Introduction
Growing linguistic and cultural diversity in many societies pose particular challenges for health care (; ). Especially in psychotherapy, mutual understanding is essential for a successful treatment, as it forms the basis for interpersonal and emotional encounters (). A high level of linguistic communication is necessary to ensure adequate treatment (). A lack of linguistic understanding can become an obstacle for the psychotherapy of migrant patients who do not yet have sufficient linguistic proficiency (; ). Despite the fact that migrants may suffer from higher prevalence of mental disorders () and lower quality of life () compared to native populations, migrant patients face great barriers and challenges in the mental health care system (). Barriers in language and communication are one of the most frequently mentioned difficulties in providing adequate mental health care for migrants with a mental disorder (; ). People with a history of migration are under-represented not only among patients but also among mental health professionals, which limits the ability to offer of treatment in the patient's mother tongue to a few languages (; ). To overcome the language barriers in mental health care, a range of formal and informal practices are employed, including the use of family members and cleaning staff as interpreters (; ), relying on machine translation (), or the use of qualified or professional interpreters ().
Overcoming language barriers through professional interpreters
The use of qualified or professional interpreters has proven to be greatly beneficial in providing adequate mental health care for patients with limited language proficiency (; ). Due to the lack of legally established qualification standards in most countries, there is no clear definition of a professional interpreter's role. The term is usually used when interpreters are somehow trained for the task (; ). The amount and type of training, however, can vary significantly. From the perspective of interpreting studies, interpreting in psychotherapy is found in the field of community interpreting (), which includes a variety of fields of activity (). In comparison to conference interpreting, there is less regulation and standardisation, which makes a demarcation between professional and non-professional interpreting even more difficult (). Nevertheless, it could be shown that training contributes to an improvement in the quality of clinical care, which is reflected in better comprehension, fewer communication errors, a more frequent utilisation of clinical services, better clinical outcomes and higher satisfaction with care (). Studies examining the effectiveness of trauma therapy with refugee patients have shown that therapy conducted with a professional interpreter is as effective as therapies that do not require an interpreter, for example, therapy with non-refugee patients or therapy in a shared second language (; ; ; ). The need for an interpreter, therefore, should not preclude the provision of therapy (; ). In this respect, it is of particular importance that interpreters receive professional training and a certain level of psychological background knowledge (; ). According to there is also evidence that the mental health field differs from other medical fields in terms of the interpreting methods required, emphasising additional special training, for both interpreters and practitioners. The use of untrained ad hoc interpreters, such as bilingual family members, acquaintances or staff members, may hinder disclosure of sensitive material and raise the risk for distortions and errors (; ). Moreover, an unclear understanding of the role of ad hoc interpreters can ultimately lead to disadvantages for patients (). If certain conditions apply, an interpreter can ideally facilitate the development of a trusting relationship between the psychotherapist and patient using knowledge of both cultures and perspectives (Hannemann & ). Mentioned conditions include a trusting relationship between all parties involved, clear roles and professional competence (, 2021; ) as well as flexibility regarding the challenges of relationship building in the triadic setting (). A cross-national study also found that ensuring communication through interpreter services between the patient and practitioner is seen as an important component of principles for migrant health care in Europe ().
Barriers to the implementation of professional interpreters in mental health care
Despite the positive aspects mentioned, implementation varies across European countries and is generally low (). Various barriers and reservations concerning the work with professional interpreters persist. According to , the unfamiliar change in therapy setting from a dyad to a triad can be accompanied by scepticism (e.g., about effectiveness and relationship building), obstructive coalition formation, or complex transference and countertransference mechanisms. Sometimes health care practitioners are unable to recognise when limited language proficiencies pose a problem for treatment (). Some believe that they can “get by” and overcome the language barrier without an interpreter through gestures and the use of limited second language skills, which risk compromising the quality of care ().
Two of the main obstacles in terms of working with interpreters are bureaucratic hurdles and unclear financing prospects (, ; ; ). In Germany, where the current study was conducted, enabling linguistic communication between psychotherapist and patient, including the use of interpreters, is not part of the scope of services covered by the statutory health insurance (, ). Long processing times and very restrictive procedures include some of the initial barriers in implementing interpreter services (). In addition, the scarcity and accessibility of qualified interpreters varies greatly from region to region within Germany (, ). Further, even the initial access to psychosocial care can be impeded by a language barrier and thus lead to an under-utilisation of existing language mediation structures ().
