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

Introduction
Language plays a central role in making people understand 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 appropriate 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 outside countries is historically high and where people speak varied languages. A Google search reveals that there are presently 7117 living languages in the world and the number of spoken languages exceeds 200 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 country may have only one official language, several languages may be spoken.

The United Kingdom (UK) census of 2011 suggests the use of more than 80 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 4.2 million people (aged > 3 years) in England and Wales spoke a main language other than English. Among this group, approximately 20% indicated an inability or difficulty in speaking English. 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 permits them to interact effectively with health care providers” (p. 728). Individuals 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. Interpreters, are individuals who intervene in such situations and help practitioners and service users to understand each other and communicate effectively. The issue of language barriers and use of interpreters is not limited to the UK or English speaking countries. Increasing immigration and the use of multiple languages in most countries makes the use of interpreters an international concern.

Interpreter and the need for an interpreter
The word ‘interpreter’ is derived from the Latin ‘interpres’ 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 ‘middleman’, ‘intermediary’ or ‘commercial go-between’), but others believe the word is from the Sanskrit language. Interpretation is identified as a translational activity, but one that is done immediately, on the spot. Interpretation 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 language. Interpretation 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 1980s and 1990s, when a series of serious court cases were conducted using untrained interpreters with limited proficiency in the language they were interpreting. For example, the case of Iqbal Begum, a woman from Pakistan who was tried for the murder of her husband and was sentenced to life imprisonment. Mrs Begum suffered years of domestic violence 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. Specifically, the interpreter provided was not trained and although 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 position. Her case review resulted in nullifying the charges and she was subsequently released in 1985 though she committed suicide a few years later.

Another high profile case was that of Victoria Climbie, a 7 year old girl from the Ivory Coast who came to the UK in 1999 with her aunt and legal guardian. Her Aunt began a relationship with Carl Manning and moved to Manning’s home in London in July 1999. Manning abused Victoria resulting in her visit to hospitals for injuries. Victoria died soon and her post-mortem revealed a total of 128 injuries and scars. The case review highlighted a failure of health and social care and police services to provide Victoria and her family with appropriate 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 interpreters, although it is always better to use professional interpreters to avoid bias, provide appropriate interpretation, and minimise the risk of misunderstanding. An interpreter may use three processes: simultaneous interpretations where the speaker and the interpreter 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. In the health and social care setting, consecutive interpretation is often used.

Interpretation can be done in various ways, including: face to face; telephone; and video interpretation. Face to face interpreting requires the person and the interpreter 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. In 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. In the UK, there is a voluntary National Register of Public Service Interpreters (NRPSI). It is a public register of professional, qualified and accountable interpreters accessible online and free of charge. According to the NRPSI, by the end of 2018, there were 1730 registered interpreters who could offer interpretation for 104 languages (54 of which are registered as Rare Language status) in the UK. Interpreters 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 NRPSI is a voluntary register and it is not necessary for interpreters to register with NRPSI or complete a specific course in interpreting. Interpreters work in a range of settings, including courts, police stations, health care settings, conferences, and with international delegations. In addition, there are sign language interpreters who interpret for people with hearing disabilities. In the UK, interpreters are known as public service interpreters as they work with professionals in the public services. In that context, an interpreter is one who possess a nationally accredited qualification, is registered as a public service interpreter, complies with the code of professional conduct for interpreters and is associated with a recognised and identifiable profession.

