the protections that you and the provider needs and the patient needs p )nterpreters considered that at times they had to play the role of neutral conduit and had to engage actively in the discussion as one interpreter mentioned asking questions that are difficult or too open ended makes it difficult for the client to answer And also by being open ended then ) ve got to sit there and write a lot of things on paper and then hope ) remember them all What ) often do when open ended questions are asked is to say Could we just go with that one at a time For example if it is a dietician saying (ow many portions of starches are you serving and that sort of thing ) ll suggest Let s go over the specific kind one by one p This work while important can cause tension between the interpreter and the practitioner who may see this as an interference or inappropriate interjection of opinion on the interpreter s part While practitioners generally valued the role of interpreters there were occasions when they felt angry and frustrated due to interpreter s inappropriate interference as exemplified by Miller et al there were a few times when ) was working with an interpreter and ) was asking about a particularly sen sitive topic and the interpreter stopped me and said Please don t ask her about that that is going too far you are going too deep she is not ready for that and ) said essentially well you are going to have to trust me as the therapist here that ) will handle this in a delicate way but ) think it is important that we take this to the next level And ) had to convince the interpreter to ac tually do what ) thought was therapeutically indicated p Practitioners also considered that interpreters do not always interpret accurately and at times in a desire to help the service user they either give wrong or incom plete information They also articulated that at times service users may not want to disclose issues with an in terpreter as they share their culture and this can be a problem Overall both interpreters as well as practi tioners perceived interpreter s role as positive and rec ognised their contribution

Psychological and emotional impact of interpreting
This theme illustrates the psychological and emotional impact of interpreting on the interpreters All studies described significant emotional and psychological im pact on interpreters resulting in the development of emotional distress and burnout Findings suggest that such issues could often become unbearable and overwhelming for the interpreters and may result from listening to the traumatic stories armed attack as saults torture persecution or other traumatic experi ences of the service users or breaking bad news during health care encounters While interpreters found such instances at times intense or too diffi cult to handle they were required to listen and ab sorb these stories and relay these back to the practi tioner One participant in a study stated You have to visualize you know when you do the interpreting the interpreting process is not just about words When you re telling a story it s complex it s set in a place and you have to process all that So you re hearing the story but you re also saying the story and imagin ing what it was like for the person You know the emotions they can never be as strong as what the client feels but you get a sense of the way they might have felt p Such emotions heighten when the interpreters them selves had a traumatic history and interpreting for the service user reminded them of their emotions and past experiences or it may have made them worried about their family members living in the affected coun WikiJournal of Medicine doi wjm Review Article try (owever Mehus and Becher found no relation ship between trauma history or refugee status with sec ondary traumatic stress burnout or compassion satis faction Such impacts were reported to have a variable length as interpreters continued to work in demanding environments The studies reported that the emotional and psychological impact was not limited to the work or professional life of interpreters but also affected their personal life )nterpreters often felt it hard to move on to the next job The studies used terms such as vicar ious trauma PTSD and secondary PTSD Table de scribes various psychological and emotional reactions reported The following quote also illustrates some of the manifestations as experienced by an interpreter ) would perhaps you know miss my stop or be for ever checking where are the car keys and keep waking up and feeling still tired Maybe ) was taking my emo tions outside with my own emotions and ) found no an swer to it ) went to bed with it and wake up and they re still there p Another powerful illustration is getting drawn into it Wishing ) could do something You want to say Well just come home with me You can t do some thing for all of them you do have to maintain your distance and be professional but you want to pick those kids up and hug em You have to worry because those kids are terrified of you too That kind of makes you feel bad p The fact that they had to keep this confidential and there is usually no other support available increased the impact )n addition unlike other health and social care practitioners such as doctors nurses or other pro fessionals interpreters are not trained to deal with emotional issues Other factors at the workplace such as the feeling of not being valued or recognised by prac titioners and employing organisations manifested as not being allowed to have breaks restricted or no ac cess to appropriate notes lack of acknowledgement of the role and underestimation of the impact of the work of interpreters All these issues contributed to the phys ical psychological and emotional impact on interpret ers (owever two studies identified positive impacts of such experiences resulting in post traumatic growth where interpreters felt that they became more empa thetic towards service users improved self understand ing and understanding of the world around them

