Moving to a foreign country is usually a stressful situation as people experience not only big changes in their lives but also face foreign culture and language. In the context of refugees, this situation becomes even more complex and stressful. Refugees are a group of people who left their home country and cannot go back safely, which caused by various reasons including war, actions of terrorist groups, racial, religious, and political issues (Dong, 2019). Due to their life background, refugees frequently experience mental and physical health disorders, treatment of which very often becomes more challenging because of the language barrier. The language barrier can cause not only difficulties but even dangers for refugees. In some cases, misunderstanding of doctor’s instructions can cost the health of the patient. The language barrier in such important life situations also may increase anxiety in patients. For avoiding possible dangers and decreasing anxiety, it is necessary for refugees to have professional interpreters in the healthcare setting.
Professional interpreters can provide more effective communication between refugees and medical staff. Better communication, in turn, may increase the level of quality of medical care and lead to the improvement of clinical outcomes. In addition, when interpreters are able to build trusting relationships with refugees, it also can be helpful for the stabilization of the psychological well-being of refugees. It is also worth noting that due to their race and ethnicity, refugees may often face discrimination that can cause anxiety as well. Being a cultural intermediary, an interpreter can help to avoid such situations. This research will argue the crucial need for refugees to have interpreters as it will decrease anxiety.
This study raises relevant themes as it is important to investigate some aspects connected with refugees, taking into account the current situation in the world. According to Bäärnhielm (2016), the war in Syria caused “the largest refugee crisis since World War II,” and 50% of the population had to leave the country (p. 375). According to the UN Refugee Agency, the total amount of refugees around the world counts for more than 25 million people, and the total number of displaced people are more than 40 million (“Figures at a glance,” 2019). Given such a large number of refugees, it is possible to agree that the problems associated with their migration and resettlement in a new country require discussion. Various studies analyze specific problems of refugees, including pre- and post-migration experience, mental health disorders, and the importance of interpreters in the healthcare setting. However, very few studies pay attention to the fact that having services of professional interpreters may help refugees to decrease anxiety. This paper will analyze secondary data and discuss this issue.
Pre- and Post-migration Living Difficulties
Changing the place of living is often a not easy experience, and refugees may face a lot of post-migration difficulties settling down in a foreign country. On a daily basis, refugees have to face challenges of the new environment, including such as related to “lack of resources, family separation, social isolation, acculturation and discrimination, socioeconomic factors, and immigration and refugee policies” (Schick et al., 2018, para. 2). Family separation turns out to be one of the most important challenges influencing the psychological well-being of refugees. According to Miller, Hess, Bybee, and Goodkind (2018), family separation causes great emotional distress in refugees. For instance, they may feel vulnerable because of being alone or be afraid for their family members who stayed in a dangerous environment. It is hard to deny that challenges that refugees face during their post-migration period cause mental health disorders or contribute to health problems that already exist.
It is also worth noting that refugees with children may feel even more stressed and anxious. Apart from having personal difficulties, parents may worry about their children’s adaptation in a new environment. In addition, they may face cultural pressure regarding their parental competence and parenting methods as they may differ from country to country. According to Fazel (2018), refugees may experience “challenges of adapting to a new parental role in a different cultural context” (p. 2). The researcher also notes that refugees are required to provide the socioeconomic necessities for their families. It means that, for instance, when facing financial difficulties, refugees need to think not only about their survival but also about the survival of their children. Thus, refugees with children may experience more difficulties and, in this regard, a higher level of anxiety.
Apart from the challenges of a new environment, it is important to discuss the refugees’ pre-migration experiences. In their countries of origin, refugees often face potentially traumatic events. It may include some global actions such as war, terrorism, and riots, or more privet issues connected with personal experience of a particular person such as torture, sexual abuse, and friend’s or relative’s death. Not to mention that both global and personal problems usually occur in the same time period. As Schick et al. note (2018), such traumatic “experiences are often prolonged, repeated, and interpersonal in nature and have a pervasive negative impact on mental health” (para. 1). Thus, both pre- and post-migration difficulties influence the development of mental health problems in refugees.