Interpreters and Vicarious Trauma
Interpreters may have to interpret regularly for individuals with traumatic experiences such as those who have experienced sexual abuse, torture, DVA or  similar traumatic experiences. This means that interpreters are exposed to emotionally demanding and burdensome situations that may make them prone to vicarious trauma which refers to the situation where: “the [practitioner] is vulnerable through his or her empathetic 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. 151). Experiencing vicarious trauma can have psychological consequences such as posttraumatic stress disorder (PTSD) whereby the practitioner may experience concentration difficulties, nightmares, anxiety, depression, and self-doubt. Practitioners may also experience secondary traumatic disorders, compassion fatigue, and burnout symptoms. Most of these conditions are similar and result from being exposed to traumatic situations either to self or by indirect exposure, such as through listening to or supporting those affected by such issues. Dealing with such situations and prevention of vicarious trauma requires appropriate opportunities to express feelings and clinical supervision. However, interpreters are generally self-employed and do not have appropriate organisational support. While there is a growing interest in this topic, we still do not understand the related issues around the interpretation and interpreters. There is limited understanding about how interpreters see their role in supporting individuals with traumatic histories, the impact of such exposure on the health and well-being of interpreters and ways whereby they cope with such situations. 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 effectiveness or the importance of provision of language concordant care through interpreters,  research exploring the use of interpreters in the context of DVA or the experiences of interpreters when providing 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. However, research on this specific aspect does not exist. Most of the research exploring interpreters’ experiences or perspectives is qualitative; however, no serious attempt has been made to aggregate studies to generate conclusions to then develop future research questions. An extensive search of common databases including MEDLINE, CINAHL, Cochrane and Joanna Briggs Library of Systematic Reviews, did not identify any review conducted to explore interpreters’ experiences of providing services to individuals and communities with traumatic histories. No review exploring coping mechanisms of interpreters providing services to vulnerable groups such as those experiencing violence and abuse could be identified. It was considered important to explore this area to aggregate available literature, to identify gaps in the literature and to improve our understanding of the role of interpreters. Findings from this review may also help identify research questions to be explored through future research.

Aims of Review
The aim of this review is to synthesise available qualitative studies exploring experiences of interpreters when working with individuals and groups who have experienced DVA or other traumatic situations. The aims and review question were developed using the PICO (Patient, intervention, Comparison and Outcome) framework and the specific review questions were:

· What are the interpreters’ experiences of dealing with individuals and groups with traumatic histories?

· What impact do such encounters have on health and well-being of interpreters?

· What coping strategies do interpreters use to protect themselves from negative experiences?

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 experiences of spoken language interpreters; empirical (quantitative; qualitative; literature review/systematic review); written in English and published in peer reviewed journals during 2000-2019). Studies that explored experiences of bilingual workers, sign language interpreters, and informal interpreters were excluded. Studies that did not explore the emotional or psychological impact of interpreting, case reports, case studies, 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; however, no studies were available on this particular issue, therefore, the scope was broadened to include participants with traumatic histories and sensitive issues.

Search Process
A comprehensive literature search using search engines including engines MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Excerpta Medica Database (Embase), Scopus, Web of Science, the Cochrane Library, and The Joanna Briggs Institute was performed. Keywords including: ‘interpreter’; ‘vicarious trauma’; ‘secondary trauma’; emotional impact’; and ‘psychological impact’ were used. Various combinations of search terms and Boolean operators (‘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. In addition, the reference list of each article was reviewed to identify studies not listed in the searched databases.

Study selection
The initial search identified 3018 potentially relevant studies. Following removal of duplicates, 2452 studies remained. A scan of titles helped reduce this to 193 potentially relevant articles. A careful review of abstracts and a scan of papers resulted in excluding a further 151 articles which did not meet the inclusion criteria resulting in 42 articles. The full texts of all 42 articles were printed for further reading and assessment. However, only 18 studies that met full inclusion criteria were finally included in the review. Figure 1 provides a flowchart of the literature search strategy.

Quality Examination
To explore the quality of qualitative studies and to perform a robust analysis, the Critical Appraisal Skills Programme (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 developed and used. Appropriate information including, author details, country of study, purpose, research design related information such as sampling, sample characteristics, data collection and data analysis, study findings, limitations and recommendations were recorded. Appropriate information is summarised and presented in relevant tables and figures in the following sections. Findings from the qualitative studies are synthesised and analysed using Noblit and Hare's method of meta-ethnography. Table 1 shows this process and how these papers contributed to the synthesis.

