Introduction
Cognitive behavioural therapy (CBT) is a widely endorsed psychological therapy, recognised for its efficacy in treating a variety of mental health disorders across a range of groups, from young to elderly adults (Fordham et al., Reference Fordham, Sugavanam, Edwards, Stallard, Howard, das Nair and Lamb2021; Hofmann et al., Reference Hofmann, Asnaani, Vonk, Sawyer and Fang2012). Whilst we might refer to it in the singular, it is important to note is not a monolithic approach but better understood as a family of therapies that share similarities but also have distinct differences.
With an array of research, highlighting its efficacy and numerous meta-analyses and systematic reviews confirming its efficacy in treating depressive disorders (Angelakis et al., Reference Angelakis, Huggett, Gooding, Panagioti and Hodkinson2022; Cuijpers et al., Reference Cuijpers, Berking, Andersson, Quigley, Kleiboer and Dobson2013; Cuijpers et al., Reference Cuijpers, Miguel, Harrer, Plessen, Ciharova, Ebert and Karyotaki2023; Santoft et al., Reference Santoft, Axelsson, Öst, Hedman-Lagerlöf, Fust and Hedman-Lagerlöf2019; Sockol, Reference Sockol2015; Werson et al., Reference Werson, Meiser-Stedman and Laidlaw2022), anxiety disorders (Bhattacharya et al., Reference Bhattacharya, Goicoechea, Heshmati, Carpenter and Hofmann2023; Carpenter et al., Reference Carpenter, Andrews, Witcraft, Powers, Smits and Hofmann2018; Hofmann and Smits, Reference Hofmann and Smits2008; Otte, Reference Otte2011; Öst et al., Reference Öst, Enebrink, Finnes, Ghaderi, Havnen, Kvale and Wergeland2023), eating disorders (Keegan et al., Reference Keegan, Waller and Wade2022; Linardon et al., Reference Linardon, Wade, de la Piedad Garcia and Brennan2017; Linardon, Reference Linardon2018; Waller and Beard, Reference Waller and Beard2024), substance misuse disorders (Magill et al., Reference Magill, Ray, Kiluk, Hoadley, Bernstein, Tonigan and Carroll2019; Magill et al., Reference Magill, Kiluk and Ray2023; McHugh et al., Reference McHugh, Hearon and Otto2010) and many other presenting problems.
A growing body of research demonstrates its successful cultural adaptations while maintaining effectiveness (Jankowska, Reference Jankowska2019; Kunorubwe, Reference Kunorubwe2023; Naeem et al., Reference Naeem, Phiri, Rathod and Ayub2019; Phiri et al., Reference Phiri, Clarke, Baxter, Zeng, Shi, Tang and Naeem2023; Praptomojati et al., Reference Praptomojati, Icanervilia, Nauta and Bouman2024; Rathod et al., Reference Rathod, Phiri and Naeem2019; Silveus et al., Reference Silveus, Schmit, Oliveira and Hughes2023).
CBT delivered across languages
CBT has demonstrated efficacy when delivered in a range of languages. To fully appreciate this, it is important to recognise that there are over 7000 spoken languages globally (Leben, Reference Leben2018). Languages are classified into families and branches based on their historical and structural relationships (Trask and Stockwell, Reference Trask and Stockwell2007), illustrating that linguistic diversity extends far beyond a simple distinction between English and non-English languages. Families such as Indo-European, Sino-Tibetan, Niger-Congo, Austronesian, and Afro-Asiatic encompass numerous languages shaped by distinct cultural, sociological, historical, and geographical influences.
CBT’s effectiveness across different linguistic families has important implications for its acceptability, appropriateness, and efficacy when culturally and linguistically adapted. Many studies have demonstrated the efficacy of CBT in languages closely related to English within the Indo-European family, such as German (Linde et al., Reference Linden, Zubraegel, Baer, Franke and Schlattmann2005), Frisian (van Apeldoorn et al., Reference van Apeldoorn, Timmerman, Mersch, van Hout, Visser, van Dyck and den Boer2010), Danish (Nielsen, Reference Nielsen2015), and Icelandic (Egilsdóttir, Reference Egilsdóttir2018).
