Standard and Ethics

Ethical Considerations in Working with

Culturally Diverse Populations:
The Essential Role of Professional
Interpreters
Caminee Blake, PhD
Postdoctoral Fellow, Division of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec

Abstract: The underutilization of professional interpreters

by mental health providers who work with immigrant clients with language barriers represents a failure to meet
basic professional ethical standards of care. Language
barriers affect key areas of ethics, including clinical assessment and decision-making, client confidentiality and
informed consent (1). This paper aims to highlight the importance of using professional interpreters while working
with clients with language barriers. The impact that language barriers have on clients and providers in clinical
care will be discussed, as well as the problems associated
with the common practice of using untrained interpreters.
Rsum : Considrations thiques au sujet du travail
auprs des populations de diverses cultures : le rle
essentiel des interprtes professionnels
La sous-utilisation des interprtes professionnels par les
fournisseurs de soins de sant mentale qui travaillent
auprs de clients immigrants ayant des barrires de
langue reprsente un chec satisfaire aux normes
dthique professionnelle des soins. Les barrires de
langue touchent des domaines cls de lthique, y compris
lvaluation et le processus dcisionnel clinique, la
confidentialit du client et le consentement clair (1). Cet
article vise souligner limportance de recourir des
interprtes professionnels quand on travaille avec des clients ayant des barrires de langue. Les rpercussions
quont ces dernires sur les clients et les fournisseurs de
soins cliniques feront lobjet dune discussion, de mme
que les problmes associs la pratique rpandue
dutiliser des interprtes non professionnels.

Key Words: professional ethics, cultural diversity,

interpreters
aced with the ever-increasing diversity of our population, it is essential that we critically examine and reassess standard practices of care and their ability to meet the
needs of those we serve. Working with cultural diversity
brings certain clinical challenges. Culture plays a critical
role in shaping the experiences, the expression of problems and the related help-seeking behaviour of clients (2).
Language is central to a persons cultural identity and is
the most basic means through which people encode and

CPA Bulletin de lAPCJune 2003 juin

express their emotions and their most complex thoughts,

beliefs and values (3). Although it seems obvious that, in
any clinical encounter, the ability to communicate effectively is essential, the underutilization of interpreters by
health professionals working with clients from
ethnocultural communities with language barriers remains
surprisingly common. Of concern is that most studies of
immigrants in Canada find that one, if not the greatest,
barrier to access to care is the lack of interpreters or of bilingual service providers (4,5).
Along with problems of accessibility, strong evidence indicates that, for those facing language barriers, services
and quality of treatment in the mental health and counselling domains differ (4). Even with successful health-care
contact, they underutilize mental health services and delay
seeking care for mental health problems, primarily because of language barriers (4). From an ethical standpoint,
mental health professionals underutilization of professional interpreters to overcome language barriers with
their clients represents a failure to meet basic professional
ethical standards of care.

Health Professional Resistance to Using

Interpreters
Several factors contribute to the current underuse of interpreters by health providers. First, the fear of malpractice
suits and other legal sanction has not been an important
motivatoras it has in the United States for increasing
the use of interpreters in Canada. However, this may soon
change. Recent cases in the health domain have been successfully argued on the basis of the Canadian Charter of
Rights and Freedoms, suggesting that legal challenges related to insufficient attention to the effect of language barriers on care may become more prominent in the future (6).
Second, the experiences and perceptions of mental health
providers affect the underutilization of interpreting services. Many mental health providers are reluctant to use
interpreters, because they are perceived to be too costly in
terms of time and effort. Further, working with an interpreter can be frustrating. It may seem to complicate communication by adding another actor to the clinical

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encounter, changing the dynamic and shifting the sense of

