Therapy Across Languages

1. Therapy Across Languages BABCP Conference, July 23rd 2014 Dr Beverley Costa, CEO Mothertongue multi-ethnic counselling service www.mothertongue.org.uk

2. Mothertongue multi-ethnic counselling service Culturally and linguistically sensitive professional counselling service for people from black and minority ethnic communities Counsellors, patients and NHS professionals reported dissatisfaction with agency interpreters who were not trained and supervised to work in a Mental Health context Mothertongue responded by creating training for interpreters and clinicians in collaborative working , a training DVD and a dedicated Mental Health Interpreting Service which is funded by the local CCG and Health Trust

3. Training to work effectively with an interpreter • The importance of working collaboratively with an interpreter • If clinicians don’t feel confident they will find ways to avoid this work • Consequences are that: • Patients who need an interpreter get pushed down the waiting list • Therapists expect the therapy to be problematic • Therapists’ anxieties are left unresolved and reacted upon rather than understood and creative solutions found

4. Some fears of the interpreter Jargon Emotional overload Risk Role in the therapeutic relationship Lack of knowledge/context Clinician’s competence

5. Some fears of the clinician Am I being translated accurately? Will there be enough time? Trust e.g.confidentiality,reliability,consistency Can I establish a rapport/connection with client? Staying in control of the session

6. Some fears of the client Will the interpreter know my family? Will they tell anyone else? Will the interpreter judge me as we are from the same community? Will we be political enemies? Will they translate me accurately?

7. Karpman’s Drama Triangle • Persecutor • Rescuer • Victim PERSECUTOR RESCUER VICTIM Even though only one is called victim, all three originate out of and end up back at the position of victim

8. The therapeutic frame Anxieties are elicited when working in a mental health context. When an interpreter is involved, anxieties are often magnified, not least because there is another person’s anxieties and another set of relationships to consider in the room. The therapeutic frame (Milner: 1952) refers to the micro- and the macro- levels of structures which enable anxieties to be contained and worked with productively in mental health settings. Essential for safety. Dynamic administration (Foulkes: 1975) refers to the essential administrative tasks which contribute to the therapeutic containment and potential for transformative experiences that therapy can provide.

9. Mothertongue MINI Good Practice guide for clinicians when working with interpreters ISSUES TO OBSERVE: Explain your method of work and expected outcome to interpreter Let interpreter know if you will be using any specific terminology Introduce yourself and the interpreter. Think how you will manage beginnings and endings of sessions. Set the ground rules including confidentiality and the fact that everything spoken in the room will be translated Arrange seating so that everyone can see each other Clarify that you, the clinician, have ultimate responsibility for the session. It is necessary that the interpreter feels able to trust you to hold that responsibility Speak directly to the client Be aware of cultural differences Ask for clarification if there is misunderstanding Allow enough time for de-briefing at the end. Work collaboratively together with interpreter to form a counselling/therapy team Speak in small chunks so that the interpreter can translate accurately ISSUES TO AVOID: Use of jargon Referring to the client in the third person Giving responsibility for the session to the interpreter Speaking in unmanageable chunks Leaving the interpreter and the client in the room alone together Having a private conversation with the interpreter in the client’s presence Expecting the interpreter to be a general assistant or to look after the client Interfering with the interpreting process if you have some knowledge of the language

10. Outline: Therapy Across Languages • Ideas about multilingualism and therapy • Examples of research with multilingual therapists and patients • Practical Implications

11. Background Over 300 languages are spoken by schoolchildren in London (Burck, 2004: 315) Era of super-diversity for languages (Vertovec, 2007) In the UK, 1,298 are able to conduct therapy in more than one language out of a membership of 7,085 UKCP (2012)

12. Some relevant ideas from Linguistics • Bilinguals’ emotional responses to moral and political dilemnas in dual languages : (Panayiotou, 2004)((Rajagopalan, 2004)

13. Primary language and emotions Learning a language early promotes heightened emotionality of native language compared to additional language because: • Family context of learning • First language learning co-evolves with emotional regulation systems • Native language has greater connections with subcortical brain structures which mediate arousal (including amygdala-mediated learning)

14. Understanding the untranslatable “Every language contains its own naïve picture of the world including its own ethnopsychology” ( Apresjan, 1974)

15. Multilingualism and implications for therapy, with illustrations from our research • Identity • Defence • Expression • Protection

16. Identity I feel like a huge part of me just doesn’t go to therapy with me. I have different personas with each language I speak so only speaking in English in therapy isn’t helpful. If I have to translate into English… it just isn’t the same for me.

17. Implications for therapy “…if an individual’s other languages are ignored in the relationship altogether, significant aspects of their experience and of themselves might never be brought forth in their relationship” (Burck, 2005:130)

18. DEFENCE Not all therapists regard the ability to switch languages in therapy as necessarily positive Kraph, E. E. (1955) considered that the choice of the languages to work in (for polyglot clients) was not always therapeutically beneficial – the client might choose the language that caused the least amount of emotional arousal. Perez Foster (1996:262) summarises the dual functions of the language operations in the psyche of defense and expression as: “the power of bilingualism to both ally itself against the experience of psychic pain and to work in transformative adaptation toward the development of new self experience.”

