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Graduate Student Journal of Psychology          Copyright 2011 by the Department of Counseling and Clinical Psychology 

2011, Vol. 13               Teachers College, Columbia University 

12 

 

 

Interpreter-Mediated Therapy for Refugees:  

A Need for Awareness and Training 
 

Stacy J. Cecchet and Dena Calabrese 
Seattle Pacific University 

 
This brief report discusses the challenges arising from interpreter-mediated therapy in the treatment 

of refugees with Post Traumatic Stress Disorder (PTSD).  Although the refugee population 

continues to grow in the United States, the treatment competency of mental health professionals 

working with this population has not adequately responded to this growth.  As a result of the 

trauma often experienced by refugees many present with PTSD symptomatology and require 

trauma-focused mental health care.  Language disparities between clinical psychologists and 

refugees often result in the need for interpreter-mediated therapy, yet psychologists lack awareness 

and relevant training in working collaboratively with interpreters to provide competent care.  The 

complex reality of interpreter-mediated therapy can involve substantial deviations from the 

refugee’s original message and deprive refugees from receiving adequate treatment.  

 

 

Of the estimated 16 million refugees globally, over 2.5 

million have been relocated to the United States (United 

Nations High Commissioner for Refugees; UNHCR, 2009).  

In addition to not speaking English (United States 

Department of State, Bureau of Population, Refugees, and 

Migration, 2001), many refugees experience forced 

separation from loved ones, a lack of formal education, 

restricted employment and housing opportunities, and 

discrimination from both the general population and other 

ethnic minorities (Iwamasa, Hsia, & Hinton, 2006).  

According to The United Nations High Commissioner for 

Refugees (1951):  

A refugee is defined as anyone fearing of being 

persecuted for reasons of race, religion, nationality, or 

political opinion who is outside of the country of his or 

her nationality and is unable or, owing to such fear, is 

unwilling to avail him- or herself of the protection of that 

country; or who, not having a nationality and being 

outside the country of his or her former habitual 

residence as a result of such events, is unable or, owing 

to such fear, is unwilling to return to it.  (p. 16)  

Given their traumatic history and the hardships they face 

upon arrival in the U.S., many refugees suffer extreme 

distress and require trauma-focused mental health care.  

However, the reality is that the refugee population continues 

to grow in the U.S., and the psychological community has not 

adapted to meet the needs of this community. 

 

 

A Rationale for Interpreter-Mediated Therapy 

There is currently a gap in the implementation of 

culturally relevant psychotherapy interventions for ethnic 

minorities. Although approximately 25% of the U.S. 

                                                 
Correspondence concerning this article should be addressed to 

Stacy J. Cecchet, Department of Clinical Psychology, Seattle Pacific 

University, 3307 Third Avenue West, Suite 107, Seattle, WA 98119-

1922. Email: cecchet@spu.edu 

population is an ethnic minority, only 7% of clinical 

psychologists fall into this category (Norcross, Karpiak, & 

Santoro, 2005).  Due to this disparity, non-English speaking 

clients may face several challenges in their communication 

with English-speaking therapists, who may misperceive 

cultural influences.  Even more, much of the language used 

in psychology, as well as in case conceptualization, is rooted 

in a Western world view and can often lead to imposing 

Western ideals of social convention and role expectation onto 

refugees (Tribe, 2007).  

 For refugees in particular, the inability to speak English 

and communicate fluently can be both frightening and 

disempowering (Tribe, 2008). Few refugees speak English 

and relatively few psychologists speak multiple languages. 

As such, therapists must rely on the use of interpreters to 

facilitate the therapeutic process (Miller, Martell, Pazdirek, 

Caruth, & Lopez, 2005).  Using interpreters, many of whom 

are insufficiently trained in the field of psychology, 

contributes to an already complex endeavor (Farooq, Fear, & 

Oyebode, 1997), including the erroneous interpretation of 

psychological symptoms and subsequent misdiagnoses.  