control over the interaction to which a mental health provider is accustomed. Perhaps most important, professionals may also underestimate the extent to which a language
barrier exists in a clinical encounter. It is easy to falsely
assess that a clients language skills are adequate.
Unfortunately, clients may reinforce this false perception;
they may wish to demonstrate their proficiency in English
or in French, which may represent a source of pride. It is
also true that some clients feel ill at ease with the presence of interpreters, because their professional status may
be ambiguous. They may have concerns about their trustworthiness and loyalty, given that interpreters and patients
are often from the same small communities, thus raising
fears about confidentiality.
Another difficulty stems from a lack of clarity on the part
of the clinician as to what is the appropriate role of the interpreter. Often, the health provider and the interpreter
have differing, if not conflicting, expectations about what
their roles should be in a clinical encounter. Some health
providers expect literal, word-for-word translation of client communication, whereas others rely on interpreters to
act as culture brokers who provide their own observations
and contextualizing information about the clients culture
and experiences. Part of the communication difficulty between the mental health provider and the interpreter stems
from the mental health providers lack of training in this
area. Most training programs in psychiatry and psychology do not formally teach, nor do they promote working
with interpreters as an essential clinical skill. This is unfortunate because providers awareness of the impact of
language barriers and of their own skill in working with
interpreters affects the effectiveness of the interpretation
process (5).
Despite the complexity associated with working with interpreters, the impact that communication barriers have on
health-care providers and their capacity to provide ethical
standards of care is significant. Henley and Schott identified poor referrals, incomplete investigations, and inappropriate interventions and treatments as consequences of
language barriers (7). Poor communication affects other
important aspects of care, such as the providers ability to
reassure, motivate and support the client, as well as to
clarify treatment expectations (8). Without clear communication, professionals cannot confidently apply their diagnostic expertise or establish the necessary empathy and
rapport for a working alliance. Overall, these practices
lower and compromise professional standards of care.
Finally, communication barriers result in stress and decreased job satisfaction for the provider. As reported by
professionals, feelings of ineffectiveness result in feelings
of frustration, guilt and anger (7).

Problems That Relate to Using Untrained

Interpreters
The most common current response to language barriers
in the health-care system is the use of untrained and often
unpaid volunteers, who are usually family members, bilingual hospital staff, or community language-bank volunteers. These services represent only a makeshift solution

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to the problem and ignore the serious ethical problems associated with this practice. Professional codes of ethics
stress the need for providers to obtain informed consent.
Clients have the right to informed decision-making with
respect to their treatment options, as well as to voluntary
decisions about receiving treatment that is based on all
available information about those treatment options.
Further, ethical conduct requires that clinicians provide
clear explanations, ensure confidentiality of information
and refrain from practising under conditions that may impair service quality. With the exception of emergency
treatment, common law in Canada places the onus of
responsibility on the health provider (primarily physicians
in this case) to ensure that the patient understands the
communicated information before administering
treatment (6).
According to experts in the field, there is consensus that
the use of untrained interpreters poses risks to the patient
and the provider, as well as to the interpreting person (6).
A report of the US Office of Minority Health noted,
the error rate of untrained interpreters (including family
and friends) is sufficiently high as to make their use more
dangerous than no interpreter at all. This is because it lends
a false sense of security to both provider and client that
accurate communication is actually taking place (9).

Family members, or untrained interpreters, may misinterpret key concepts, may distort or omit messages or may
intervene directly in the assessment or treatment process.
Their ability to remain objective in their task as interpreter is questionable at best. Any barriers related to cultural difference between provider and client will further
act as a barrier to informed consent in this context.
The use of informal interpreters represents a lack of recognition of the skills required to act as a competent interpreter. Mechanical word-for-word translation is often
insufficient to convey meaning. Often, words cannot be
literally translated from one language to another, owing to
a lack of clear correspondence between the words of the
two languages. Cultural idioms of distress and the context or meaning of a symptom can be lost in attempts at
literal translation. In addition, interpretation is a
cognitively demanding task. If a family member, also distressed about the clients situation, is asked to translate,
there is a greater possibility for error in translation.
Moreover, untrained interpreters level of language proficiency in the official and nonofficial languages may vary,
as may their knowledge of the subject area for which the
translation is being sought.
The use of family members or volunteers as interpreters
poses a direct threat to confidentiality, which is of particular concern in the area of mental health (10,11). Untrained
interpreters are unlikely to recognize the importance of
rules of confidentiality and objectivity required by professional ethical codes of conduct in health interpretation.
Some ethnocultural communities are extremely small;
thus, concerns about confidentiality may be warranted.
There are also ethical considerations involved in placing
the interpreters in this role. Often, volunteers do not want
to interpret in mental health situations but feel that they
have no option. They often report stress and discomfort
with their role (12). Similarly, the use of children as

CPA Bulletin de lAPCJune 2003 juin

translators in mental health settings is also highly problematic, given that much of the information to be translated is sensitive or potentially traumatic in nature. This
practice can disrupt normal family relationships and family structure and expose children to psychological risk.

