Kelly is a good friend of mine whom I’ve had conversations with regarding mental health. When I thought of a new blog post and came up with the idea of a post related to mental health I knew she’d be the person to call. Kelly is a certified medical interpreter through both NBCMI and CCHI. She is also the co-founder of the InterpreMed website. I prepared some questions for Kelly to answer in this interview, to which you will find her answers below. I hope you all enjoy our discussion! Make sure to let us know your thoughts in the comments.
Q: As interpreters, what part of the job can affect one’s mental health?
A: As with any job, interpreting can affect our mental health. Even if you’re like me and medical and mental health interpreting is your lifelong passion, you’re not immune to the unique mental health challenges that this profession can throw our way. I actually did a survey recently of about 60 medical interpreters about the stressors they face that affect their mental health, as well as the strategies and supports they use to cope, so I’d like to share what I found here.
1. People not knowing how to work with medical interpreters, and not listening to us when we try to educate them about how
It can be incredibly frustrating when you want to do your job well, know that someone’s health can be affected by not doing your job well, and despite your best efforts, the people you’re working with just aren’t letting it happen. Then, when you try to speak up and give some direction on how best to utilize your talents for the benefit of all involved, you get ignored. It’s no wonder that when I discussed the results of this survey at the 2022 Annual Membership Meeting of the National Council on Interpreting in Healthcare (NCIHC), many participants began fervently nodding their heads when I revealed this as the number one stressor reported by survey respondents.
2. Patients or providers being rude, insulting, or unfeeling
It’s no secret that the way the U.S. healthcare system functions leaves a lot of people feeling stressed out. Patients are often not feeling well, many of them have to jump through hoops to get the care they need, and it’s not uncommon for them to have to wait a long time to get what they need. Providers are under a lot of pressure from all angles. Now, sometimes when people feel stressed or overwhelmed, those emotions spill over and affect the people around them. If someone is feeling powerless, they may exert power over others to regain a sense of control. All of this can result in a complex web of emotions and subsequent reactions that an interpreter may get caught up in. Many interpreters who took the survey reported witnessing (or being at the receiving end of) rudeness, entitlement, apathy, and dehumanizing attitudes.
3. Feeling overworked, rushed, or helpless, especially as the result of understaffing
Reading the responses of the interpreters who took the survey, the stress of being overworked was palpable. Many respondents reported struggling to maintain a healthy work-life balance, and that while they interpreted, they felt like they were being rushed. I can speak from personal experience when I say: an English-speaking patient’s 30 minutes is not the same as a Spanish-speaking patient’s 30 minutes with a provider. If we’re interpreting consecutively, communicating with the provider can take an LEP patient with the same issues as an English-speaker twice the time to express themselves fully. We, as interpreters, feel this pressure.
These are only the top three responses in terms of stressors that affect medical interpreters’ mental health. Below, you can find the next 7 stressors that respondents shared, in order:
- Interpreting difficult topics & situations
- Feeling like they’re not doing a good job
- Lack of understanding or recognition of the interpreter role
- Mistreatment of interpreters by their agency, company, or department (often mentioned was being forced to do things)
- Complex utterances (e.g. very long utterances, complex medical terminology, idiomatic expressions)
- Feeling alone or without support
- Audio quality and other technological issues
I have to admit, while I agree with many of the points in the list based on my own experience as an in-person contract interpreter, one of the things that was at the bottom of the list of the survey respondents’ was at the top of mine. I’d have to say the use of ad hoc or unqualified interpreters (such as a patient’s friend or family member) would make my top 3, though it ranked at number 15 on the list. There are more than a few unscrupulous interpreting agencies that send wholly unqualified interpreters to interpret, and I witness the aftermath of this personally as an in-person interpreter. It results in resentment from patients and providers alike, as well as missed diagnoses, misunderstood instructions, and even inadvertently causing emotional harm to patients and their families. Many times I feel personally responsible for picking up the pieces, which is a huge emotional burden to carry.