Psychologists have rigorous standards that include an ethics 

code, state laws, and institutional mandates, yet none of these 

appear to sufficiently address how to work collaboratively 

with an interpreter to provide competent care.   

In addition to our ethical obligation to provide treatment 

to this population, the absence of interpreter-mediated 

treatment for refugees violates the standards put forth by the 

Office of Minority Health (OMH) for Culturally and 

Linguistically Appropriate Services (CLAS; OMH, 2001).  In 

an effort to improve the health of minority populations, the 

OMH adopted 14 CLAS standards to address culturally 

competent care, language access services, and organizational 

support for cultural competence.  While the CLAS standards 

have signaled an appropriate first step towards addressing the 

inequities of health care, the standards regarding access to 

language services are largely directed at policy makers and 



CECCHET & CALABRESE 

 

13 

 

have, unfortunately, circumvented awareness in the field of 

psychology. This lack of awareness coupled with the 

substantial refugee population in the U.S. highlights our 

ethical responsibility to gain training and experience with this 

population.   

We believe that training standards for collaboration 

between psychologists and interpreters have yet to be 

established.  This absence of training is a direct result of a 

lack of awareness and a gap in the literature, all of which 

deprive a large population of refugees from receiving 

adequate treatment.  Culturally competent treatment of 

refugees requires the training of both psychologists and 

interpreters in collaborative care.  In order to generate greater 

awareness of this subject matter, and thereby influence the 

psychological community to take action, the current paper 

presents a brief report on interpreter-mediated therapy as it 

exists today.  First, we seek to establish the need to provide 

competent care to the refugee population by illustrating their 

unique experiences of trauma.  Second, we will address the 

complex reality of interpreter-mediated therapy as it relates 

directly to the refugee population.  Finally, we provide 

suggestions for areas of future research and growth. 

 

Understanding PTSD Experiences Among Refugees 

Although the symptom presentation of PTSD is largely 

cultural and dependent on race, gender, and the type of 

trauma experienced, many refugees exhibit enough 

symptoms to meet diagnostic criteria of PTSD as outlined in 

the Diagnostic and Statistical Manual of Mental Disorders 

(American Psychiatric Association [DSM-IV-TR], 2000; 

Keller, et al., 2006; Regel & Berliner, 2007).  In addition to 

experiencing the intrusive, avoidant, and arousal symptoms 

characteristic of PTSD, other often multiculturally influenced 

characteristics  include feelings of self-blame, guilt, shame 

(Drozdek, 1997), poor coping strategies, negative self-

concept, and hyper-vigilance (Silove, Sinnerbrink, Field, & 

Manicavasagar, 1997). 

Despite the universality of PTSD clinical features, the 

traumatic experiences of refugees are qualitatively different 

from the traumatic experiences of non-refugee clients 

(Kinzie, 2001), even those from ethnic minority 

backgrounds.  The traumatic experiences of refugees are 

typically extreme (i.e., torture), prolonged, and persistent 

(Kinzie, 2001; Nicholl & Thompson, 2004).  Literature is 

abundant in describing the traumatic events experienced by 

refugees.  One Cambodian woman recounted the time she 

was forced to witness her husband being slaughtered while a 

knife was held to her throat and her life threatened if she 

spoke a word (Kinzie, 2001).  An Iraqi Kurdish man detained 

by Iraq security forces was subjected to prolonged 

interrogations, frequent beatings, cold water dousing, 

suspensions off the floor for hours with his arms bent 

backwards, and genital mutilation for three months; he was 

taken to the hospital twice when his body gave way to the 

torment, only to be returned to the prison when he was 

revived (Regel & Berliner, 2007).  A Rwandan woman was 

raped by her son as soldiers held a knife to his neck.  Her 

husband was forced to watch and their young children were 

forced to hold open her legs (Landesman, 2002).  Examples 

such as these illustrate the extreme, prolonged, and persistent 

traumas refugees experience, and unlike non-refugees, the 

environmental realities from which they seek asylum.  For 

refugees, everyday life equates to a continuous threat to 

safety; trauma is a perpetual state of existence. 