Working with refugees requires an understanding of their life background and current problems. The research conducted by Schick et al. (2018) has shown that the reduction of daily stressors and the improvement of post-migration living experiences help to reduce the level of anxiety and depression in refugees. In this regard, it is important to take into consideration the past and present problems of refugees when working towards positive outcomes of the treatment of mental health disorders.
Refugee Health Disorders
Mental Health Disorders
The problem of mental health disorders can be considered one of the most common problems among refugees. According to Sijbrandij et al. (2017), refugees often face the risk of developing symptoms of common mental issues. Many researchers call post-traumatic stress disorder (PTSD), depression, and anxiety the most common mental health problems in refugees (Kartal, Alkemade, Eisenbruch, & Kissane, 2018; Langlois, Haines, Tomson, & Ghaffar, 2016; Sijbrandij et al., 2017). Thus, it is hard to deny that this issue is widespread.
Given the seriousness of the mentioned health disorders, it is possible to agree that, in most cases, refugees require psychotherapeutic treatment. Thompson, Vidgen, and Roberts (2018), in their research, prove the effectiveness of psychotherapy for refugees but point out that they need a more adapted approach, in particular, trauma-focused psychotherapy. According to Dong’s findings (2019), cognitive-behaviour therapy, psychoeducation, parenting intervention, and art therapy can be helpful for the treatment of mental disorders in refugees. The researcher also notes the necessity of building a safe and trusting working environment during refugee psychotherapy and points out that social workers should adapt to the client’s needs and responses (Dong, 2019). Thus, to achieve the positive effects of psychotherapy, it may require more complex approaches and understanding the specifics of working with refugees.
However, it is worth noting that there is a problem of mental health stigma. The researchers MacDowell, Pyakurel, Acharya, Morrison-Beedy, and Kue (2020), in their study, surveyed Bhutanese refugees resettled in the U.S regarding their attitude toward psychological help. According to their findings, “more than half of the participants (55.2%) believed that it is shameful to see a mental health counselor and is a sign of weakness” (p. 4). This factor also should be taken into account by specialists working with refugees.
Physical Health Disorders
Apart from facing mental health problems, refugees often have physical disorders due to the experience they had. According to Langlois et al. (2016), refugee victims of torture and violence often have physical disabilities, “including malunited fractures, soft tissue injuries, musculoskeletal symptoms, neuropathies, head injuries, and epilepsy” (p. 2). In addition to creating difficulties in daily life, physical health issues may contribute to mental disorders. For instance, when losing the ability to perform usual physical activities, people may feel suppressed, vulnerable, and depressive. In addition, physical injuries may remind about traumatic events of the past.
It is also worth mentioning that anxiety or other mental health issues may become one of the reasons for physical disorders. The researchers note a high percentage of refugee patients with post-traumatic stress disorder having somatic symptoms (Morina et al., 2018). According to Morina et al. (2018), “somatization is considered a vital part of post-traumatic symptomatology in relation to complex trauma” (p. 51). Thus, it can be considered that mental and physical health are often interconnected.
It is also possible to agree that, being caused by a traumatic experience, problems of physical and mental health also make it more difficult for refugees to adapt to a new foreign environment. In this regard, it usually becomes almost impossible for them to cope with these issues themselves. Refugees need to get medical help regarding both physical and mental health. However, the language barrier problem may arise here, being especially acute in the healthcare setting. Given the complexity of the medical vocabulary, it may be more difficult for refugees to understand what is said, even if they know the foreign language on a sufficient level.
The Language Barrier in the Healthcare Setting
The researchers identify the language barrier as one of the challenges that prevent refugees from getting medical care. Gartley and Due (2017) point out that, in resettlement countries such as Australia, “lack of accessible information in languages other than English” creates difficulties for refugees when taking mental health services (p. 36). In addition, refugees often cannot get access to crucial information. According to Mangrio and Forss (2017), “the refugees are lacking information both regarding the healthcare system itself and their right to access it in the host countries” (p. 15). The bad quality of communication can lead to discomfort and fear of misunderstanding, which also may cause an increase in the level of anxiety.