Findings
Eighteen studies were finally included in the review. These included three quantitative and 15 qualitative studies published between 2003 and 2017. Various aspects of studies are explored below.

Purpose of the studies
Five studies explored the role and experiences of interpreters working in different settings. Some studies explored professionals' experiences of working with interpreters   and interpreters’ impact on the process of psychotherapy. Other studies explored the psychological and emotional 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. In addition to qualitative exploratory approaches,  other commonly used methodologies included grounded theory,   ethnography, phenomenology,   interpretative phenomenological analysis (IPA)    narrative methods,  and practice 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 services,  or other therapeutic and criminal justice 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 psychotherapists, mental health professionals  or other professionals such as police officers. In most studies, the main focus was to explore the role or impact of interpreters on the therapeutic process, although 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 3-30 in qualitative studies and 119-271 in quantitative studies. In total, the number of participants contributing to the studies was 618 which included 534 interpreters, 68 other professionals and 16 refugees. This sample included 188 male and 455 females and 2 other participants where gender was unspecified. Some studies did not provide information about the gender composition of the sample. The participants had different ethnic backgrounds and spoke various languages.

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 discussion. 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 remaining quantitative studies did not report using validated measures.

Data analysis used in studies
Most studies (n=16) used a qualitative approach, the specific data analysis approaches included interpretive phenomenological analysis,  grounded theory, thematic analysis and narrative analysis. In quantitative studies, data were analysed using descriptive and statistics. Table 2 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 interpreter’; ‘psychological and emotional impact of interpreting’; ‘workplace challenges faced by interpreters’; ‘coping strategies used by interpreters’; and ‘interpreters’ support needs’. These themes are presented in the following section and appropriate quotes are used to illustrate the points. Table 3 presents the process of developing these themes and the contribution of included papers to each theme.

Role of the Interpreter
This theme describes how interpreters and other professionals perceived and understood the role of interpreters. It explores the concepts related to ‘self-perception 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 interrelated, the analysis is presented as one.

Most studies explored interpreters' self-perceptions about their role. Interpreters considered their broader role or job was to facilitate and enhance communication between the service user and practitioner, who did not speak the same language, by conveying their messages/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 counsellor’s language. … In a way, you’re just a language between two people, because you are the communicator, you are the one who passes one information from one to another. We are messengers… '(p. 198).

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 services meet their service related support needs as effectively as possible.

Interpreters considered that they also play the role of a ‘cultural broker’ as languages and the process of communication are affected by the culture and norms of the speaker. Simultaneously, understanding or interpretation of a message is also affected by culture and orientation 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. 8). Another example is where the interpreter has to take a role of cultural broker for the service user as well as a practitioner: ‘I 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. 10)

Interpreters 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 requires 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 explained by the following quote: ‘In translating, it’s not just saying the literal [equivalent of] what they’re saying. Interpreting is making some sense of it. . . . Those are two different things’ (p. 140).

Interpreters and professionals considered that interpreters need to be able to multitask as, unlike conference interpreting (which requires only one-way interpretation), 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. It is possible that interpreters may be unaware of many technical terms that they encounter and therefore have to ascertain, 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 I have said, “All right. I am just really stuck on this one. Hang on just one second, I will go ask somebody or try to look it up." It 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]... I would have two copies of the glossary— one sorted by Spanish, the other sorted by English...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 terminology, all the patient rights, all the protections that you [and] the provider needs and the patient needs' (p. 140).

Interpreters 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 I’ve got to sit there and write a lot of things on paper and then hope I remember them all. What I 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, “How many portions of starches are you serving?” and that sort of thing, I’ll suggest: “Let’s go over the specific kind one by one’ (p. 41).

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 I was working with an interpreter and I was asking about a particularly sensitive 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 I said essentially, “well you are going to have to trust me as the therapist here that I will handle this in a delicate way, but I think it is important that we take this to the next level.” And I had to convince the interpreter to actually do what I thought was therapeutically indicated’ (p. 33).