As a result of severe trauma experienced by refugees, up 

to 86% of this population displays PTSD symptomatology 

(Thulesius & Hakansson, 1999).  Currently, Trauma-Focused 

Cognitive Behavioral Therapy (TF-CBT) is recognized as a 

first line treatment for individuals who manifest symptoms of 

PTSD (Bisson & Andrew, 2005).  TF-CBT is an adapted 

model of CBT that specifically addresses PTSD symptoms, 

depression, behavior problems, and other difficulties related 

to traumatic stress (Cohen & Mannarino, 2008; for a review, 

see Child Sexual Abuse Task Force and Research & Practice 

Core, National Child Traumatic Stress Network, 2004).  TF-

CBT has been found to be efficacious in diverse cultural 

backgrounds and multiple languages, as well as in the 

treatment of multiple traumas, sexual abuse, and traumatic 

grief.  Despite the effectiveness of this treatment (Cohen & 

Mannarino, 2008; Mendes, Mello, Ventura, de Medeiros 

Passarela, & de Jesus Mari, 2008), TF-CBT remains 

unutilized with refugees.   

 

The Complex Reality of Interpreter-Mediated Therapy 

Therapy would not be possible for many refugees 

without interpreters.  The use of an interpreter allows the 

refugee to communicate in his or her native tongue and 

utilize culturally relevant linguistics to facilitate accurate 

communication and a comfortable working pace.  Yet, the 

presence of an interpreter adds new dimensions to the 

therapeutic process, including additional factors that need to 

be considered in therapy.  Interpreters imbue translations 

with corrected cultural meaning and may not interpret 

verbatim (Farooq, Fear, & Oyebode, 1997).  Farooq and Fear 

(2003) identify common interpretation errors while using an 

interpreter: (a) omission (a portion of the therapist’s question 

or the client’s answer is left out of the interpretation); (b) 

addition (the interpreter adds his or her own information into 

the client’s response); (c) condensation (the interpreter 

paraphrases a client’s response); (d) substitution (an 

interpreter replaces a concept that the therapist uses with 

another similar, but abstractly different concept); (e) role 

exchange (the interpreter asks his or her own question instead 

of the therapist’s); (f) closed-ended questioning (the 

interpreter tries to shorten or simplify the questioning process 

by shifting the questions to a closed format); and (g) 

normalization (the interpreter is unsure of how to interpret 

information from a client and thus will attempt to provide a 

rationalized version of the client’s response). 

In addition to interpretation errors, other factors may 

play a role in confounding the therapeutic process.  

Interpreters often play multiple roles when working with 

clients; they are translators for language and culture, client 

advocates, co-workers, neighbors, social workers, and family 



INTERPRETER-MEDIATED THERAPY FOR REFUGEES 

 

14 

 

members (Farooq & Fear, 2003; Raval & Smith, 2003).  

Multiple roles can create complications for both the client 

and the interpreter.  If the refugee and the interpreter share 

the same culture, the interpreter may feel that the client’s 

disclosure will bring shame to his or her country of origin.  

As a result, this is likely to lead to errors in interpretation.  

An additional complication arises when the interpreter has a 

close relationship with the client outside of therapy (i.e., 

family member, neighbor), which can contribute to the client 

withholding information for fear of embarrassment or lack of 

privacy.  Moreover, if the interpreter has experienced a 

trauma, the interpretation process may lead to a re-

experiencing of trauma for the interpreter.   