Workplace Challenges
This theme explains the findings of the study regarding workplace challenges that interpreters face daily and consequently experience negative impact on their health and well being Most studies explored or ad dresses concerns related to workplace challenges and these included heavy workloads unrealistic expecta tions and lack of appreciation lack of appropriate or ganisational support )nterpreters stated that their workload was too much and sometimes they had to work up to hours without appropriate breaks The is sue of long hours is expressed by one of the participants in a study as )f we have to do an all day conference two people working they switch off and on all day We can t do that when we re interpreting in the medical set ting We complain about the hours we work the amount of concentration You get to the point where you just physically cannot do it anymore ) ve had so many calls at or in the morning from interpret ers who have been at the hospital Emergency Depart ment all night and they re like You have to come in and take over ) m sorry to wake you up but ) just can t do it anymore My brain s just not working )t s because we keep switching languages ) have to work Spanish English English Spanish So it skips back and forth back and forth back and forth When you re doing medical interpreting you keep switching languages all the time )t gets confusing and it gets to the point that you speak English to the (ispanic patient and Spanish to the doctor because you are so tired or you paraphrase p Other issues such as need for frequent language switch ing attentiveness and the need to travel for outside as signments long waiting times and connection difficul ties and delays added to the pressure contributing to physical and psychological stress on interpreters More recently most services are moving towards tele phone interpretation creating additional challenges as a participant in one of the study stated )t s harder be cause you can t see the person face to face You re tell ing somebody something really bad on the phone and they can t even handle it face to face p )nterpreters thought that there were too many expec tations from too many people including the practition ers the service user their family and the organisations They considered that it was too difficult to keep every one happy and remain aware of every term used by the practitioner and the service user )nterpreters also considered they were not valued by their colleagues and often seen as a technical tool or a translation ma chine with no feelings or views They are often not invited to team meetings or events and decisions made at work This then has an impact on interpreters feelings of integration )n addition they are often spoken to in degrading tones They consid ered that their needs for information about the clients are often ignored and as a result they do not feel fully prepared for an assignment resulting in apprehension and stress For instance one interpreter stated ) think it would also be better if for all mental health cases to have five minutes with the professional be fore you go into the interview room p )n the absence of formal training for interpreters rele vant for many interpreters interpreters frustration and lack of trust on organisations can be easily understood )n addition lack of provision for appropriate supervision opportunities for interpreters also conveys a lack of recognition

Coping strategies
This theme explains the coping strategies that inter preters used to cope with the psychological and emo tional impact of interpreting )nterpreters said that they really needed various strategies to be able to continue to work effectively and to be normal in their life As a participant in one of the studies reported Because they are so emotionally charged these ses sions you have to find your own ways of dealing with it and if you don t have a way you don t have this protec tion then ) don t know how you can do interpreting in those context s really ) think it would be hard because ) would be crying every session p Most common strategies included self control self medication detachment accessing social support Regarding self control inter preters reported using various strategies essentially to regulate themselves and ensure that the emotional im pact of interpreting was limited Examples included ne gotiating and taking a break from interpreting activi ties getting involved in a different activity was men tioned by one of the interpreters ) tried to swallow it and keep it down After work ) went into the country side ) concentrated on something quite different like fishing sometimes when ) felt sick ) just drove around in my car p The same study also reported use of self medication as a coping strategy as one participant reported When ) get headaches while interpreting ) take some medi cine right away When ) can t stand it anymore then ) need some headache pills p A very common strat egy reported in most studies was the act of detach ing distancing or distracting themselves from the issue Participants in another study reported ) try to find something that can distract me or move me on to some thing else p Another participant from (olmgren et al re ported While interpreting ) had to tell myself This is just work remember ) have not been exposed to this One has to switch off part of the brain and look at it as work p Such strategies were used as a defence mechanism and to help them to not to think about trau matic and distressing experiences encountered while interpreting Accessing appropriate social support was another common strategy used by many interpreters They felt that it helped them share their feelings with colleagues or friends and consequently helped to take it out of their mind One participant in (olmgreen et al s study stated ) spent many evenings together with my Albanian friends we talked about our worries our situation was the same many of my friends had no idea where their families were or if they were still alive we found strength in one another p Use of various coping strategies helped interpreters to carry on with their daily personal and professional life