Studies on interpreting in mental health care repeatedly point out that there are various barriers preventing practitioners from involving interpreters in their everyday care. An additional hurdle is that most studies primarily involve practitioners who already work with (professional) interpreters (; ; ; ; ). To increase the use of professional interpreters in outpatient mental health care, it seems particularly relevant to include those who do not yet work with professional interpreters. To date, no empirical study has examined the attitudes, especially subjective concerns, perceived barriers as well as possible benefits, of psychotherapists who have not yet worked with professional interpreters in outpatient interpreter-mediated psychotherapy (IMP). The aim of this study was to address this shortcoming by exploring 1) the psychotherapist's subjective factors influencing their expectations about IMP and 2) the structural factors that currently prevent or hinder interpreter integration into their everyday outpatient therapeutic practice. Moreover, this study explores how outpatient psychotherapists can be encouraged to provide IMP for migrants with limited language proficiency.
Method
The results are reported according to the COREQ checklist (consolidated criteria for reporting qualitative research; ).
Ethics
Ethical approval was obtained from the Ethics Committee of the University Medical Centre Hamburg-Eppendorf (4 April 2020; LPEK-0133). Participants received information about the purpose of the study and a description of the ethical rules used for research including confidentiality and informed consent. Information was conveyed via email in advance of the study and in oral form at the beginning of each interview. All participants gave written informed consent for the digital audio recording of the interviews, the recording transcription and the anonymous publication of the results. The interviews took place on a voluntary basis and participants received no monetary compensation.
Study design and researchers’ characteristics
We opted for a qualitative research design to explore the subjective perception of psychotherapists. The procedure followed the general basic design of qualitative research according to . A circular procedure of explication and specification was chosen to ensure that the selected methodological approaches were sufficiently tested and proved. The study was conducted by KG, SHR, MM and JB. KG is a female psychologist (MSc) who was a master's student majoring in cross-cultural psychology at the time the interviews were conducted. SHR is a female psychologist (MSc) and doctoral student (research areas: interpreting in social and health care, IMP, multilingualism in health care) with many years of experience conducting semi-structured interviews and qualitative data analysis. JB is a female professor of social psychology and member of the institute of migration research and intercultural studies (IMIS) with expertise in the area of attitudes toward migrants, prejudice and racism. MM is a male psychotherapist, researcher (research areas: migration and health, multilingualism in health care, health care service research) and professor of clinical psychology. He has many years of experience in conducting semi-structured interviews and qualitative data analysis. None of the other authors have a migration background.
Participants and recruitment
The study was aimed at outpatient psychotherapists in Northern Germany, either fully qualified or still in training, who had no experience in working with interpreters in psychotherapy. Participants were selected via purposive sampling (). Because we could not locate an adequate number of participants without prior experience with interpreters, we included psychotherapists who possessed only limited exposure to professional or nonprofessional interpreters in both inpatient and counselling environments. Furthermore, psychotherapists with limited familiarity with nonprofessional interpreters (such as family members) in outpatient settings were also incorporated. Psychotherapists experienced in working with professional interpreters in an outpatient setting were excluded from participation.
A maximum variation sample () was aimed for, with respect to therapeutic approach, years of work experience and gender. The recruitment process was carried out in two steps. First, a call for participation was published twice in the newsletter of the chamber of psychotherapists Hamburg, Germany. In a second step, all licensed psychological and child and adolescent psychotherapists in Hamburg listed on the public accessible website “www.therapie.de” (N = 322) were personally contacted via email or phone. Additionally, seven psychotherapy training institutes in Hamburg were contacted and asked to forward the call for study participation.
Interview guide and data collection
The interview guide was developed by KG in close consultation with SHR and MM, based on existing literature on the subject identified through a literature search on Google Scholar, PSYINDEX and PsycIndex databases. The conception of the interview guide followed the “SPSS” method according to , where questions are collected, reviewed and sorted, and finally subsumed. They were critically discussed and modified within an interdisciplinary research team and pilot tested by KG with two psychotherapists in training. Only a small change specifying the definition of an interpreter was made after the pilot interviews to avoid misunderstandings. The problem-centred interview according to was chosen, which is designed based on general probing questions, ad hoc questions and specific probing questions. The content of the interview focused on experiences with multilingualism in outpatient therapy and particularly aimed at accessing attitudes toward working with interpreters. The interviews opened with the preformulated warm-up question “Could you start by telling me a bit about yourself and your work as a psychotherapist?”, followed by the question “What experiences have you already had with the topic of multilingualism in therapy?”. Next, previous experiences and points of contact with the topic of interpreters in general were asked about, followed by a more specific discussion of concerns and positive aspects about working with professional interpreters. Subsequently, circumstances that currently prevent or complicate the use of interpreters and aspects that increase readiness were discussed. Finally, space was given to address previously unspoken issues. All interviews were conducted in German, subsequently translated into English by KG and submitted to a native speaker for correction.