Q: How can interpreters prepare for and cope with difficult interpreting scenarios?
A: Of course, all of these stressors play off of each other. What might start off as a provider not knowing how to work with an interpreter (#1 on our list) may result in rudeness (#2 on our list) when the interpreter tries to politely inform the provider that they need to allow the interpreter a chance to interpret. Managing the flow of communication takes time, which only compounds the time crunch many interpreters feel on the job (#3 in our list). When we’re already emotionally depleted from just these first three things, it can make it even more difficult to handle #4, which is interpreting difficult situations. All of these factors affect our job performance, which can lead us to feeling like we just aren’t cut out for what we do, which just so happens to be #5 in our list.
I think before we can go about answering this question, we need to sort of categorize “difficult interpreting scenarios.” Most interpreters’ minds jump to emotionally-challenging subject matter, such as interpreting for someone recounting a traumatic experience, interpreting a difficult diagnosis, or any number of difficult topics. But that’s really only one type of difficult interpreting scenario. I like to differentiate this from interpersonal friction, which are situations that are often emotionally-challenging in a different way because they’re the result of people in an encounter just not getting along or being rude or even hostile towards each other or the interpreter. Sometimes it doesn’t even result in overt actions, but it can certainly still be palpable just beneath the surface.
Another type of difficult interpreting scenario as mentioned in the survey is encounters in which the flow of communication is affected. This can result from patients and providers alike not knowing how to work with us, and can be complicated further by when we try to give them direction but aren’t listened to. Conflict (included under the umbrella of interpersonal friction) often exacerbates flow issues as well. And from personal experience I can say that interpreting for young children can be tricky because they just don’t have the wherewithal to understand how interpreting works or how to even take turns! I like to consider feeling rushed to be a flow of communication issue as well, since it often results in a sort of forced, sped-up flow that often actively seeks to gloss over standard flow management protocol.
There are also scenarios riddled with communication that is difficult to understand. This can include utterances with complex medical terminology that the interpreter has to grapple with. Technological issues can also result in things being hard to hear for remote interpreters. I recently recorded a video on my YouTube channel in which I compared grappling with poor audio quality with interpreting for patients with speech issues (e.g. language delays or apraxia), and how it can drastically increase our cognitive load, sort of siphoning off our brain power from our main task of interpreting. Juggling all these things can be exhausting, and can even make us doubt ourselves and our abilities.
Preparing
I think it’s very important to take preventative measures as much as possible to try and at least sort of nip these things in the bud before they grow into bigger issues. One of the best ways we can do this is to find out as much as we can about the appointment before it even begins. It helps us know what to expect and develop strategies to manage any issues that might come up. As an in-person interpreter I’m certainly more privileged in this aspect, but not as privileged as some people might think! Sometimes, all I get is an address, date/time, and name of the patient or provider. But that address is a key piece of information for me, because more often than not it tells me about the medical specialty I’m interpreting for. If I get a date of birth, it gives me an idea about the age of the patient. Sometimes I’m lucky enough to get an appointment type. I can use all of this information to consider the challenges I may face.
One of my favorite ways to set up the encounter for success is something that’s already baked into the interpreter protocol, which is your pre-session. Now, let’s be real: it’s not uncommon for your pre-session to go in one ear and right out the other of the patient or provider. I’m very fortunate to be an in-person interpreter and see many of the same patients and providers, so I can usually custom-tailor my pre-session to my audience. I think the key with the pre-session is to be as brief but as clear as possible. The more information you bombard people with, the more likely it is for them to gloss over the details. Also, experimenting with different versions of the same disclosure can yield unexpected results. I’ve found saying, “I will interpret everything I hear in this room,” catches everyone a little off-guard (which makes them put their listening ears on), but solidly gets the point across that I will interpret everything. This can help tremendously with the flow of communication and potentially prevent certain conflicts that arise from not understanding the interpreter’s role fully.