Evidence also supports the efficacy of CBT in Indo-European languages that are more distant from English, including Russian (Pchelina et al., Reference Pchelina, Poluektov, Krieger, Duss and Berger2024), Farsi (Kananian et al., Reference Kananian, Ayoughi, Farugie, Hinton and Stangier2017), Urdu (Amin et al., Reference Amin, Iqbal, Naeem and Irfan2020), and Kurdish (Zemestani et al., Reference Zemestani, Mohammed, Ismail and Vujanovic2022). Beyond Indo-European languages, research demonstrates CBT’s adaptability across diverse linguistic families, including Arabic (Afro-Asiatic; Lindegaard et al., Reference Lindegaard, Seaton, Halaj, Berg, Kashoush, Barchini and Andersson2021), Igbo (Niger-Congo; Ede et al., Reference Ede, Igbo, Eseadi, Ede, Ezegbe, Ede and Ali2020), Chinese dialects (Sino-Tibetan; Fan, Reference Fan2022), and Māori (Austronesian; Bennett et al., Reference Bennett, Flett and Babbage2014).
Whilst this summary cannot capture all studies across language families, it demonstrates that CBT’s efficacy extends across a broad range of linguistic contexts when adapted appropriately. Figure 1 presents a visual taxonomy of the languages and language families represented in these studies.
Illustration of taxonomy of the languages.
These findings demonstrate the adaptability and robustness of CBT as a therapeutic approach when delivered in the client’s language by someone who also speaks that language. When it is not possible to deliver CBT in the client’s language, the use of interpreters offers an alternative. Effective use of interpreters in CBT requires specific strategies to adapt typical practices, ensuring accurate communication, fostering therapeutic rapport, and preserving the core aspects of CBT. Therapists must work effectively with interpreters to promote accessible psychological therapies, ensure good clinical practice, and achieve equal outcomes and service delivery (Tribe and Lane, Reference Tribe and Lane2009).
Rationale for current research
There is limited empirical research on interpreter-mediated CBT, and to the researcher’s knowledge, no systematic reviews have been conducted. Therefore, a systematic review of interpreter-mediated CBT is crucial for considering its effectiveness in treating mental health conditions, identifying best practices, and highlighting research gaps.
This review aims to systematically identify, evaluate, and integrate the findings of the existing empirical literature on interpreter-mediated CBT. It attempts to answer the following research questions:
Is interpreter-mediated CBT a beneficial treatment for mental health problems?
What are the best practices for conducting interpreter-mediated CBT for mental health issues?
Method
Database search
An electronic literature search was conducted in July 2024. Due to the lack of research on this specific topic, searches were completed in four databases:
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CINAHL
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MEDLINE
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PsycINFO
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Scopus
Search terms
The search terms, truncations and Boolean operators (Table 1) were utilised as they represented the main concepts for the research topic and are words used in practice.
Search terms, truncations and Boolean operators
Due to limited research on interpreter-mediated CBT, it was decided not to use search terms that would limit the potential results to specific populations, outcomes, or countries. Although the approach may be more time-consuming and require additional effort in the screening process, it aims to provide a broad range of results.
Inclusion and exclusion criteria
Empirical studies on interpreter-mediated CBT for mental health problems published in the past 20 years were included. A 20-year timeframe was selected to maximise the inclusion of relevant studies, given the limited and emerging nature of research in this area. All studies related to the involvement of a professional interpreter to facilitate communication between the therapist and client in the delivery of CBT.
The initial search resulted in 5490 studies being identified, of which 2563 duplicates were removed, giving a total of 2927 studies to be considered for initial screening. Exclusion criteria included research that was not specific to psychotherapy, not specific to CBT, not empirical, not related to interpreters or where the primary problem was not a mental health problem. As part of the initial screening, the titles and abstracts were assessed utilising the inclusion/exclusion criteria (Table 2), with a total of 2888 being excluded.