Poor language skills are not the only reason for a communication barrier. Mangrio and Forss (2017) analyzed several studies that discuss the feelings of refugees when communicating with doctors. According to their findings, refugees may not feel comfortable enough to start discussing their mental health problems themselves, especially depression. They would prefer a doctor to start asking questions regarding their psychological well-being. In addition, refugees often cannot achieve a personal level of communication with medical staff, which also prevents them from discussing their mental health. It is necessary to provide interpreters for refugees to solve the problem of the language barrier and create a comfortable environment during the treatment process.
The Role of Interpreters for Refugees
Using interpreters in the healthcare setting can help to increase the quality of providing medical services and create a more comfortable atmosphere for refugees. According to Dubus and LeBoeuf (2019), “interpreters are critical for effective, culturally competent service delivery” (p. 839). As Kletečka-Pulker, Parrag, Drožđek, and Wenzel (2019) note, understanding healthcare information is crucial, especially in emergency situations. Some studies also prove that refugees themselves express the need for interpreters. According to Kletečka-Pulker et al. (2019), surveyed refugees living in the US “expressed willingness to seek healthcare more frequently if interpreters were available in healthcare facilities” (p. 347). In addition, as the researchers state, refugees would like to have an opportunity to gain access to an interpreter through healthcare websites (Kletečka-Pulker et al., 2019). It is possible to agree that refugees’ willingness to have interpreters proves that, in their presence, they feel more confident and calm.
The Importance of Trusting Relationships Between Interpreters and Refugees
An interpreter can be considered not only the provider of language translation but also the source of support for refugees. When sharing a similar cultural background, interpreters and refugees can build trusting relationships, which contributes to the positive outcome of psychotherapeutic treatment. According to Gartley and Due (2017), interpreters perform multi-functional work “providing meaningful communication in terms of not only language translation, but also the mediation of cultural or ethnic norms and understandings” (p. 37). Moreover, the researchers assume that, with the help of interpreters, it is more likely to build trusting relationships between refugees and psychotherapists, even during the initial phase of the treatment process (Gartley & Due, 2017). It is possible to agree that when having the trust toward interpreters and psychotherapists, refugees are more likely to experience a lower level of anxiety during the treatment process.
It is worth noting, however, that the same ethnic and cultural origins do not guarantee the trust of refugees towards interpreters. There are even cases when it causes quite the opposite situation. Mangrio and Forss (2017) discuss Fang’s research that analyzed the setting when the interpreters were from the same community as refugees. According to Fang, in that situation, refugees “were afraid of personal information being disclosed among the community” (as cited in Mangrio & Forss, 2017, p. 10). In this regard, to be able to develop trusting relationships with refugees, it is more important for interpreters to have a high level of empathy and professionalism.
Apart from cultural aspects, such factors as an interpreter’s gender also can play a significant role. Nithianandan et al. (2016) conducted the study interviewing refugee women with depression and anxiety symptoms, focusing on perinatal mental illness. Some interviewed women reported that it feels more safe and comfortable for them to have a female interpreter (Nithianandan et al., 2016). In this regard, it is hard to deny that some life aspects, especially in the context of mental health disorders, can be discussed more easily with specialists of the same gender as a refugee. It also leads to the conclusion that refugees require a more individual approach when choosing an interpreter.
The interpreters who have experience of work with refugees also note that it involves a deep understanding of many factors. The study conducted by Dubus (2016) included results of a survey of interpreters who worked with refugees. According to the researcher’s findings, many interpreters see refugees not as usual clients but as people who need help and support. For instance, one of the surveyed interpreters notes: “They have more needs than other clients. They look to you not just as an interpreter but as a link between the two cultures, two worlds… they need more, like housing and food, and help that is more than just interpreting” (Dubus, 2016, p. 654). Thus, many interpreters also consider refugees as more vulnerable and understand their need for support.