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 incomplete information. They also articulated that, at times, service users may not want to disclose issues with an interpreter as they share their culture and this can be a problem. Overall, both interpreters as well as practitioners perceived interpreter’s role as positive and recognised 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 impact 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, assaults, torture, persecution or other traumatic experiences of the service users or breaking bad news during health care encounters. While interpreters found such instances, at times, ‘intense’ or ‘too difficult to handle’, they were required to listen and absorb these stories and relay these back to the practitioner. 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. 1709).

Such emotions heighten when the interpreters themselves 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 country. However, Mehus and Becher found no relationship between trauma history or refugee status with secondary traumatic stress, burnout or compassion satisfaction. 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. Interpreters often felt it hard to move on to the next job. The studies used terms such as vicarious trauma, PTSD and secondary PTSD. Table 4 describes various psychological and emotional reactions reported. The following quote also illustrates some of the manifestations as experienced by an interpreter: ‘I would perhaps, you know, miss my stop, or [be] forever checking where are the car keys, and keep waking up and feeling still tired. Maybe I was taking my emotions outside with my own emotions and I found no answer to it. I went to bed with it and wake up and they’re still there’ (p. 1710).

Another powerful illustration is: ‘getting drawn into it. Wishing I could do something. You want to say, “Well, just come home with me.” ... You can’t do something 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. 143).

The fact that they had to keep this confidential and there is usually no other support available, increased the impact. In addition, unlike other health and social care practitioners such as doctors, nurses or other professionals, 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 practitioners and employing organisations manifested as not being allowed to have breaks, restricted or no access 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 physical, psychological and emotional impact on interpreters. However, two studies identified positive impacts of such experiences resulting in post traumatic growth where interpreters felt that they became more empathetic towards service users, improved self-understanding 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 addresses concerns related to workplace challenges and these included heavy workloads, unrealistic expectations and lack of appreciation, lack of appropriate organisational support. Interpreters stated that their workload was too much and sometimes they had to work up to 14 hours without appropriate breaks. The issue of long hours is expressed by one of the participants in a study as: ‘If 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 setting... We complain about the hours we work... the amount of concentration... You get to the point where you just physically cannot do it anymore... I’ve had so many calls at 2:00 or 3:00 in the morning from interpreters who have been [at the hospital Emergency Department] all night, and they’re like, “You have to come in and take over. I’m sorry to wake you up, but I just can’t do it anymore. My brain’s just not working.” It’s because we keep switching languages... I 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. It gets confusing, and it gets to the point that... you speak English to the Hispanic patient and Spanish to the doctor because you are so tired... or you paraphrase’ (p. 143).

Other issues such as need for frequent language switching, attentiveness and the need to travel for outside assignments, long waiting times and connection difficulties and delays added to the pressure contributing to physical and psychological stress on interpreters. More recently, most services are moving towards telephone interpretation creating additional challenges as a participant in one of the study stated: ‘It’s harder because you can’t see the person face to face. You’re telling somebody something really bad on the phone and they can’t even handle [it] face to face’( p. 240).

Interpreters thought that there were too many expectations from too many people, including the practitioners, the service user, their family and the organisations. They considered that it was: ‘too difficult to keep everyone happy’ and remain aware of every term used by the practitioner and the service user. Interpreters also considered they were not valued by their colleagues and often seen as a technical tool or a ‘translation machine’ 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. In addition, they are often spoken to in degrading tones. They considered 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: ‘I think it would also be better if for all mental health cases… to have five minutes with the professional before you go into the interview room’ (p. 233).