Inclusion/exclusion criteria
The remaining 39 were full-text screened, using the inclusion and exclusion criteria mentioned above, resulting in 28 being excluded.
One study (Emmelkamp and van Schaik, Reference Emmelkamp and van Schaik2010) was excluded as an English full-text version could not be sourced. Non-English papers were not automatically excluded to ensure comprehensive coverage of global research contributions and minimise the risk of assuming CBT is only for English speakers. Rather, English translations of journals and articles were sourced, which was possible for most, except for this one.
Another study (König, Reference König2013) was excluded after careful consideration and supervision, as it related to sign language interpreting. Including this could lead to the homogenisation of the distinct challenges and techniques unique to each field, thereby obscuring the specialised training, considerations, and communication dynamics inherent in both. Sign language interpretation involves unique cognitive, linguistic, and cultural competencies and considerations of language deprivation that may differ from those required for spoken language interpretation; see Glickman and Harvey (Reference Glickman and Harvey1996), Glickman and Gulati (Reference Glickman and Gulati2003), Glickman (Reference Glickman2013), Glickman (Reference Glickman2016), and Glickman and Hall (Reference Glickman and Hall2018).
This resulted in nine studies that met the criteria.
Hand searching of references was utilised to identify any relevant studies, with 22 studies identified; titles and abstracts were assessed utilising the inclusion/exclusion criteria (Table 2), with 20 being disregarded, leaving two deemed acceptable.
A total of 11 studies were included for quality assessment.
Systematic search results (PRISMA chart)
The procedure used for selecting articles follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher et al., Reference Moher, Liberati, Tetzlaff, Altman and PRISMA2009). Please refer to Fig. 2.
Search results: PRISMA flow diagram of study selection procedure. From Page et al. (Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann, Mulrow and Moher2021).
Quality assessment (risk of bias)
This was conducted independently by the primary researcher and another researcher for all the papers; this was important to reduce the risk of bias and subjective judgements.
The Mixed Methods Appraisal Tool (MMAT; Hong et al., Reference Hong, Pluye, Fàbregues, Bartlett, Boardman, Cargo and Vedel2018) was utilised. This review included a range of study types, such as qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies, and mixed methods studies, making the MMAT an appropriate choice for critical appraisal.
With the MMAT, each paper is initially screened based on two questions:
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(1) Are there clear research questions?
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(2) Does the collected data address these questions?
If either answer was ‘No’ or ‘Cannot tell’, the paper was deemed unsuitable for further evaluation, but no papers in this review fell into that category. Subsequent questions varied by study methodology, addressing aspects such as the appropriateness of the research approach, sample representativeness, data collection methods, and methodological integration. Each item was rated as ‘Yes’ if the study fully met the criteria, ‘Unclear’ if it partially met the criteria, and ‘No’ if it did not meet the criteria at all. See Table 3 for the MMAT rating from two raters.
MMAT rating from two raters
Y, yes; N, no; C, can’t tell. A 5-star rating (*****), signifies that the study meets 100% of the quality criteria; a 4-star rating (****) indicates it meets 80% of the criteria; a 3-star rating (***) reflects 60% adherence to the criteria; a 2-star rating (**) represents 40%; and a 1-star rating (*) means it meets only 20% of the criteria.
Hong et al. (Reference Hong, Pluye, Fàbregues, Bartlett, Boardman, Cargo and Vedel2018) discouraged calculating an overall score from the ratings of each criterion and typically advised against excluding studies based on low methodological quality. The MMAT does not have cut-off values, as such categories can be arbitrary (Hong et al., Reference Hong, Pluye, Fàbregues, Bartlett, Boardman, Cargo and Vedel2019); therefore, they have not been used in this review. Consequently, papers were not excluded based solely on these categories. Instead, the author has provided a more detailed representation of the papers’ quality by including a quality rating in Table 3.