Regardless of the interpreter’s role, the task of 

translating communication from the refugee to the 

psychologist involves an unconscious act of gatekeeping 

(Davidson, 2000; Wadensjö, 1993). As a function of 

gatekeeping or coordinating communication, the message 

between the refugee and psychologist is altered, albeit 

unconsciously, by the interpreter.  Though the reasons for 

altering the message remain unconscious, this creates an 

unavoidable bias in communication that is beyond the 

purview of the psychologist.  There appears to be intrinsic 

and extrinsic forms of gatekeeping.  Intrinsic gatekeeping 

reflects the interpreter’s personal belief system and may 

reflect attempts to “communicate more clearly, avoid 

conflict, or present a cultural perspective different from what 

is given in the intended message” (Hwa-Froelich & Westby, 

2003, p. 82).  Extrinsic gatekeeping reflects differences in 

linguistic systems and variations in comprehending socio-

cultural differences embedded within the context of 

communication (Davidson, 2000).    

Though interpretation errors, multiple roles, and 

gatekeeping are inevitabilities of interpreter-mediated 

therapy, many interpreters have little or no training in these 

areas. While these problems may always exist to some extent, 

it is likely that awareness and training in these areas may 

limit deviations in the original communication. Hwa-Froelich 

and Westby (2003) acknowledge an overall lack of available 

educational opportunities for professional interpreters, 

highlighting that certification requirements are also not 

established.  In fact, the role of the interpreter first came into 

play when translators were needed to facilitate political and 

diplomatic work.  With over 300 languages spoken in the 

U.S. today, the role of the interpreter has since shifted to 

include providing services in education, medical, and 

community settings (Avery, 2001).  Certainly, the training 

required for translating in a psychological setting differs from 

the skills required for translating in a diplomatic setting.  

Unfortunately, training interpreters to work in psychological 

settings has not caught up with the growing demand for their 

service.   

 

Gaining Greater Awareness and Experience 

 Refugees face several problems when relocating to the 

United States. While they face normative problems of 

acculturation (i.e., cultural differences and language barriers), 

these problems are further exacerbated by the traumatic 

experiences that precipitated their relocation.  The inability to 

meet the language and cultural demands of refugees leaves 

them with scant resources for treatment after relocation.  The 

reality is that while a large refugee population suffers from 

PTSD, most do not receive adequate treatment.   

 The role of the interpreter has only recently shifted to 

include providing services in professional arenas outside of 

diplomacy.  Currently, there are two forms of interpretation 

that appear to be consistently used in most settings: 

simultaneous interpretation and conservative interpretation 

(Hwa-Froelich & Westby, 2003). Simultaneous interpretation 

occurs when the interpreter translates at the same time as the 

client is speaking; this type of interpreting is often used for 

political or diplomatic work and is most common at the 

United Nations (Ohtake, Santos, & Fowler, 2000).  

Consecutive interpretation occurs when the interpreter waits 

to translate until the client pauses, indicating to the 

interpreter that it is the appropriate time to translate; this 

method of translation is often used in medical and 

educational settings.  At this time, no research has examined 

the effect of simultaneous versus consecutive interpretation 

in health care settings.  Research in this area could provide a 

strong foundation from which to develop guidelines for 

psychologists working with interpreters.  Psychologists as 

well as interpreters would certainly benefit from a standard 

and consistent approach to interpretation. Outcome studies 

comparing the efficacy of TF-CBT to other trauma-focused 

therapies among refugee populations would also contribute to 

the implementation of adequate care for this population.  If a 

best practice can be established for treating refugees, 

interpreter training can be tailored more effectively. 

 Although guidelines have been suggested for working 

with interpreters (see Tribe, 2007 for a review), too often 

these suggestions represent conceptual considerations (e.g., 

creating a good atmosphere to ask for clarification), rather 

than concrete practices (e.g., allocating time to meet with the 

interpreter prior to meeting with the client), for managing the 

relations of the psychologist-interpreter-client triad (Tribe, 

2007).  Yet, there remains an absence of awareness, 

literature, and training to target the dyadic relationship 

between psychologist and interpreter.  Such guidelines might 

offer suggestions on how to effectively address issues of 

multiple roles, interpretation errors, and gatekeeping with the 

interpreter.   