Interviews were conducted between August and November 2020. Due to the coronavirus pandemic, it was up to the participants whether they preferred the interview in person, via phone or via a virtual meeting on an online platform. One participant preferred a personal meeting, the rest of the interviews were carried out via telephone. Before the interview, all interviewees were contacted by phone or email to clarify the framework and to answer questions about the design and topic of the study. In addition, written information on the study was sent out. The interviews were digitally audio recorded. They lasted on average M = 26:34 (range = 19:32–49:51) minutes.
Transcription and data analysis
Audio recordings of the interviews were transcribed by KG according to the simple, anonymous, and semantic transcription system of . Participants were offered the opportunity to proofread the transcripts as a part of communicative validation (), but no participant elected to do this. All interviews were analysed by KG in close consultation with SHR according to Kuckartz’s (2018) content-structuring qualitative analysis using the computer program MAXQDA Analytics Pro 2020. Relevant text passages were first marked. Main themes were then developed, and the entire text was coded accordingly. This was followed by summarising main themes of the text passages and an inductive determination of subthemes. These differentiated subthemes were used to categorise the entire text material again. From the literature search, aspects relevant to the research question were also included in the analysis as main themes and subthemes, so that the process was both inductive and deductive. Since comprehensibility of the data is a central quality criterion of qualitative content analysis (), parts of the anonymised interviews were read and coded by two other members of the interdisciplinary research team. In order to ensure the study’s traceability, the entire research process was documented.
Sample
The sample consisted of 13 psychotherapists (n = 10 female, n = 3 male). Twelve were licensed psychological psychotherapists. Three of them specialised in child and adolescent psychotherapy, and one was a licensed child and youth psychotherapist. The majority of interviewees specialised in cognitive behavioural therapy (n = 11), one in psychodynamic and one in psychoanalytical psychotherapy. The participants were on average M = 47.62 (range = 31 to 66) years old and had M = 13.61 (range = 2 to 40) years of work experience in the field of psychotherapy. Most of the participants (n = 12) were German nationals. None of the interviewed psychotherapists worked with professional interpreters in an outpatient setting. Four stated they had no experience with the topic of interpreters prior to the interview. Two stated they had some experience with interpreters in an inpatient or counselling context. One participant had worked on a regular basis with interpreters in an inpatient setting during her psychotherapist training. Another participant had worked once with an interpreter in a counselling context. Five participants had encountered the situation of relatives acting as ad hoc interpreters but had never worked with professional interpreters.
Results
Based on the qualitative content analysis, the following four main themes were identified: 1) subjective concerns about interpreter-mediated psychotherapy (IMP), 2) perceived opportunities regarding IMP, 3) currently hindering structural barriers and 4) potential facilitating factors that could make working with interpreters more feasible. Each main theme splits into several subthemes, which in turn consists of several subthemes (see Tables 1–4 in Supplemental Material online).
Subjective concerns about interpreter-mediated psychotherapy
Almost all therapists expressed concerns about IMP, with only three seeing no cause for concern. Four related subthemes were identified: Concerns regarding the 1) psychotherapist, 2) interpreter, 3) patient and 4) psychotherapeutic process (see Table 1 in Supplemental Material online).