The last bit of preparation is perhaps the most important: know thyself! Know what situations are emotionally challenging for you. If you had a close family member pass away from cancer, oncology might be difficult or even potentially impossible for you to handle. Know what modes of interpretation you’re proficient in. How are you going to handle long utterances? Will you engage in long consecutive with extensive note-taking? Will you interpret simultaneously? Would you like to interpret simultaneously but don’t feel confident enough in your skills? That might be a good sign that this is a skill you’d like to work on, and if you have enough time before the appointment, you might be able to do it. Also, if you know you are prone to feeling pressured by providers to do things you probably shouldn’t, maybe find support with your colleagues in how to manage this. With just this one strategy, we can preemptively cover almost all of the difficult interpreting scenarios mentioned at the beginning of this section.
Coping
Preventative measures can’t prevent everything, so we have to know how to handle things as they happen, but also how to handle things after they happen. There’s a little bit of overlap here in terms of which strategies I personally use at which point, so I’m going to focus on each strategy and where I may apply them.
Reframing
Reframing, as I explained it to my 11 year-old stepson, is like taking the same picture and putting it into a different picture frame to make it look better. A patient has a terminal illness and you’re tasked with interpreting the news to their family. Your heart immediately sinks and you think to yourself about how terribly sad this is. Your face feels hot and your eyes begin welling up with tears. A great way to cope with these sorts of situations, in my experience, is to think about them differently. I often tell myself, “I’m glad I’m here to help them through this,” and remind myself of just how much more difficult this situation would be for the family if I weren’t there to communicate everything clearly to them. It doesn’t fix the situation. It doesn’t stop making it sad, but it fills me with a sense of purpose and gives me the strength to focus and do my very best. This is my go-to strategy with interpreting for emotionally-challenging subject matter.
Empathy is another tool we can use in reframing. I once had a parent of a patient accuse me of incorrectly interpreting a very simple utterance that I was certain I had interpreted correctly. They then went on to say many negative things about me and then went on to complain about the provider that they were talking to! I could have certainly gotten angry or even defensive, but I didn’t. I thought to myself, “I can only imagine how much this person has been through to go on the defensive with two people who are doing their best to help their family.” Empathizing with people is a great way to recognize that sometimes it’s nothing personal and can help how you react in situations where there is interpersonal friction.
I’d like to address one aspect of the survey here when we talk about reframing, and that’s in response to those interpreters who reported that feeling like they weren’t doing a good job was a major stressor for them. Reframing is perfect for this! Actually, when I hear interpreters reporting this, in a weird way it gives me hope. But why? Well, I imagine I frame this situation a little differently in my mind than those interpreters do: I see this as an indication that interpreters want to do well for the communities they serve, but aren’t being given the tools or conditions to do it. Read that again: interpreters want to do well. Interpreters want to provide the highest quality of service to marginalized communities. If there is one thing this pandemic has shown me, it’s the very ugly truth that our world is too often apathetic in the face of the hardship and suffering of others. That interpreters report they want to do well shows me they haven’t lost the passion to serve the communities they interpret for, and that, for me at least, is so incredibly encouraging.
Focusing on what you can control
The first step to this one is recognizing that you can’t control every little thing in an interpreting encounter. As much as we like to convince ourselves sometimes that we can, we really can’t! This is why I like to employ what I call the rule of threes: I interject three separate times for the same thing, but after that point, in most cases, I stop interjecting and/or may change my strategy. If I ask someone to speak directly to the patient three separate times over the course of the encounter and they keep on saying, “Tell her to xyz,” what’s the likelihood that they’re going to listen to me a fourth time? I typically employ longer and longer interjections each time with more information maybe about why this is important, but if I’ve expressed this and they’re not listening after three times, they’re probably not going to listen. This is a personal strategy of mine, and I know some people won’t agree with it, but at a certain point for my own sanity, I have to focus on what I can control: how I interpret the information I’m tasked with interpreting.