Awareness and advocacy serve as the foundation for new 

research and ultimately the clinical application of that 

research into training opportunities.  As a new generation of 

emerging psychologists, we must hold ourselves to higher 

standards when providing treatment to refugees by bringing 

awareness to professionals in our field and through advocacy 

efforts.  Graduate students interested in developing clinical 

experience and competency in working with interpreters to 

treat refugees may want to first begin by becoming involved 

in local community outreach and advocacy efforts and by 

demanding training opportunities from professors, leaders in 

the field, American Psychological Association (APA) 



CECCHET & CALABRESE 

 

15 

 

division representatives, and the American Psychological 

Association of Graduate Students (APAGS).  While a 

seemingly daunting task, APA divisions have historically 

been formed in the same manner.  It is our hope that this 

paper will inspire small efforts in each of its readers that, in 

turn, will launch future efforts in research and clinical 

training.    

 

References 

 

American Psychiatric Association. (2000). Diagnostic and 

Statistical Manual of Mental Disorders: DSM-IV TR 

(4th, text revision ed.). Washington, D.C.: American 

Psychiatric Association . 

Avery, M. B. (2001). The role of the health care interpreter: 

An evolving dialogue. The National Council on 

Interpretation in Health Care Working Paper Series, 

April 2001. 

Bisson, J., & Andrew, M. (2005). Psychological treatment of 

post-traumatic stress disorder (PTSD) (Review). The 

Cochrane Collaboration. John Wiley & Sons, Ltd. 

Child Sexual Abuse Task Force and Research & Practice Core, 

National Child Traumatic Stress Network. (2004). How 

to Implement Trauma-Focused Cognitive Behavioral 

Therapy. Durham, NC and Los Angeles, CA: National 

Center for Child Traumatic Stress. 

Cohen, J., & Mannarino, A. (2008). Trauma-Focused 

Cognitive Behavioural Therapy for Children and Parents. 

Child and Adolescent Mental Health, 13, 158–162. doi: 

10.1111/j.1475-3588.2008.00502.x 

Davidson, B. (2000). The interpreter as institutional 

gatekeeper: The social- linguistic role of interpreters in 

Spanish-English medical discourse. Journal of 

Sociolinguistics, 4, 379–405. 

Drozdek, B. (1997). Follow-up study of concentration camp 

survivors from Bosnia-Herzegovina: Three years later. 

Journal of Nervous and Mental Disease, 185, 690-694. 

doi: 10.1097/00005053-199711000-00007 

Farooq, S., & Fear, C. (2003). Working through interpreters. 

Advances in Psychiatric Treatment, 9, 104-109. 

Farooq, S., Fear, C., & Oyebode, F. (1997). An investigation 

of the adequacy of psychiatric interviews conducted 

through an interpreter. Psychiatric Bulletin, 21, 209-213. 

doi:10.1192/pb.21.4.209 

Hwa-Froelich, D. A., & Westby, C. E. (2003). Considerations 

When Working with Interpreters. Communication 

Disorders Quarterly, 24, 78-85.  

Iwamasa, G. Y., Hsia, C., & Hinton, D. (2006). Cognitive-

behavioral therapy with Asian Americans. In G. Y. 

Iwamasa (Ed.), Culturally responsive cognitive-

behavioral therapy: Assessment, practice, and 

supervision. (117-140). Washington, DC US: American 

Psychological Association.  

Keller, A., Lhewa, D., Rosenfeld, B., Sachs, E., Aladjem, A., 

Cohen, I., Porterfield, K. (2006). Traumatic experiences 

and psychological distress in an urban refugee population 

seeking treatment services. The Journal of Nervous and 

Mental Disease, 194, 188-194.  

 doi:10.1097/01.nmd.0000202494.75723.83 

Kinzie, D. (2001). Psychotherapy for massively traumatized 

refugees: the therapist variable. American Journal of 

Psychotherapy, 55(4), 475-490. 

Landesman, P. (2002, September 15). A woman’s work. New 

York Times, 82-131. 