In relation to inter-rater reliability, Cohen’s kappa (κ) was initially calculated for each paper. However, for several papers, there was no variability in ratings because both raters consistently chose the same rating (‘Yes’, fully met criteria). As a result, Cohen’s κ was deemed unsuitable for evaluating agreement, as it can be unreliable when there is no variation in ratings or when agreement is perfect. Therefore, raw agreement was calculated for each paper, as shown in Table 4. The overall inter-rater agreement for all studies was 98.79%.
Inter-rater agreement for all studies
Results
Characteristics of the studies
Three out of the 11 included studies were quantitative, exploring the feasibility and outcomes of interpreter-mediated CBT for trauma-affected refugees (d’Ardenne et al., Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a; Sander et al., Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019; Schulz et al., Reference Schulz, Resick, Huber and Griffin2006). One study was a case study on interpreter-mediated CBT for phobia and depression (Mofrad and Webster, Reference Mofrad and Webster2012). Another was a quantitative study evaluating a training program for interpreters in the field of interpreter-mediated CBT (Müller et al., Reference Müller, Herold, Unterhitzenberger and Rosner2023). One study employed mixed methods aimed at developing good practice guidelines for interpreter-mediated CBT (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). One study focused on clients’ experiences of interpreter-mediated CBT (Costa and Briggs, Reference Costa and Briggs2014), another explored interpreters’ perspective on interpreting within psychotherapy (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021), and three studies were qualitative, exploring therapist experiences of interpreter-mediated CBT (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021; Tutani et al., Reference Tutani, Eldred and Sykes2018; Wardman-Browne, Reference Wardman-Browne2023).
Seven of the studies were conducted in England, two in the USA, one in Denmark, and one in Germany. Sample sizes varied considerably, ranging from 1 to 646 participants. Three studies did not specify participants’ gender; however, among those that did, there was a slight predominance of females (464 females compared with 405 males). While the level of detail provided about the languages used in interpreter-mediated CBT varied, 44 specific client languages were reported. The dominant languages used by therapists, which reflected the predominant language of the healthcare settings, included English in nine studies, Danish in one study, and German in one study.
Notably, there is a lack of detailed information on race, ethnicity, nationality, or cultural background in many of the studies, with a few studies conflating some of these categories. In several studies, data on gender, age, and language is either missing or unspecified. This lack of detailed demographic information could limit the depth of analysis or interpretation of the results.
To enable the systematic data analysis, key features of each study were synthesised and organised using a data extraction tool created by the researcher (Table 5).
Table of characteristics of studies
Summary of results
Studies on interpreter-mediated CBT reveal interesting findings regarding its feasibility and outcomes. On one hand, quantitative studies suggest that while interpreter-mediated CBT can be effective, the results are not conclusive. Some studies show significant improvements in symptoms related to PTSD (d’Ardenne et al., Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a; Schulz et al., Reference Schulz, Resick, Huber and Griffin2006), and a case study reported improvements in a client with phobia and depression (Mofrad and Webster, Reference Mofrad and Webster2012). However, Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) reported less benefit from interpreter-mediated CBT compared with sessions without interpreters. Additionally, training for interpreters has been found to positively impact their knowledge and attitudes towards treatment (Müller et al., Reference Müller, Herold, Unterhitzenberger and Rosner2023).
On the other hand, qualitative studies highlight varied experiences from different perspectives. Clients who have received interpreter-mediated CBT often find the presence of interpreters essential, acting as a conduit for therapy. However, clients also report challenges related to disruptions in the typical flow of communication and struggle with conveying meaning (Costa and Briggs, Reference Costa and Briggs2014). Interpreters themselves face difficulties such as vicarious trauma and limited time to process the emotional load of therapy sessions (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021). Therapists delivering CBT with interpreters report both benefits, such as reaching clients who might otherwise be excluded, and challenges, including changes to the traditional therapeutic dynamic, potential disruptions to the flow of therapy, and friction with service delivery (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021; Tutani et al., Reference Tutani, Eldred and Sykes2018; Wardman-Browne, Reference Wardman-Browne2023).
