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Introduction
The chosen topic of research is aimed at looking at the role of interpreters in Mental Health Act Assessments (MHAA).  This will be examined in relation to national policy, as in the Mental Health Act 1983 (MHA) and Department of Health (1999) Mental Health Act Code of Practice (CoP).  This will also include the working practice of a Community Mental Health Team (CMHT) in East London, which has 6 Approved Social Worker’s (ASW) and is part of the X NHS Mental Health Trust.  Further reference will be made to the wider body of literature on interpreting in mental health.  The interest to carryout research of this subject has grown from my own interest in the words “suitable manner” in relation to language noted in section 13 of the MHA.  Inspiration for this study has also come from the documented evidence of the misdiagnosis of Black and ethnic minorities in the psychiatric system, which partly stem from language problems and cultural misunderstanding (Littlewood & Lipsedge, 1989; Fernando 1995; Bhugra & Bahl, 1999; Hussain, 2001; Bhui 2002).  It is envisaged that this study will thus explore the impact interpreters (or lack of it) have on the process and outcome of assessment of mental health need under the MHA. 

The importance of effective communication, the exchange of understandable language between the client and the ASW, during the interview process in a MHAA is highlighted in the Act.  This is most explicitly shown in section 13, which defines the role of the ASW.  Under s. 13 (2) MHA, it stated that “Before making an application for admission of a patient to hospital an approved social worker shall interview the patient in a suitable manner and satisfy himself that detention in a hospital is in all circumstances of the case the most appropriate way of providing care…”.  In the general notes, Jones (2003, 8^th edition, paragraph 1-178) makes the point that ASW’s should work in a sensitive manner to the difficulties faced by individuals from ethnic minority communities, who lack English speaking abilities.  In the CoP (1.5), the guidance suggests that barriers to communication can occur when the patient’s language is not English and also when medical terminology or jargon is used. 

In the CoP (1.6), it is further stated that staff ought to be aware of how communication difficulties affects individual patients so that they are able to address the needs of the patients in a manner that best suits them.  Also, that specialist support such as an interpreter, who is of similar cultural background, dialect, religion, age including gender, to the patient, should be made available from across health and social care sectors, statutory and voluntary, to aid communication.  Professionals are then warned not to use relatives or friends in general circumstances as interpreters.  The importance of continuity in effective communication is highlighted in CoP (1.7), which suggests that it is important to frequently check that the patient has fully understood the information provided to them and that information may also need to be repeated when they have recovered from their acute phase of illness.  The Audit Commission has also recently highlighted the need for services to plan language services to help the problems of poor communication facing non-English speaking patients (Audit Commission, 1994).   

Methodology
Four different methods of data collection were used. 

1)      Telephone contacts were made with local interpreting services and NW Social Services (SS) Policy department.  Using the snowball sampling technique, I was able to identifying 1 person, who then identified another person (Robson, 1993).  They were asked whether they had carried out any interpreting work in the last 3 months and what their experiences were.   

2)      A questionnaire was developed and given to the 6 ASW’s of the team to complete and return to me.  Open-ended questions were built into the questionnaire to enable the ASW’s to explore and express freely. 

3)      Analysis of the ASW local authority reports was done for the month of May, June and July.  This particular period was chosen because this was the time I had spent my placement with the team.

4)  Secondary sources was used to help improve the results of the research study and thus increase precision, as well as provide comparability with previous research.  Also, as I am faced with the limitations of time, the use of secondary sources may provide higher quality data than could be obtained with this research approach (Robson, 1993).  

Findings
Having spoken to the NM Language Shop manager, I was told that he was unable to give me any information on telephone.  At present he was e He writing up the annual report, and so the retrieval of information will take time.  Figures and statistics were available, which show the number of booking made by CMHT X, but this information will not necessary show whether it was for general mental health assessments or MHAA.  I was not offered a time frame by which time I would be given the information.  The Bi-lingual Health AS manager recalled 2 booking being made with the Lingala and Bengali interpreters for MHAA.  I was told that their booking came mainly from the Primary Care Trusts than CHMT’s.  I was not informed of the interpreter’s experiences, as they were on a training course.  I was given the name of Project A and The Advocacy Service.  Project A, informed me that there was no booking made with them for an interpreter in the last 3 months and that interpreting is not done by them but rather contracted through them from NM Language Shop.  I left messages with the Advocacy Service but since have not received a response.  Having communicated with NW’s policy department, I was told that is no policy on the use of interpreters, however I was made aware that new guidance was currently been developed.           