19. Client (L1 Greek, L2 English) self report “I think when I talk about emotional topics I tend to code-switch to English a lot. I remember when I was seeing a psychologist in Greece for a while I kept code-switching from Greek to English. We never really talked about this ( …) To my mind it may have been some distancing strategy…. (JM Dewaele, 2010)

20. Emotional Expression “Sometimes the acquisition of a new language can provide a person with the “right expression” for a particular sentiment, and thus can be used as a coping mechanism to express emotionally loaded experiences. ……a second language served as a vehicle to become more self regulated by finding ways to verbalise feelings that were once censored or restricted by external forces” Imberti P. Exploring and understanding the Language Experience of the Non- English- Speaking Immigrant. Families in Society: The Journal of Contemporary Social Services; 2007: 71

21. Emotions When speaking in English my therapist assumed that I suppress emotions and advised me to let myself go.. then she changed into Spanish and noticed that I do not suppress emotions at all. Shame Speaking about topics which I was ashamed of. It is a way to put facts in the distance.

22. Protective function of second /subsequent language A language learned after the early childhood years can serve as a protective psychic defence, de Zulueta, F. (1984,1990). It can help clients to talk about traumatic events. If, for example, trauma happened in one language an individual may be able to talk about it in one of their other languages with a lessening of the emotional intensity, which makes it bearable.

23. Language in which trauma is recalled The Tehrani, N. & Vaughan,S. (2009) article: Lost in translation- using bilingual differences to increase emotional mastery following bullying. Counselling and Psychotherapy Research. Vol.9. No.1, explores the use of language switching in a bilingual client in order to increase emotional mastery after a traumatic experience: strategic use of bilingual identity for « repair »

24. Separate processing areas keep the intensity of feelings in one language separate from the experience of retelling the events in the other language. This is partly explained by reference to Dufour and Kroll’s (1995) identification of two separate language stores in the brain for first and other languages.

25. Trauma I felt more comfortable speaking about traumatic events in my non-native tongue. I feel that in my particular case I was able to let go of pain easier thus. I remember being given permission/being asked to express a traumatic incident in the language in which it happened. This I found very liberating.

26. Our research conclusions A multilingual client is different from a monolingual client Most multilinguals feel different in their different languages Language switches in therapy are more frequent when the emotional tone is raised Clients feel that switching languages helps them to self-regulate proximity and distance to/from feelings Language -switching in therapy could allow them to express themselves more completely

27. Multilingual clients’ experiences of therapy – a complex picture “Pisser dans un violon” v“Let the lips share it” My therapist did not understand my L1, however she asked me to talk about my childhood which seemed irrelevant in the therapy in English, however when I mixed in some words from my L1s, it started to make more sense talking about my childhood. As if English language did not let my memories come back efficiently enough, and I just needed some key words in L1 to bring memories back

28. Some of the issues identified with bilingual IAPT and other therapists No terms or appropriate language Client expectations from the relationship Concern about taking things too fast Finding one’s professional identity Feeling a fraud Maintaining their therapeutic footing when working in a shared “other” language Managers’ expectations and the realities of working therapeutically in multiple languages

29. Some tips for working therapeutically across languages • Train your clinicians to work with interpreters and work to a Code of Practice • Invite clients’ languages into the room even if you don’t understand them ( get the client to back translate for you so you can understand) • Set up a support/supervision group for your therapists who are working in more than one language • Attend to when bi/multilingualism can be used strategically for: • Repair (especially in trauma work) • Expression • Exploration of identity

30. Speaking like falling ….The problem with English is this: You usually can’t open your mouth and it comes out just like that – first you have to think what you want to say. Then you have to carefully arrange those words in your head. Then you have to say the words quietly to yourself, to make sure you got them okay. And finally, the last step, which is to say the words out loud and have them sound just right.   But then, because you have to do all this, when you get to the final step, something strange has happened to you and you speak the way a drunk walks. And because you are speaking like falling, it’s as if you are an idiot, when the truth is that it’s the language and the whole process that’s messed up. And then the problem with those who speak only English is this: they don’t know how to listen; they are busy looking at your falling instead of paying attention to what you are saying. (p.194) • We need new names, by No Violet Bulawayo, Chatto and Windus 2013

31. Suggested Reading • Burck, C. (2004). Living in several languages: implications for therapy. Journal of Family Therapy, 26, 314-339. • Burck, C. (2005). Multilingual Living: Explorations of Language and Subjectivity. London: Palgrave • Amati-Mehler, J. Argentieri, S. & Canestri, J. (1993). The Babel of the Unconscious, Mother Tongue and Foreign Tradition. Madison: International Universities Press. • Perez Foster, R. (1996). The bilingual self: duet in two voices. Psychoanalytic Dialogues, 3, 69-121. • Hoffman, E.(1989).Lost in translation: A life in a new language. New York: Penguin Books. • Dewaele, J.-M. (2010) Emotions in Multiple Languages. Basingstoke: Palgrave Macmillan. • De Zulueta,F. ( 1984) "The implications of Bilingualism in the study and treatment of psychiatric disorders: A Review", Psychological Medicine 14:541- 57. • De Zulueta,F. (1990) "Bilingualism and Family Therapy",  Journal of Family Therapy 12: 255-65. • Costa B. A working model of a community based, culturally sensitive counselling service, in Psychotherapy and Culture by Zack Eleftheriadou, Karnac Books 2010 • Costa, B. & Dewaele, J.M. (2012) Psychotherapy across Languages: beliefs, attitudes and practices of monolingual and multilingual therapists with their multilingual patients, Language and Psychoanalysis: http://www.language-and-psychoanalysis.com/ • Costa, B. & Briggs, S. (In Press) Service-users’ experiences of interpreters in psychological therapy: a pilot study DOI 10.1108/IJMHSC-12-2013-0044. • Costa, B. (2014) Counselling in many tongues. Therapy Today Vol. 25/4, 20 -23 • Dewaele, J-M., Costa, B. (2013) Multilingual Clients’ Experience of Psychotherapy Language and Psychoanalysis, 2013, 2 (2), 31-50 http://dx.doi.org/10.7565/landp.2013.0005