Mendes, D., Mello, M., Ventura, P., de Medeiros Passarela, C., 

& de Jesus Mari, J. (2008). A systematic review on the 

effectiveness of cognitive behavioral therapy for 

posttraumatic stress disorder. International Journal of 

Psychiatry in Medicine, 38, 241-259. 

doi:10.2190/PM.38.3.b 

Miller, E., Martell, Z., Pazdirek, L., Caruth, M., & Lopez, D. 

(2005). The Role of Interpreters in Psychotherapy With 

Refugees: An Exploratory Study. American Journal of 

Orthopsychiatry, 75, 27-39. doi: 10.1037/0002-

9432.75.1.27 

Nicholl, C., & Thompson, A. (2004). The psychological 

treatment of post traumatic stress disorder (PTSD) in 

adult refugees: a review of the current state of 

psychological therapies. Journal of Mental Health, 13(4), 

351-362. doi:10.1080/09638230410001729807 

Norcross, J., Karpiak, C., & Santoro, S. (2005). Clinical 

psychologists across the years: The division of clinical 

psychology from 1960 to 2003. Journal of Clinical 

Psychology, 61(12), 1467-1483. doi:10.1002/jclp.20135  

Office of Minority Health. (2001) National standards on 

culturally and linguistically appropriate services (CLAS) 

in health care final report. Retrieved March 7, 2011, 

from http://minorityhealth.hhs.gov/assets/pdf/checked/ 

finalreport.pdf. 

Ohtake, Y., Santos, R. M., & Fowler, S. A. (2000). It’s a 

three-way conversation: Families, service providers, and 

interpreters working together. Young Exceptional 

Children, 4(1), 12–18. 

Raval, H., & Smith, J. (2003). Therapists' experiences of 

working with language interpreters. International 

Journal of Mental Health, 32(2), 6-31. 

Regel, S., & Berliner, P. (2007). Current perspectives on 

assessment and therapy with survivors of torture: the use 

of a cognitive behavioral approach. European Journal of 

Psychotherapy and Counseling, 9, 289-299. 

doi:10.1080/13642530701496906 

Silove, D., Sinnerbrink, I., Field, A., & Manicavasagar, V. 

(1997). Anxiety, depression and PTSD in asylum-

seekers: Associations with pre-migration trauma and 

post-migration stressors. British Journal of Psychiatry, 

170, 351-357. doi:10.1192/bjp.170.4.351 

Thulesius, H., & Hakansson, A. (1999). Screening for 

posttraumatic stress disorder symptoms among Bosnian 

refugees. Journal of Traumatic Stress, 12, 167-174. 

doi:10.1023/A:1024758718971 

Tribe, R. (2007). Working with interpreters. The 

Psychologist, 20(3), 159–161. 



INTERPRETER-MEDIATED THERAPY FOR REFUGEES 

 

16 

 

Tribe, R., & Thompson, K. (2008). Working with Interpreters 

in Health Settings: Guidelines for Psychologists. British 

Psychological Society, October, 2008. 

United Nations High Commissioner for Refugees. (2009). 

UNHCR annual reports shows 42 million people 

unrooted worldwide. Retrieved from http://www.unhcr. 

org/4a2fd52412d.html . 

United Nations High Commissioner for Refugees. (1951). 

Convention and protocol relating to the status of 

refugees. Geneva, United Nations. 

United States Department of State, Bureau of Population, 

Refugees, and Migration. (2001, October 17th). Fact 

Sheet: U.S. Refugee Admissions and Resettlement 

Program. Retrieved November 9th, 2008, from 

http://www.state.gov/g/prm/rls/fs/2001/5412pf.htm. 

Wadensjö, C. (1993). The double role of a dialogue 

interpreter. Perspectives: Studies in Translatology, 1, 

105–121.

 

 

http://www.unhcr.org/4a2fd52412d.html
http://www.unhcr.org/4a2fd52412d.html
http://www.state.gov/g/prm/rls/fs/2001/5412pf.htm