Out of 6, 5 questionnaires in total were returned to me.  I have analysed their response and presented them in the following heading.  The numerical findings will appear in total figures, while the explanatory findings will appear in a narrative form.       

1) How many MHAA did you do in the last 3 months?

            46

2) How many of them were from minority ethnic group?

37

3) How many of those needed an interpreter?

6

4) How do you identify who needs an interpreter?

Most ASW’s reported that the need for an interpreter would be indicated on the referrals.  Others said, that this would be identified through meeting the client and the nearest relative prior to MHAA.  Another ASW commented, that there were no set tests, but rather an indication from other professionals where English is not understood and spoken by the client.  It is clear from this that there does not appear to be a central way of obtaining the information on who requires an interpreter.  Are all ASW’s asking for this information at the referral stage? Why are some not? What level of English constitutes the need for interpreters? How would a client with linguistic needs be able to self-refer, if the ASW taking the referral does not understand their language? Where there is an interpreter booked, at what stage of the MHAA is consent from the client taken, given the principals of inclusive practice (Payne, 1997)?  It interesting to learn from Phelan & Parkman (1995) and Raval (1997), that interpreter should be employed as an integral member of the team. They are then able to provide input at an early stage of contact, which reduces the delay in identifying the need for an interpreter.    

5) When interpreters are not used who interprets for them?

In an emergency the ASW’s would consider using family members and relatives, although this was strongly indicated as an option only used where formal interpreters were unavailable.  One ASW commented on the difficulty this posed and considered issues around risk, impact on their relationship, information not being translated properly and whether the relative was biased towards getting the client into hospital or preventing an admission.  Where relatives and friends were unavailable, some ASW’s commented that they would seek help from colleagues of same language to do translating, while 1ASW said they would also think about approaching a counsellor through a local voluntary organisation.  While the ASW’s did consider using family members, albeit in an emergency, there are also other difficulties that occur when discussing sensitive issues such as sexual health, gynaecological problems, domestic violence, which may be associated to mental illness (Burnett & Peel, 2001).  This may place inappropriate responsibilities on them.  Where there is a delay in booking an interpreter, how much of the 14 day time gap before making an application (s.6(1), CoP 2.31) is being utilised in arranging an appropriate interpreter?  Again there is a strong case here for using bi-lingual interpreters, as they would be familiar with the clinical aspects of the work and be knowledgeable of the NHS, while having expertise in the cultural context of the client (Free, 1998; Raval, 1996).  Using trained interpreters over family members also relate to confidentiality and accuracy of reporting (Adams, 2002; Cushing, 2003).  Research has found that people from ethnic minority groups in emotional distress preferred bi-lingual workers employed within the same team as the practitioner to interpreters from outside (NHS Executive, 1994). 

6) How are interpreters provided?

Call ASW’s indicated NM Language Shop and is mainly booked through fax.

7) What major difficulties have you had with interpreters?

Nearly all the ASW’s had commented that the interpreters did not fully understand mental health, while 1ASW had commented that there was a difference between interpreters and translators and that it was important this work is done using the latter.  The ASW’s generally commented that the interpreters often did not turn up in time.  While some felt that they arrived very early and went into the clients home, even though requested to meet outside the property.  One ASW commented that interpreters are not always able to interpret accurately the questions being asked or ask the questions in the way the ASW had initially put it across.  As the ASW was of the same language of the client and interpreter she noticed this inaccuracy.  Two ASW’s commented that at times interpreters can have prior social contact with clients and get into a dialogue with them, which is not associated to the MHAA.  Perhaps it is a need of the client to talk at length with the interpreter and explain their difficulties more fully, rather than the other way around?  Does the cultural familiarity between the interpreter and client encourage strong engagement and so represent a shift in power for the ASW? 