Concerns regarding psychotherapists themselves
The most frequently mentioned concerns among psychotherapists themselves and their own work were insecurities regarding the novel triadic situation. Due to the unfamiliarity of the situation, doubts arose regarding the procedure of a therapy session with the involvement of a third person. Feelings of being observed and judged as well as a sense of possibly being overwhelmed by the unfamiliar setting and demands were also described. Uncertainty about dealing appropriately with different cultures was also mentioned. Overall, a lack of preparation for the specifics of a triadic intercultural situation was mentioned. Due to a lack of preparation, situational peculiarities, and the oftentimes precarious situation of refugees in particular, a sense of possible failure to meet one's own therapeutic aspirations was expressed:
They have already experienced so much insecurity and still have a lot of insecurity in their lives and then […] that makes everything distrustful. If I can’t offer that [reliability and security], then I don’t want to be responsible for it. (IP 4; “IP” = interview partner)
Concerns regarding interpreters
The personal and professional suitability of the interpreter were considered very important. Some psychotherapists were concerned that a lack of motivation and empathy from the interpreter may hinder or even interrupt the therapeutic process. Further concerns included insufficient emotional resilience and distancing capacity and the concern of having an additional person to care for in the room. Regarding professional competence, there was a concern that the interpreter might lack the necessary psychological background knowledge to grasp the therapy's objectives, processes or the specialised terminology being used. Without adequate linguistic knowledge and the ability to identify and differentiate nuances, the meaning of the content might not be interpreted correctly. In addition, misunderstandings due to insufficient cultural background knowledge were identified as a potential concern. Particularly, as some had experience with family members or acquaintances rather than professional interpreters, specific concerns were expressed; they believed that important topics, such as family conflicts or sexuality, might not be adequately discussed due to shame or reticence. In addition, the situation might be stressful for family members, especially for children.
Another obstacle mentioned was a possible incompatibility between interpreter and patient due to gender. For example, the presence of a male interpreter might present difficulties for a woman affected by sexual abuse by a man. Finally, almost all therapists were concerned about the proper interpretation of the communication. For some, another point of concern was a loss of information either due to the interpretation process or to a possible lack of objectivity:
Well, that's also a person who perhaps evaluates things differently, sees things differently, so there's the sender and the receiver and then another person in between. Yes, does something fall by the wayside, that would perhaps be my concern or, […] in the worst case, he or she evaluates or changes it. (IP 3)
Concerns regarding patients
The presence of a third person was assumed to be detrimental in some part to the patient's ability to develop trust:
These are already very, very sensitive topics that are addressed in such a therapy and it also takes time until someone can and wants to really open up and until a good basis is established. That would have to be the same with the interpreter, that there is trust. (IP 10)
One interviewee suggested that some patients may have difficulty trusting the interpreter's confidentiality, especially if both come from the same small and well-connected cultural community. In addition, a possible obstructive heightened sense of shame was mentioned, which related not only to the discussion of one's own intimate topics but also to the protection of the family. Especially in a context of psychoanalytical therapy, a reduced feeling of protection was mentioned:
Analytical work is about opening up and being very intimate, that is, about what you don’t want to see and have, what you reject. And then the person him-/herself already has to deal with it. If there's a third person, it's like a hole in the wall. Or the open window to the outside. That should not be. It should be closed, so that you can feel really safe and protected. (IP 4)
Additionally, some concerns regarding the patient did not refer to the work in the triad itself, but to culture-associated differences, which were assumed to hamper successful psychotherapy. Compared to German therapists, patients from other countries or with diverse cultural backgrounds might not have the same understanding about the concept of psychotherapy itself or the therapy relationship. This could go hand in hand with a more medical understanding of the therapy being associated with different expectations and demands. Other potential hurdles identified by participants were cultural differences in perceptions of gender roles, which might pose barriers to therapy access for women. Some psychotherapists described difficulties dealing with patients who had a patriarchal attitude.
Concerns regarding the therapeutic process
Several inherent characteristics of IMP were described as potentially hindering a smooth and successful therapy. The general framework of therapy might become overly complex. Some difficulties mentioned included arranging appointments between three people, more missed appointments and an increased time expenditure due to the interpretation process. In addition, there were some uncertainties regarding data protection issues, such as the interpreter's compliance with confidentiality.
There were further concerns that the interpreter’s presence could hinder or even prevent the general therapeutic process. It was also mentioned that the interpretation process may delay patients’ affect and the therapist's possibility of reacting to it; thus, emotional processes could be interrupted. Doubts were expressed as to whether some specific therapeutic techniques, such as relaxation procedures or hypnotherapeutic treatment, could be applied in the presence of another person.
Differences were mentioned with regard to the therapeutic approaches. The presence of an interpreter in psychodynamic procedures was assumed to be more obstructive than in cognitive behavioural therapy due to complex transference patterns and a loss of the inner, unconscious level. One psychodynamic therapist ruled out the possibility of the therapy having the desired effect in the presence of a third person, stating that such a presence would influence systemic dynamics. Two others mentioned a fear that conflicts could arise between the psychotherapist and interpreter, such as competition and devaluation or an alliance forming between the interpreter and patient due to linguistic and cultural proximity. In addition, a lack of clarity regarding the synergy of psychotherapist and interpreter could lead to an unclear distribution of roles and more conflicts.