The Need for Use of Professional Interpreters

In support of using professional interpreters, research indicates that a much higher level of satisfaction occurs
with professional interpreters, compared with volunteer
interpreters. A study by the Montreal interregional interpreters bank found that 76 per cent of clients reported that
they preferred to have a professional interpreter when
dealing with medical personnel, and 88 per cent had
greater confidence in the accuracy of the interpretation
provided. Likewise, 83 per cent had greater confidence in
their discretion with private information (13).
Despite the lack of consensus on how to achieve the most
effective interpretation, it is generally accepted that it
must involve more than just interpreting words. In fact, it
should also include the interpretation of meanings and the
clarification of misunderstandings that may arise owing to
cultural differences between provider and client (14).
What is also required is competency in translating the
culture of the psychiatric system in terms of the terminology, assumptions, practices and expectations to the client.
Finally, as professional interpreters are subject to clear
professional standards of conduct, ethical concerns about
informed consent and breaches of confidentiality are
addressed.

Issue of Quality of Care

In conclusion, ethically sound practice also represents
better quality of care. Reviews of the research literature
indicate that a relation exists between the quality of
patientprovider communication and the patients health
outcomes with respect to recovery from symptoms, anxiety, treatment compliance and patient satisfaction with
care (6). Poor communication impacts the professional by
increasing the likelihood of diagnostic errors and exposure to lawsuits. Moreover, there appear to be significant
health-care costs associated with communication barriers,
including an increased number of visits to the doctor and
an association with frequent changes of doctor (6). In
summary, interpreter services are essential, and mental
health-care providers should regularly access these services when working with clients who have language barriers. The reasons for their use include ensuring mutual
understanding, assuring quality of care, upholding users
rights and, ultimately, reducing health-care costs in both
financial and human terms (15).

CPA Bulletin de lAPCJune 2003 juin

References
1. Emmanuel ER, Rosen P. A professional response to demands for accountability: practical recommendations regarding ethical aspects of
patient care. Working Group on Accountability. Ann Intern Med
1996;124:2409.
2. Kirmayer LJ. Cultural variations in the response to psychiatric disorders and emotional distress. Soc Sci Med 1989;29:32739.
3. OHagan K. Cultural competence in the caring professions. London:
Jessica Kingsley Publishers; 2001.
4. Canadian Task Force on Mental Health Issues Affecting Immigrants
and Refugees. After the door has been opened; mental health issues
affecting immigrants and refugees. Ottawa: Minister of Supply and
Services Canada; 1988.
5. Lenoir-Achdjian A. Use of interpreters in the Quebec health care
system: a status report. Montreal: Regie regionale; 2000.
6. Bowen S. Language barriers in access to health care. Ottawa: Health
Canada; 2001.
7. Henley A, Schott J. Culture, religion and patient care in a
multi-ethnic society. London: Age Concern; 1999.
8. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of
physicianpatient interactions on the outcomes of chronic disease.
Med Care 1989;27:S110S127.
9. Office of Minority Health, US Department of Health and Social Services. Ensuring cultural competence in health care: recommendations for national standards and an outcome-based agenda.
Washington: Office of Minority Health. US Department of Health
and Social Services; 1999.
10. Betancourt JR, Jacobs EA. Language barriers to informed consent
and confidentiality: the impact on womens health. J Am Med
Womens Assoc 2000;55:2945.
11. Stevens SB. Community based programs for a multicultural society:
a guidebook for service providers. Winnipeg: Planned Parenthood
Manitoba; 1993.
12. Affiliation of multicultural societies and services agencies of BC.
Interpreter services in health care: a call for provincial standards.
Affiliation of Multicultural Societies and Services Agencies of BC;
2000.
13. Mesa AM. The cultural interpreter: an appreciated professional. A
study on interpreting services: client, health care worker, and interpreter points of view. Regie regionale de la sante et des services
sociaux; 1997.
14. Dias MR, ONeill EO. Examining the role of professional interpreters in culturally-sensitive health care. Journal of Multicultural
Nursing and Health 1998;4:2731.
15. Weiss R, Stuker R. Interpreteriat et mediation culturelle dans les
systeme de soins. Rapport de Recherche (11). Berne: Universite de
Neutchatel; 1998.

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