In addition, interviewed interpreters also point out how important to build trusting relationships with refugees. Some of them seek to know their clients’ experience and origins, understand their fears to be able to provide a safe environment for refugees (Dubus, 2016). For example, one of the research participants assumes that trust is more important with someone who is a refugee as they are more scared of people, being afraid to get hurt again (Dubus, 2016). When analyzing the findings of the mentioned study, it is possible to agree that understanding the specifics of working with refugees allows the interpreters to provide better service and build more trusting relationships with clients.
It is also worth noting that refugees often may face discrimination due to their nationality or race. Researchers Dhalimi, Wright, Yamin, and Arnetz (2018) found out that ethnicity remains a significant factor influencing the attitude to refugees. According to Kim, Keovisai, Kim, Richards-Desai, and Yalim (2019), Vietnamese Americans experience “various types of discrimination in the United States, related to such characteristics as race/ethnicity, limited English language proficiency, cultural differences” (p. 386). Chen et al. describe that there are reported cases when doctors put on an extra pair of gloves, examining refugee patients (as cited in Mangrio & Forss, 2017). Thus, discrimination still occurs rather frequently, including the healthcare setting. As it was mentioned above, an interpreter contributes to building more positive relationships between refugees and medical staff. In this regard, it is possible to agree that an interpreter, being a mediator between two cultures, can also help to avoid some situations involving discrimination.
Machine Translation, Video and Telephone Interpreting
It is important to discuss the problem of the lack of on-site interpreters. It is suggested that the lack of interpreters in healthcare can be addressed by machine translation (Showstack, 2019). However, according to Showstack (2019), this type of translation cannot provide adequate service and can be considered “extremely risky in healthcare contexts” (p. 580). As for telephone interpreting, some researchers also consider that type as not appropriate in the context of refugees. According to Kletečka-Pulker, Parrag, Drožđek, and Wenzel (2019), “working with refugees requires more attention from the interpreter” that can be hardly achieved via telephone (p. 355). It does not allow to create face-to-face communication and follow the gestures and mimics of participants.
In cases when it is not possible to have a professional interpreter on-site during the treatment, communication with interpreters via video conference can become a possible solution. Schulz, Leder, Akinci, and Biggs (2015) conducted the research aiming to understand the acceptability of video conference with an interpreter during the treatment process of refugees and immigrants. Their findings show that video conferencing with an interpreter is well accepted by both doctors and patients (Schulz et al., 2015). Thus, in situations of the lack of interpreters in certain countries or regions, it is possible to get services of interpreters having technologies for video conferencing.
Professional and Ad Hoc Interpreters
It is also crucial to consider the level of qualification of interpreters providing services for refugees in the healthcare setting. Some researchers discuss the problem that exists in the USA, Australia, and UK, resettlement countries for many refugees. According to Showstack (2019), many patients, especially belonging to linguistic minority groups, are left without sufficient language services in the hospitals of the US, Australia, and the UK. It creates potentially dangerous situations for refugees who usually belong to the mentioned linguistic minority groups. With the absence of professional interpreters, refugees often have to use the services of ad hoc or untrained interpreters. As Showstack (2019) notes, “the use of non-professional ‘ad hoc’ interpreters can cause dangerous errors in communication” (p. 580). These errors in communication, in turn, can lead to serious consequences regarding the physical and mental health of patients.
In addition, in some cases, the interpreter’s role is performed by the patient’s relatives or even children who achieved more advanced language skills. These situations may lead not only to inaccurate translation but may become a traumatic experience for children. According to Showstack (2019), “using children as ad hoc interpreters, or ‘language brokers,’ can cause them to suffer from emotional trauma” (p. 580). Other researchers note that it also may affect the relationship structure within a family (Granhagen Jungner, Tiselius, Blomgren, Lützén & Pergert, 2019). Thus, the need for professional interpreters is caused not only by consequences for refugees who need treatment but, in some cases, by implications for their children.