Interpreters' support needs
This theme presents interpreters views about the exist ing support systems available and recommendation to improve support system Nearly all of the studies ex plored the interpreters view about available support system and commented on the lack of appropriate structures )nterpreters in many studies reported the need to have debriefing sessions to talk about the impact of interpreting traumatic stories as these often shocked interpreters )nterpreters said that there was not appropriate provision of debriefing and support ses sions As most interpreters are self employed formal arrangement of clinical supervision are often unavaila ble Another important aspect raised by interpreters was a lack of appropriate training and preparation as suggested by Butler )t s all supposed to be a certain way when you study interpreting then when you are in the field it s not at all as thorough as that because of time constraints or people just can t be bothered or they just don t know p Most interpreters either had none or very minimal train ing for their job )n contrast they had to deal with a va riety of traumatic and difficult situations which require not only an understanding of how to translate or inter pret but how to support vulnerable and distressed peo ple deal with situation and protect themselves from emotional and psychological impact of the traumatic stories All of these aspects are often missing and there is none or minimal provision of education and training for interpreters during their career As one of the inter preters in a study explained The most difficult things ) would think emotionally We don t have the training like nurses or other health care personnel have (ow to deal with the very intense situations you re in as far as life death situations like having to tell parents that their child has a terminal disease or something like that So that we have these debriefing sessions back in the office very informally within the guidelines of obeying ()PAA But it makes it very difficult because you know legally someone can t go tell their husband this is what happened today So we have to have these sessions where basically sometimes you come in that office and you just have to vent because this or that happens So that is one major problem p )nterpreters believed that appropriate peer support clinical supervision opportunities briefing as well de briefing sessions may help One interpreter stated Unfortunately that is a problem that we all have that there is no debriefing for interpreters So ) can walk out of an appointment feeling very very bad and there is no one that you can talk to )n all the years that ) have been working as an interpreter only once have ) been offered debriefing and that was at the Coroner s Court Never in any other situation p )nterpreters also considered that training in coping strategies would be useful Other suggestions in cluded shorter working hours improved wages and ob servance of breaks ) think it s very difficult for inter preters to interpret for hours at a time ) ve had a call as long as two and a half hours and that s very difficult on an interpreter s voice physically because you re say ing everything twice And it takes a lot longer so it tires you out )t s very draining Doing it for hours can be very draining ) ve been called at home ) ve been called on the weekends ) ve been called on a holiday after hours p )n addition interpreters consid ered that working with the same professionals may help increase familiarity with each other and therefore would help make interpreters work easier )n summary the findings of this review suggest that while the role of an interpreter is important in helping service users and practitioners communicate with each other effectively it has its own challenges The inter preters may themselves have experienced difficult situ ations in their life and working as interpreter means that they have interpreted and relayed traumatic sto ries of service users with whom they work and this may make them remember their own traumatic experi ences The findings of the studies revealed that inter preting for people with traumatic histories can have a serious emotional and psychological impact (owever there appears to be a lack of appropriate support sys tems to help interpreters perform their job effectively and protect them from the negative impacts of their job

Discussion
The need for interpretation and interpreters is increas ing owing to internal and external migration within and between countries (ealth and social care and other professionals such as those working in for example criminal justice system or other professions cannot pro vide appropriate services to those unable to communi cate in the mainstream language of the country )t is im portant to recognise that interpretation or language barriers are not only relevant to an English speaking country but any country where there is a problem with provision of language concordant services The role of interpreters is important as without their help service users and practitioners could not understand each other appropriately however it is not always acknowledged and recognised While research related to interpreters and their needs is an emerging field there are many ar eas that have not yet been explored For instance the impact of interpreters on women s ability to disclose their domestic violence experiences preparedness or interpreters in supporting women and men to disclose their experiences of gender based violence and or do mestic violence and abuse perceptions of men and women with domestic violence histories about the role and impact of interpreters on the process One of the reasons