Overall, as an important point, difficulties in establishing a therapeutic relationship between psychotherapist and patient were mentioned:
I actually believe that […] the therapeutic relationship suffers from this − or could suffer if you do not talk directly to each other, but through a third person. And that is probably also the biggest problem, because I think the therapy relationship is almost perhaps the most important thing in therapy. (IP 4)
Perceived opportunities regarding interpreter-mediated psychotherapy
Even though several concerns were voiced, the psychotherapists also saw opportunities in an IMP. Three related subthemes were identified: perceived opportunities regarding the 1) psychotherapist, 2) patient and 3) psychotherapeutic process (see Table 2 in Supplemental Material online).
Psychotherapists
First, IMP was seen as an opportunity to personally gain knowledge and experience. This could be gained by both the encounter with people from other cultural backgrounds and the experience of a new way of working and thinking.
Second, it was mentioned that a positive collaboration may arise when the interpreter and the psychotherapist successfully develop a strong team dynamic. If the overall work and communication responsibility could be shared, a possible feeling of relief could manifest in both parties. Further, the therapeutic work could be perceived as less lonely and more varied. Another opportunity included using the time during the interpretation to collect one's own thoughts and assess the patient's body language. Additionally, the need for a more structured way of working and expressing oneself in order to avoid ambiguities was cited as a positive aspect.
Patients
A central positive aspect of IMP, mentioned by all therapists, was the improvement and expansion of therapy for patients with limited German language skills. One interviewee's impression wasIntegrating these patients into the outpatient care system was seen as a particularly necessary step to receive adequate treatment.
[…] that so many people are desperately looking for help and support right now and it is not possible other than with an interpreter and so we come into a better supply […] of these people. (IP 12)
If an interpreter could effectively communicate, both in terms of linguistic and cultural understanding, the effectiveness of the psychotherapeutic treatment was assumed to be enhanced. Facilitated comprehension could also enable the patient to engage and open up in therapy through a heightened sense of safety and protection. In addition, an interpreter could ensure or enable the immediate treatment of symptoms, which may prevent chronic psychopathy and symptomatic decompensation and promote further integration into society.
Psychotherapeutic process
Some possible positive aspects of working with an interpreter were also mentioned for the therapeutic process itself. With positive cooperation, a kind of teamwork could emerge, enabling interdisciplinary collaboration. The interpreter's presence was in some cases assumed to have a potential de-escalating effect, which may support therapeutic techniques.
In contrast to the previously mentioned suspected difficulties, the support of an interpreter was also mentioned to have a potential advantage in the facilitation and promotion of the therapeutic relationship between the therapist and patient:
It is also possible to say that the patient enters into a therapeutic relationship more quickly because, conversely, he or she learns more from the psychotherapist about how psychotherapy is supposed to work, about the framework, about the type of procedure, about the points of view and then − I would also say from experience − feels more quickly taken care of and in a safe environment than when he or she is insecure for so long because of the language barrier. (IP 11)
Currently hindering structural barriers
The following two subthemes were identified as currently hindering psychotherapists from working regularly with professional interpreters: 1) barriers in their day-to-day therapeutic treatment and 2) structural barriers to accessibility and implementation (see Table 3 in Supplemental Material online).
Barriers in day-to-day therapeutic treatment
It was mentioned that the additional workload may be a major obstacle. This referred to the additional time and organisational effort required for finding appointments, applying for interpreting services, preparation and follow-up, etc., which was also not remunerated:
So, it’s mostly this extra effort. If I have to do an insane amount of phoning around and organising and that’s mostly unpaid working time for me and actually always ends up in overtime, then I tend not to do it […]. (IP 8)
In particular, the bureaucratic hurdles for funding were perceived as very high. This was accompanied by reports of insufficient treatment capacity, which was often linked to a general work overload. In two cases, it was also stated that the premises were not suitable for a three-person setting.
In addition, feeling unprepared for the triadic therapy situation was reported, as there was a lack of adequate preparation or discussion of IMP during their studies and psychotherapy training. Later in their work life, the existing IMP training offers by the chamber (working group and representation of interests on federal level of the psychological psychotherapist in Germany) were also perceived as insufficient.
Lastly, there were obstacles presented by the existing structures, which hindered their use of interpreters, for example, associations that provide interpreters were often not known. Many were not aware of the possibility of applying for interpreters and their region's reimbursement policy; thus, there was a lack of clarity about the access and application procedure itself.