Professional interpreters are trained specialists having a set of specific competences. As Kletečka-Pulker et al. (2019) note, ad hoc interpreters have only general language competence, which is not enough for efficient work. A professional interpreter, apart from high proficiency in at least two languages, must have cultural and translation competences. It is crucial to have an understanding of all cultures that participants of the dialog present, including specific behaviour patterns (Kletečka-Pulker et al., 2019). As for translation competence, it includes the ability to convert the linguistic content to another language accurately and behave in a professional manner before, after, and during communication (Kletečka-Pulker et al., 2019). In addition, using the technique of note-taking, a professional interpreter is able to convert not just the main ideas, but all statements without missing important details. At the same time, the trained specialist can omit statements of personal opinion or assessments, remaining objective and impartial. Thus, the work of a professional interpreter includes many skills that cannot always be mastered without special education.
Only with the help of professional interpreters, it is possible to provide accurate and objective information and build meaningful communication. Showstack (2019) points out that “the use of highly proficient language concordant providers leads to greater patient trust, more agreement, and, in some cases, better health outcomes” (p. 580). The research conducted by Granhagen Jungner et al. (2019) also shows positive results for health outcomes when using professional interpreters. The researchers analyzed several studies that “show that treatment time increases and patient-safe communication decreases when professional interpreters are not used” (Granhagen Jungner et al., 2019, p. 1015). At the same time, researchers note the opposite situation: when using professional interpreters, the frequency of errors in translation is significantly reduced (Granhagen Jungner et al., 2019). In this regard, it is possible to agree that only professional interpreters can be allowed to work with refugees in the healthcare setting.
With a professional interpreter, it is also easier for refugees to discuss some sensitive personal issues. According to Nithianandan et al. (2016), the interviewed refugees noted that it was easier for them to speak on personal topics if they trusted the professionalism of an interpreter. Thus, the level of professionalism of an interpreter has a crucial role when providing services for refugees. It is also possible to agree that when having professional and trusted specialists, the refugees experience a lower level of anxiety.
It is hard to deny that professional interpreters positively influence the psychological well-being of refugees in the healthcare setting. When having access to professional interpreters, it increases the chance that refugees will be able to visit a doctor or psychotherapist. The researchers Felsman, Humphreys, and Kronk (2019) surveyed a group of refugee women. According to their findings, “a lack of trained interpreters contributes to reduced access to health and social service, causing further distress” (p. 310). With an interpreter participating, the communication process can also occur without additional stressors. As Gartley and Due (2017) note, some of the refugees they interviewed reported that, when interpreters were not used, they had difficulties trying to formulate their issues and concerns. The expression of one’s thoughts, feelings, and concerns is an essential part of the psychotherapeutic process. When not having the ability to do this, it may become a stressful situation and reduce the possibility of a positive outcome.
Introducing interpreters in the psychotherapeutic process often causes controversy. However, some researchers note that with the adequate approach, it may have additional advantages apart from helping dialog participants to understand each other. According to Dickerman and Alfonso (2015), when an interpreter and therapist discuss their work and goals to be achieved, contributing to a common understanding of cultural and psychological contexts, it can be tremendously helpful. Thus, in case all specialists participating in the process have a high level of professionalism, introducing an interpreter can have a positive effect on the treatment process.
Conclusion
One may conclude that interpreters play a significant role for refugees in the healthcare setting. However, they become helpful for the reduction of anxiety in refugees only when certain requirements are met. Interpreters must possess a high level of professionalism that involves language, cultural, and translation competences. It is also necessary to know the specifics of working with refugees. It is crucial to understand refugees’ origins, their experience involving traumatic and stressful events, the limitations and challenges they face living in a foreign country. Together with a high level of empathy, this understanding may help to build trusting relationships with refugees. In the framework of psychotherapy, interpreters also need to understand the goals to be achieved during the psychotherapeutic process. Meeting the mentioned requirements and conducting multi-functional work, interpreters can greatly contribute to anxiety decreasing in refugees that may also result in a positive treatment outcome.
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