In the absence of formal training for interpreters (relevant for many interpreters) interpreters’ frustration and lack of trust on organisations can be easily understood. In 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 interpreters used to cope with the psychological and emotional impact of interpreting. Interpreters 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 sessions, you have to find your own ways of dealing with it, and if you don’t have a way, you don’t have this protection, then I don’t know how you can do interpreting in those context[s] really. I think it would be hard because I would be crying every session’ (p. 171)

Most common strategies included self-control, self-medication, detachment,    accessing social support. Regarding self-control, interpreters reported using various strategies, essentially, to regulate themselves and ensure that the emotional impact of interpreting was limited. Examples included negotiating and taking a break from interpreting activities, getting involved in a different activity was mentioned by one of the interpreters: ‘I tried to swallow it and keep it down’; ‘After work, I went into the countryside. I concentrated on something quite different, like fishing; sometimes when I felt sick, I just drove around in my car’ (p. 26).

The same study also reported use of self-medication as a coping strategy as one participant reported: ‘When I get headaches while interpreting. I take some medicine right away. When I can’t stand it anymore, then I need some headache pills’ (p. 26). A very common strategy reported in most studies was the act of detaching/distancing or distracting themselves from the issue. Participants in another study reported: ‘I try to find something that can distract me or move me on to something else’ (p. 1711).

Another participant from Holmgren et al. (2003) reported: ‘While interpreting I had to tell myself: This is just work, remember! I have not been exposed to this. One has to switch off part of the brain and look at it as work’ (p. 26). Such strategies were used as a defence mechanism and to help them to not to think about traumatic 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 Holmgreen et al.’s study stated: ‘I 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. 26) 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 existing support systems available and recommendation to improve support system. Nearly all of the studies explored the interpreters' view about available support system and commented on the lack of appropriate structures. Interpreters in many studies reported the need to have debriefing sessions to talk about the impact of interpreting traumatic stories as these often shocked interpreters. Interpreters said that there was not appropriate provision of debriefing and support sessions. As most interpreters are self-employed, formal arrangement of clinical supervision are often unavailable. Another important aspect raised by interpreters was a lack of appropriate training and preparation as suggested by Butler: 'It’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. 9)

Most interpreters either had none or very minimal training for their job. In contrast, they had to deal with a variety of traumatic and difficult situations which require not only an understanding of how to translate or interpret, but how to support vulnerable and distressed people, 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 interpreters in a study explained: "The most difficult things—I would think emotionally. We don’t have the training like nurses or other health care personnel have. How 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 HIPAA. 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. 143)

Interpreters believed that appropriate peer support, clinical supervision opportunities, briefing as well debriefing sessions may help. One interpreter stated: 'Unfortunately that is a problem that we all have that there is no debriefing for interpreters. So I can walk out of an appointment feeling very, very bad and there is no one that you can talk to. In all the years that I have been working as an interpreter only once have I been offered debriefing and that was at the Coroner’s Court. Never in any other situation.” (p. 15)

Interpreters also considered that training in coping strategies would be useful. Other suggestions included shorter working hours, improved wages, and observance of breaks: "I think it’s very difficult for interpreters to interpret for hours at a time... I’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 saying everything twice. And it takes a lot longer so it tires you out... It’s very draining. Doing it for hours can be very draining... I’ve been called at home. I’ve been called on the weekends. I’ve been called on a holiday, after hours" (p. 143). In addition, interpreters considered that working with the same professionals may help increase familiarity with each other and, therefore, would help make interpreters' work easier.