When it comes to interpreting emotionally-challenging subject matter, you can’t change the fact that someone was the victim of abuse, but you can control how you think about it and how you react to it to some degree (see: reframing). If someone chooses to be rude to you and the patient you’re interpreting for, you can’t pull out a Playstation controller and start tweaking their behavior. You can accept the fact that their behavior is out of your control and you can change your behavior or your perception of the situation to make it less unpleasant. You can’t change the fact that the patient is joining their telehealth session from a cell phone with poor signal and that they sound like the Swedish chef from the muppets, but you can control how you react to it and handle the situation. It can be liberating to let go of the things that are outside of your control and just accept them as they are!
This brings me to practicing mindfulness as a way we can take charge of what we can control. I’m going to talk about this more a little later in a more general sense when we discuss self care, but in the heat of challenging encounters, we can also employ some targeted mindfulness techniques. The late Nhat Hanh, often regarded as the father of mindfulness said, “Mindfulness helps you go home to the present.” It’s all about being present, being aware, and simply just being. This is why Nhat Hanh spoke often about breathing. Oftentimes when we’re in stressful situations, we can hold our breath without realizing it, so remembering to take a deep breath when things get tough can be surprisingly effective.
Advocating for yourself
We often hear about the controversial patient advocate role of the medical interpreter, as well as the ethical principle of advocacy from the medical interpreting codes of ethics. But what about advocating for ourselves? The fact is, many employers and clients of medical interpreters frown upon this and actively discourage it. Let’s go back to the National Council on Interpreting in Healthcare’s National Standards of Practice for Interpreters in Health Care, specifically standard 24:
“The interpreter advocates for working conditions that support quality interpreting.”
NCIHC National Standards of Practice for Interpreters in Health Care, page 9
The example given is if we’re on a long assignment and we’re feeling like fatigue may impact our ability to interpret accurately, we should let someone know. Now, let’s go back to an example that I mentioned previously: you’re interpreting for an oncology appointment, but recently had a close family member pass away from cancer. Are you going to be able to provide quality interpretation? This is where knowing thyself comes into play, but also recognizing that sometimes we can’t know how we’re going to react in a situation until we’re in it. Speaking up for yourself, ensuring you’re not placed in a situation that would cause you emotional harm and therefore impact your ability to interpret effectively, is both self-advocacy and in keeping with the NCIHC standards of practice.
While the example given above is more likely to happen before an encounter, there are many scenarios that can play out during encounters that can be handled professionally and ethically with self-advocacy. Much like patient advocacy, I try to first engage in less intrusive means whenever possible, such as managing the flow of communication or providing information via a third-person interjection, but in certain instances such as those that impact my safety, I may immediately advocate for myself. We also have to recognize that self-advocacy isn’t selfish and that the vast majority of these situations result in us advocating for interpreters as a whole, thereby supporting the integrity and sustainability of the interpreting profession, ensuring quality language access for marginalized communities for many years to come.
One of my go-to strategies for self-advocacy after encounters that have gone awry is to immediately report it to the interpreting agency. This ensures they get my side of the story first, and sometimes, like in the instance of the nurse who aggressively attempted to interrogate me about who pays me, may result in corrective action being taken. Never assume no one cares and isn’t going to listen to you, because (just like I was after reporting the incident with the nurse) you may end up being surprised by the outcome.
After Challenging Encounters
Some of these strategies, as I mentioned, can be practiced even after challenging encounters, such as reframing or even advocating for yourself, but for the most part, coping with the difficulties we encounter after they’ve ended falls under the category of self-care, which I’m certain we’ll be discussing soon!
I want to take this time to thank you for reading this blog post and to thank Kelly for taking the time to discuss with us such an important topic. Don’t worry this is just the beginning…there will be a part two to this conversation so definitely keep an eye out! Feel free to share this blog post with fellow colleagues. – Miriam