Structural barriers to accessibility and implementation
On a structural level, little or no demand for IMP was reported due to a lack of requests from migrants with insufficient knowledge of German. This was partly attributed to a lack of information for migrants about existing services. It was also suspected that the existing language barrier could prevent or make it more difficult to establish initial contact. Furthermore, the placement into outpatient care structure was perceived as insufficient. A second major structural hurdle was the possibility of difficulties financing interpreter costs. This partly referred to a generally perceived sense of low allocation of health insurance funds to the treatment of people with a migrant background and the associated high bureaucratic hurdles. Psychotherapists also stated that the treatment itself would be prevented due to a lack of billing modalities:
So my willingness is high. The willingness of the patients is also high from my point of view. I don’t know that anyone doesn’t want it. I only know that it is refused or not possible because of the structural restrictions. Either that there is no [interpreter] or that none is approved. Or that the whole therapy is not approved. (IP 11)
Potentially facilitating factors
Lastly, the following factors, from the psychotherapists’ point of view, were mentioned which could enable or facilitate work with interpreters. Two subcodes were identified: potentially conducive factors on a 1) (inter-)personal level and 2) structural level (see Table 4 in Supplemental Material online).
(Inter-)personal level
On a personal level, promoting the therapists’ own sense of competence in relation to IMP might increase internal feelings of preparedness for such a novel triadic situation. The possibility of including the topic within the framework of psychotherapy training and increasing the exchange of experiences with colleagues were seen as particularly helpful in eliminating ambiguities and uncertainties.
Another key point mentioned was the promotion of trust between therapist and interpreter by emphasising the need to build an initial collaboration outside of the triadic relationship:
There should be a real cooperation with the interpreter, so that we can trust each other and know how the other person works, so that there is a real understanding for the way of working. (IP 10)
It was mentioned that ensuring the interpreter's suitability and competence would make it easier to engage with them. To facilitate the establishment of a relationship and also for the benefit of the patients, there was also a desire for the continuity of the interpreters.
Structural level
On a structural level, a reduction of bureaucratic hurdles was seen as necessary. The framework conditions in applying for interpreting services, as well as the further joint work should be “[…] clear, unambiguous and not too complicated in structure” (IP 4). Overall, the organisational effort should be kept as low as possible.
Another important point mentioned was an improvement of associated financial aspects. In particular, securing finance should be the responsibility of all those involved in the therapy. There should also be an increased sensitivity and willingness on the part of the health insurance funds to support interpreter services and an improvement in therapy options for people with insufficient knowledge of German.
Another point of discussion was the expansion of the information and training offered to psychotherapists to provide more opportunities to familiarise oneself with the triadic situation.
Finally, to enable requests for interpreters at all, access to outpatient psychotherapy for people with a history of migration should be facilitated, for example, by providing information about existing care structures, which involve a broader network of involved persons and institutions:
[…] or maybe with the clinics or the psychiatrists, that they can also pass on to us. I think that's really important, because otherwise it doesn’t reach the people who really need it. (IP 6)
Discussion
The purpose of this study was to explore the attitudes, especially subjective concerns, perceived barriers, and possible benefits of IMP from the perspective of outpatient psychotherapists who have not yet worked with professional interpreters in outpatient care. This study aimed to identify factors hindering the use of IMP in outpatient mental health care and to explore whether and under what conditions these factors could be overcome. Structural as well as subjective barriers and concerns were addressed.
The perceived lack of contact points between therapists and patients in need of interpreters, both in theory and in practice, confirms that intercultural access to the health care system has not been sufficiently implemented on various levels (; ; ; ). In particular, the lack of anchoring of intercultural topics in training institutions () was mentioned. Thus, although research has been conducted for several years in various disciplines on the special requirements of interpreting in health care, it becomes clear that results and recommendations already formulated in theory (; ; ; ; ; ; Penka et al., 2012; ; ; ) have so far found their way into practical work only inadequately. The interviewees reported not feeling sufficiently prepared for IMP. Unfamiliarity with the triadic setting was a recurring theme, with many therapists expressing uncertainty with regard to its implementation in sessions (e.g., seating arrangement, direction of view, etc.). Organisational aspects and questions about the ability to fulfil one's therapeutic role were listed as additional concerns. The need for further training was identified to help therapists acquire the necessary competence and confidence and increase dialogue and exchange on IMP-related topics among practitioners (; ).