to embark on this project was to identify avail able literature on this particular topic however we did not manage to find any studies on the topic and there fore broadened the topic area to look at interpreters and their work with people traumatic histories and emotional and psychological impact of such exposure on interpreters and their health and well being The narrative analysis of the concept discussed in the studies is presented in five themes including role and impact of interpreter psychological and emotional im pact of interpreting workplace challenges faced by in terpreters coping strategies used by interpreters and interpreters support needs The first theme explored WikiJournal of Medicine doi wjm Review Article the role of interpreters as perceived by themselves and by other professionals )nterpreters and other profes sionals agreed that interpreters play very diverse and important roles when helping service users and profes sionals to communicate with each other Many studies explored this particular aspect and various roles identi fied included that of communicator voice box cultural broker advocate and a neutral conduit The findings of the study reveal that although the role of an interpreter appears simple it is complex and demand ing An interpreter needs to pay attention to both par ties to communicate and this requires multitasking Professionals while recognising the role of interpret ers also articulated their frustration as they considered that interpreters do not always interpret all information relayed by the professional to the service user or vice versa or that they interject inappropriately There ap pear to be issues with the development of trust and rap port with the service user and many a times profession als thought that their position was not maintained )n terpreters consider that professionals and others do not always understand the role of an interpreter This find ing is consistent with many studies The next theme explored the psychological and emotional im pact of interpreting on the interpreter The findings of the review suggest that interpreters are required to in terpret the traumatic experiences of those they are in terpreting for This is a complex task and requires inter preters not only to listen to the experiences but to relay it back to the professional and to so they have to imag ine that experiences Nevertheless repeated listening to traumatic situations can produce negative emotional and psychological symptoms Symptoms reported in clude sadness anger feeling upset insomnia depres sion and anxiety Such symptoms are re ported in previous research Our findings suggest that interpreters considered that such experience had a very negative impact on interpreters and that there is not much support available to help interpreters cope with the such negative impacts )n addition to exposure to traumatic situations studies also explored workplace challenges faced by interpret ers )nterpreters identified many different workplace stressors such as a feeling of not being treated as equally as their professional colleagues not being in vited to meetings and not being involved in decisions making at the workplace They also considered that working conditions for interpreters are not good as they are required to work long hours often do not get breaks during work and their requests for change in work are not listened to The next themes explored coping strategies used by in terpreters to deal with the negative impacts of inter preting Various strategies were used including detach ing themselves from the situation self regulation self medication and accessing social support Stud ies also explored the interpreters views about their sup port needs and how these can be met )nterpreters sug gested various ways that may help them cope with the negative impact of interpreting and improve their work ing conditions These included provision of peer sup port the opportunity to have briefing and debriefing session opportunities to talk to counsellors and profes sionals availability of clinical supervision sessions and shorter working hours )n summary this review has identified many issues with regard to interpreting and interpreters While most studies conducted on this topic there are many differ ent aspects that still need to be explored For instance research needs to be conducted on the role of interpret ers with regards to provision of services to victims of gender based violence Views of women men profes sionals as well as interpreters could be explored Pre paredness of interpreters with regards to provision of services to such vulnerable groups should be explored

Implications
The findings of the study have implications for profes sionals clinical practice and future research Present findings clearly highlight that interpreters roles need to be recognised by organisations and professionals With regards to interpreters better education and training opportunities should be made available for interpreters to prepare them better for their roles and especially to provide appropriate services to those with traumatic histories )nterpreters should also have education and development opportunities to learn about coping strat egies to enable them to cope with negative impacts of interpreting Many universities now offer degree pro gramme in interpretation and it may be useful to ar range specific continuous professional development programmes for the interpreters by their employing agencies with regards to interpreters field of practice While it may be difficult to cover every eventuality helping interpreters principles of practice self care recognition of when to seek support may be useful Use of problem based learning may also be useful )n addi tion provision of clinical supervision sessions may be useful There appears to be a lack of clear boundaries and role definitions among interpreters as well as professionals Further work involving interpreters and professionals is