The process of translation is complex and the interpreter constantly has to make fine adjustments about how to word certain questions and convey information in a way that makes sense (Tribe & Raval, 2002).  The interpreter then enables the practitioner and client to negotiate the different explanatory models that each hold about ‘the problem or illness’ (Kaufert, 1990).  Given that the interpreter is doing much more than word-for-word translating, which may take time and concentration, can this be misunderstood by ASW’s as interpreters not keeping their role and boundary? Interpreters may also find it difficult to work with practitioners, who are of different gender to themselves (Granger, 1996). How aware are ASW’s of this possibility and how could this difference be reconciled during a MHAA?

8) What do you think are the implications for the service user? 

a) When there is an interpreter available?   

One ASW said that it give clients clarity, while another said that it enables a fair assessment during a MHAA, as information otherwise can easily be misconstrued and misinterpreted by professionals.  Other ASW’s said that the client is able to fully understand the questions and ask in a way they want.  This enables them to have an opportunity to explain their feelings, behaviour and actions.  There is further opportunity to discuss alternative to hospital admissions and devise a community care plan.  It allows a full assessment of need to occur with an English speaking professional with a client, who has limited or no English, without language barriers.                       

b) When there is no interpreter available?  

There was a consensus that clients would not fully understand what is expected of them and so the professionals would fail to get an accurate picture or view of the problem.  Most of the ASW’s commented that there is a potential for misunderstandings by the client and the professionals, which may lead to a client being detained unnecessarily.  One ASW commented that a client who cannot speak any English and is distressed or behaving strangely may just be responding appropriately to events in their lives.  They could be responding culturally appropriately, which may seem bizarre from a western model.  Another ASW said that clients would also be unable to put forward their reasons for their actions and understand why an ASW had turned up at their flat or what a MHAA was.  Two ASW’s had said that without an interpreter there would be issues around a client’s human rights and the whole MHAA can then be questionable.  

The ASW’s have shared considerable insight in both the above responses, which show the important use of interpreters to bridge the language gap for clients not speaking English.  It is well documented that peoples’ ethnicity does play a part in the way they present and make sense of their social reality and mental distress (Helman, 2000).  Some of them view psychiatric institutions, as places where they will be hospitalised and have little input in their treatment (Bhugra & Bahl, 1999).  Among some Black and ethnic minority groups there is often a wide spread belief that mental illness should be dealt with within the family and cultural system (Klienman, 1980; Kareem & Littlewood, 1992; Helman, 1994).  Concepts of health and illness and metaphors and specific words inevitably vary across cultures.  Meaning and reality are also created through language, which is dependent upon the context in which they are created.  It is then the role of interpreters, being the cultural advisers, to grasp the societal and political values which influence a client’s belief and bring about that shared meaning and understanding between the practitioner and client, between two different explanatory models (Tribe & Raval, 2002).  According to Marcos (1979), the role of interpreters was not meant to be anymore more than a ‘mouthpiece’.  This is obviously now refutable, as they are clearly an integral part of ‘interviewing in a suitable manner’ of a client not being able to speak the dominant language in their country of residence and in the context of a MHAA.   

Conclusion 
There were inevitable limitations in the study.  In analysing the ASW local authority reports, on the front page there was a tick box option to indicate whether interpreters were needed.  Then at the back of the report there was a section with a tick box option to indicate whether the interview was done in a suitable manner.  Although this latter option was ticked in every ASW report, I did question whether it was done so according to the ASW’s interpretation or that of the clients.  It was difficult to also tell from this whether interpreters were actually used, as there was no mention of them in the writing of the reports.  There was also a discrepancy between the number of interpreters used by the ASW’s reported in the questionnaires and the number of interpreters used shown in the ASW reports.  As the ASW preferred me to leave the questionnaire with them due to their busy workload, I was unable go through the questions with them in an explorative manner or clarify any questions they may have had. 