Furthermore, a lack of demand for IMP was also reported. While the precise cause of this issue remains unclear, it can be inferred that it is partially due to barriers in accessing outpatient psychotherapy services for individuals with limited language skills in the country of immigration (; ). As noted by , the mere provision of professional interpreters is not sufficient when there is a lack of systematic identification and referral of patients who need them. As already mentioned, it is necessary to incorporate culturally sensitive oral and written information about health care services, including the possibility of using interpreters (). An important potential step is the development of a broader care network of referral practices from treating institutions (general practitioners, psychiatrists, psychosocial centres, etc.) to outpatient structures (, ).
The hurdles regarding funding (, ; ; ) were oftentimes still perceived as a main barrier.
Therapists' hesitancy about IMP was also associated with a high level of uncertainty and additional bureaucratic work due to time-consuming correspondence with the funding agencies. In addition, health insurance companies were found to lack awareness regarding the challenges and demands of health care access for migrants. The enduring perception of barriers to funding illustrates the need for secure funding, a standardisation of regulations, and increased training opportunities about existing structures, as is already in place in other European countries (; ).
Due to the perceived increased time and organisational and bureaucratic effort, IMP seemed difficult to implement with the psychotherapists’ generally high workload and lack of treatment capacities. As described by , access to interpreters must be embedded in adequate structural conditions in order to enable their use with as little time and organisational capacity as possible. To overcome these barriers the following solutions were expressed: financial remuneration for the extra effort, establishment of stable conditions regarding application procedures and remuneration of the interpreters, and facilitating the application process and communication channels with funding agencies. Although in most cases an improvement in the framework conditions could increase willingness and facilitate the possibility of increased work with interpreters, concerns were also named regarding the course of a triad approach to therapy. These concerns included the psychotherapist, the interpreter, the patient and the therapeutic process itself. At the same time, however, the work with professional interpreters was also associated with positive factors and opportunities.
Concerns about the interpreter included a lack of professionalism, competence and fit. This illustrates, as already emphasised in the literature (; ; ; ), the importance of using professional interpreters who have sufficient background knowledge on a linguistic, cultural and psychological level. Especially in the field of community interpreting, a divergence between the high standards expected and (in)sufficient qualification and preparation of interpreters exists (). In most countries, there are no legally established standards defining who may work as an interpreter in psychotherapeutic settings. However, interpreting in psychotherapy, like psychotherapy itself, needs to be recognised as a profession that requires formal training of the interpreters. adds that there could also be potential long-term benefits from professionalisation for the interpreters themselves, such as greater self-confidence, higher pay and better working conditions. The potential lack of emotional stability on the part of the interpreter concerns psychotherapists and is seen as a major burden which warrants sufficient supervision (; ).
In addition to professionalism and competence, the establishment of a coherent interpreter–therapist relationship was also named as an important point, as described in previous studies (). Getting to know each other in person, understanding the way of working, and interpreter continuity were mentioned as facilitators to build trust. This might also counteract the mentioned mistrust regarding the correctness and completeness of the interpretation. Given good cooperation and mutual trust, the presence of a third person was also described as offering opportunities, such as the possibility of consultation and interprofessional cooperation in therapeutic processes.
Doubts about aspects of the therapeutic process and its implementation were primarily linked to a lack of familiarity with the triadic situation. Our findings also highlight concerns about an increased risk of treatment dropouts due to scheduling difficulties, as already discussed (). Changes in the therapeutic process due to the presence of the interpreter were partly perceived as a hindrance, but also as an opportunity. Obstacles included an increased time expenditure, indirect communication, temporal displacement of what is discussed with a possible interruption of emotional processes, limited possibilities to react and to validate affectively, and limitations in applying certain therapeutic techniques. Although this raised ambiguities, it did not, for the most part, trigger any general doubts about the effectiveness of the therapy itself. Only one psychoanalytically working therapist believed that certain unconscious processes are lost in the presence of another person, which made IMP at this level difficult or even impossible. However, the effect of differences in various therapeutic orientations with IMP should be examined using a broader sample representing different schools.
At the same time, positive factors including acquisition of knowledge and experience when working in a transcultural environment, clearer and more concise speech and thoughtfulness, feeling supported and relieved by the interpreters and a higher level of reflection were assumed. This goes in line with previous reports from psychotherapists who have already worked with interpreters (; ).