In 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 interpreters may themselves have experienced difficult situations in their life and working as interpreter means that they have interpreted and relayed traumatic stories of service users with whom they work, and this may make them remember their own traumatic experiences. The findings of the studies revealed that interpreting for people with traumatic histories can have a serious emotional and psychological impact. However, there appears to be a lack of appropriate support systems 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 increasing owing to internal and external migration within and between countries. Health and social care and other professionals such as those working in, for example, criminal justice system or other professions cannot provide appropriate services to those unable to communicate in the mainstream language of the country. It is important 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 areas 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 domestic 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 available literature on this particular topic; however, we did not manage to find any studies on the topic and, therefore, 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 impact of interpreting’; ‘workplace challenges faced by interpreters’; ‘coping strategies used by interpreters’; and ‘interpreters’ support needs’. The first theme explored the role of interpreters as perceived by themselves and by other professionals. Interpreters and other professionals agreed that interpreters play very diverse and important roles when helping service users and professionals to communicate with each other. Many studies explored this particular aspect and various roles identified 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 demanding. An interpreter needs to pay attention to both parties to communicate and this requires multitasking. Professionals, while recognising the role of interpreters, 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 appear to be issues with the development of trust and rapport with the service user and many a times, professionals thought that their position was not maintained. Interpreters consider that professionals and others do not always understand the role of an interpreter. This finding is consistent with many studies. The next theme explored the psychological and emotional impact of interpreting on the interpreter. The findings of the review suggest that interpreters are required to interpret the traumatic experiences of those they are interpreting for. This is a complex task and requires interpreters not only to listen to the experiences, but to relay it back to the professional and to so they have to imagine that experiences. Nevertheless, repeated listening to traumatic situations can produce negative emotional and psychological symptoms. Symptoms reported include sadness, anger, feeling upset, insomnia, depression and anxiety. Such symptoms are reported 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.

In addition to exposure to traumatic situations, studies also explored workplace challenges faced by interpreters. Interpreters identified many different workplace stressors such as a feeling of not being treated as equally as their professional colleagues, not being invited 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 interpreters to deal with the negative impacts of interpreting. Various strategies were used including detaching themselves from the situation, self-regulation, self-medication and accessing social support. Studies also explored the interpreters' views about their support needs and how these can be met. Interpreters suggested various ways that may help them cope with the negative impact of interpreting and improve their working conditions. These included provision of peer support, the opportunity to have briefing and debriefing session, opportunities to talk to counsellors and professionals, availability of clinical supervision sessions, and shorter working hours.

In summary, this review has identified many issues with regard to interpreting and interpreters. While most studies conducted on this topic, there are many different aspects that still need to be explored. For instance, research needs to be conducted on the role of interpreters with regards to provision of services to victims of gender based violence. Views of women, men, professionals as well as interpreters could be explored. Preparedness of interpreters with regards to provision of services to such vulnerable groups should be explored.

Implications
The findings of the study have implications for professionals, 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. Interpreters should also have education and development opportunities to learn about coping strategies to enable them to cope with negative impacts of interpreting. Many universities now offer degree programme in interpretation and it may be useful to arrange 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. In addition, 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 required to develop a clear understanding of the role boundaries and their mutual roles. This may help reduce tensions between interpreters and professionals. It is also important to help interpreters prepare for their assignments by providing them with some information about the service user they are going to provide services to. Workplace conditions for interpreters need to be improved, so that interpreters feel valued and not alienated in their workplace. Appropriate service structures should be developed for interpreters for progression in their roles and for better job satisfaction.

Research exploring the role of interpreters, impact of qualification and accreditation on service provision by interpreters and factors affecting interpreters’ performance should be conducted. Research should also be conducted to explore similar issues among sign language interpreters. Further research should be conducted, using validated measures to explore psychological and emotional impacts of interpreting. Finally, further research to explore the impact of telephone interpreting or online interpreting should be explored

Conclusion
Interpreting is an important part of the provision of appropriate health and social care services to those with limited language proficiency in the mainstream language. However, research related to psychological and emotional aspects of interpreting is scarce. This review was conducted to explore the psychological and emotional impact of interpreting. The findings revealed that interpreting has significant impact on interpreters’ personal and professional life. Interpreters develop and use various strategies to cope with the impacts of psychological and emotional impacts of trauma. Further work needs to be done to improve working conditions for interpreters and to support them to provide appropriate services to those affected.

Additional information
The authors did not recieve any funding for this research.

Competing interests
The authors have no competing interests.

Ethics statement
Ethical permission was not required to conduct this study.