These shortcomings or gaps in information did make me think about the validity of the information I had received.  The generality of the research is also questionable.  The result of the questionnaire sample was based on the individual experience of 5 ASW’s and for a 3 months period, when there are in total 3 CMHT’S, 1 Assertive Outreach Team and 1 Emergency Duty Team in NW, with over 20 ASW’s covering the whole of the borough.  Time constraints was also a strong factor, which prevented me from receiving information from NM Language Shop and possibly observing the new policy on interpreters being developed.  Given the limitations, the research does have some validity.  It has generated new thought and a strong need for research looking at the role of interprets in MHAA, as oppose to general mental health work.  Given the increase in mental disorders in multi-ethnic societies, including Muslims and other faith groups (Bhugra & Bahl, 1999; Bhui & Bhugra, 2002), this will inevitably be an important area of work.  In the body of the findings the ASW’s have shown there adherence to the CoP, however there needs to be more consorted efforts and commitment at trust level to recruit bi-lingual workers in CMHT’s in promoting empowerment of their clients rights and wishes (Tribe & Raval, 2002).  This would then ultimately comply with the Department of Health’s, National Service Framework for Mental Health (1999), Standard 1, which aims to address mental health promotion and strategies to combat discrimination faced by Black and minority ethnic groups. 

References 

Adams, K. (2002) Making best use of health advocates and interpreters. BMJ, 2002, 325: S9  

Bhugra, D & Bahl, V. (1999) Ethnicity: An agenda for Mental Health, Gaskell, The Royal College of Psychiatrists, London.  

Bhui, K. (2002) Racism and mental health: prejudice and suffering, London, Jessica Kingsley

Bhui, K & Bhugra, D. (2002) Mental Illness in Black and Asian ethnic minorities: pathways to care and outcomes. Advances in Psychiatric Treatment (2002), vol. 8, pp. 26-23

Burnett, A & Peel, M. (2001) Health needs of asylum seekers and refugees, BMJ, 322: 644-7 

Cushing, A. (2003) Interpreters in medical consultations in: Tribe, R & Raval, H (Eds). (2003) Working with interpreters in Mental Health, Brunner-Routledge, UK

Department of Health (1999) Modern Standards and Service Models: National Service Framework for Mental Health. London: Department of Health

Department of Health (1999), Code of Practice Mental Health Act 1983, HMSO, Department of Health.

Fernando, S. (1995) Mental Health in a Multi-Ethnic Society London, Routledge.

Free, C. (1998) Meeting the needs of black and minority ethnics groups. BMJ 1998, 316:380

Granger, E. (1996) A psychological investigation into the role and work experience of interpreter in: Tribe, R & Raval, H (Eds). (2003) Working with interpreters in Mental Health, Brunner-Routledge, UK

Helman, C. (2000). Culture, Health and Illness, An introduction (4th Edition) Oxford, Butterwork-Heinemann

Hussain, A. (2001) Islamic beliefs and mental health. Community Psychiatric Nurses Association, vol 21, 2, 6 - 8.

Jones, R (2003) Mental Health Act Manual, 8^th Edition, Sweet & Maxwell Ltd, UK

Kareem, J, & Littlewood, R. (1992), Intercultural Therapy: Themes, Interpretations and Practice, London, Blackwell Science

Kaufert, J. (1990) Sociological and anthropological perspectives on the impact of interpreters on clinical/client communication, Sante Culture Health 8, 209-235  

Kleinman, A. (1980) Patients and Healers in a Cultural Context, Berkeley, University of California Press.

Littlewood, R & Lipsedge, M. (1998) Alien and Alienists: Ethnic Minorities and Psychiatry, 3^rd Edition, London, Routledge. 

Marcos, L. (1979) Effects of interpreters on the psychopathology in non-English-speaking patients in: Tribe, R & Raval, H (Eds). (2003) Working with interpreters in Mental Health, Brunner-Routledge, UK

NHS Executive. Black mental health: a dialogue for change. Heywood, Lancashire: Health Publications Unit, 1994

Payne, M. (1997)  Modern Social Work Theory, London, Macmillan

Phelan, M & Parkman, S. (1995) How to do it: Work with an interpreter. BMJ, 1995, 311:555-557

Raval, H. (1996) A systemic perspective on working with interpreters, Clinical Child Psychology and Psychiatry 1, 29-43  

Raval, H. (1997) Family therapy, race, and culture. Context 31, 6-10

Robson, C. (1993) Real World Research: A source for social scientists and Practitioner-Researchers, Blackwell, UK

Tribe, R & Raval, H. (2003) Working with interpreters in Mental Health (Eds, Brunner-Routledge, UK