Since the relationship between patient and therapist is considered an essential criterion of psychotherapeutic work, psychotherapists expressed varying opinions on the influence of a third person on this relationship. In some cases, establishing a strong relationship was assumed to be more difficult due to the presence of the interpreter and the indirect contact. However, it was also noted that only through the use of an interpreter was the cultivation of this relationship possible, since patients may feel more protected in the presence of someone that understands them linguistically and culturally. Similarly, other studies showed that the influence of an interpreter on the therapeutic relationship is perceived ambivalently by practitioners (; ). However, it should also be considered that both the interpreter in their person and visibility and the triadic interaction itself are real additional components in the psychotherapeutic setting (; ). Taking this into account, as already described by , one might envision rethinking psychotherapeutic characteristics specifically adapted to the triadic situation rather than deriving one-to-one rules only applicable in a dyadic situation.
Further concerns were mentioned relating to culturally associated differences, for example, in the understanding of the concept of psychotherapy itself. Once again, it is important to mention that there is a need for culturally adapted information for migrants () and the establishment of culturally sensitive training of health professionals with an emphasis in intercultural communication ().
Almost all respondents said they could imagine working with interpreters. This indicates that—despite existing personal concerns—structural factors rather than general personal reservations may be the major obstacle for the comprehensive integration of interpreters into outpatient care. Without exception, the possibility of increasing access to psychotherapeutic health care for migrants was named as a positive aspect of IMP. The need for enhanced integration that we described earlier (, ) was also voiced by the interviewees. However, one must keep in mind that the response rate of the study was only 4.04%, which may indicate that the present sample had an above-average interest in the topic of multilingualism and thus does not reflect the attitude of the majority of outpatient therapists. Nevertheless, opportunities were seen in preventing the chronicity of psychopathology, reducing the burden and symptoms of mental disorders and ultimately promoting integration. In particular, there was a consensus that the outpatient system was responsible for ensuring the continuity of care and providing opportunities for empathetic integration.
Strengths and limitations of the study
For a thorough evaluation of the presented results, the study should be considered in light of its limitations. The response rate of outpatient psychotherapists was very low. One possible reason is that the study population focused on psychotherapists who had no prior experience with IMP, which may be a limited group. Furthermore, psychotherapists with no prior experience with IMP may not have been motivated to participate. Thus, it may be that precisely those with deeper concerns did not participate in the study. Although therapists from different schools of therapy (CBT, psychodynamic, psychoanalysis) were interviewed, behavioural therapists were most frequently represented. Possible differences and difficulties with regard to therapeutic style (e.g., analytic, systemic, etc.) would therefore have to be examined with a larger sample. Due to the difficulties in finding appropriate study participants and a limited time frame of the study, data saturation could not be reached.
Nevertheless, the main strength of the present study is that it provides new perspectives and approaches in promoting the use of professional interpreters in outpatient mental health care—a necessary component to provide adequate care to migrant patients with insufficient language proficiency. The qualitative and exploratory study design allowed for the identification and in-depth understanding of a variety of factors currently preventing psychotherapists from working with interpreters in outpatient mental health care. Most studies that examine the perspective of practitioners on IMP primarily involve practitioners who already work with (professional) interpreters (; ; ; ; ). To date, no study could be found that focuses on the attitudes of psychotherapists who have not yet worked with interpreters in outpatient care. This study attempted to address this gap. Although no study participant had experience with professional interpreters specifically in outpatient mental health care settings, it must be critically noted that, due to recruitment difficulties, only four participants could be included who had no prior experience with interpreters in all clinical settings. The remaining participants had some prior contact points with professional interpreters or relatives as ad hoc interpreters in inpatient or counselling settings, or during their psychotherapist training. However, since the focus of this study was on barriers to use of interpreters in the outpatient setting, we nevertheless decided to include them. Reaching psychotherapists who have no experience with interpreters (“non-users”) and exploring their perspective proved to be highly challenging. However, understanding and addressing their concerns and perceived barriers is necessary to continue promoting the integration of interpreters in the outpatient setting and should, therefore, be considered in future studies.
Compliance with ethical standards
This study was pre-approved by the principal investigator's institutional review board (LPEK-0133) and complies with research ethical standards, including the rights, privileges, and protection of the participants, as well as contact information for participants to obtain further information and resources as needed. Participation was voluntary and withdrawal was possible at any time. Anonymity was preserved and identifiable places or situations related to the participants have been changed. Oral and written consent to participate were obtained.
Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD Saskia Hanft-Robert https://orcid.org/0000-0001-5766-1609
Supplemental material Supplemental material for this article is available online.
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