A mixed-method study developed good practice guidelines for interpreter-mediated CBT based on telephone polls, focus groups, and team reflections (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b).
Is interpreter-mediated CBT beneficial?
d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) and Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) reported a statistically significant reduction in PTSD symptoms and some improvement in other areas, such as symptoms related to depression or quality of life. Mofrad and Webster (Reference Mofrad and Webster2012) conducted a single-case design study and reported some improvement but did not provide statistical tests.
In contrast, Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) found that the use of an interpreter in psychotherapy was associated with less improvement in outcome measures compared with when no interpreter was used because the client and therapist were able to communicate without a spoken word interpreter. However, the discrepancies may not only be due to the use of an interpreter but could also involve other factors, and the impact of therapist/interpreter proficiency on outcomes was not explored. It is essential to consider other variables that may affect the results, and further research is needed to understand the role of such proficiency in outcomes. All of these studies were related to individual interpreter-mediated CBT with adults, rather than group or family work. Overall, based on the reviewed studies, interpreter-mediated CBT shows potential, although further research is needed.
Consideration was given to conducting a meta-analysis focused on the outcomes or feasibility of interpreter-mediated CBT or performing a statistical analysis to combine the results of multiple studies. Only four studies were identified; as such, the researcher decided against this approach due to the limited number of available studies.
Typically, a meta-analysis requires a larger number of studies to ensure that the results are robust and reliable (Macaskill et al., Reference Macaskill, Takwoingi, Deeks, Gatsonis, Deeks, Bossuyt, Leeflang and Takwoingi2022). With such a small sample size, the results of a meta-analysis would likely be inconclusive and would not provide a meaningful or comprehensive understanding of the efficacy of interpreter-mediated CBT. Therefore, this section provides a narrative description of the results instead.
There is a clear need for more research into the efficacy or feasibility of interpreter-mediated CBT. To support future empirical research, a second data extraction tool (Table 6) was developed to summarise outcomes for the research exploring whether interpreter-mediated CBT was effective, including whether the intervention was statistically significant and the effect size.
Summary of main findings for studies reported efficacy/feasibility of interpreter-mediated CBT
An asterisk (*) indicates that the result did not meet the threshold for statistical significance (p<0.05).
IES, Impact of Events Scale (Horowitz et al., Reference Horowitz, Wilner and Alvarez1979); BDI, Beck Depression Inventory (Beck and Steer, Reference Beck and Steer1987); MANSA, Manchester Short Assessment of Quality of Life (Priebe et al., Reference Priebe, Huxley, Knight and Evans1999); PHQ-9, Patient Health Questionnaire (Kroenke et al., Reference Kroenke, Spitzer and Williams2001); IAPT Phobia Q3, IAPT Phobia Scales (IAPT Toolkit, 2008); GAD-7, Generalised Anxiety Disorder Questionnaire (Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006); HTQ, Harvard Trauma Questionnaire (Mollica et al., Reference Mollica, Caspi-Yavin, Bollini, Truong, Tor and Lavelle1992); HSCL-25, Hopkins Symptom Check List-25 (Mollica et al., Reference Mollica, Wyshak, de Marneffe, Khuon and Lavelle1987); SI-SCL-90, somatisation items of SCL-90 (Derogatis, 1994); SDS, Sheehan Disability Scale (Sheehan and Sheehan, Reference Sheehan and Sheehan2008); WHO-5, the WHO-5 Well-being Index (Folker and Folker, Reference Folker and Folker2008); PSS, PTSD Symptom Scale (Foa et al., Reference Foa, Riggs, Dancu and Rothbaum1993).
What are the practice points for interpreter-mediated CBT for mental health issues?
Across the included studies, a range of practice points for interpreter-mediated CBT were identified. These were summarised and synthesised to provide a narrative description of best practices as reported in the literature. An inductive narrative synthesis process was used to develop these findings. Following familiarisation with all included studies, a data extraction tool was employed to generate initial recommendations, which were then iteratively refined. This process was supported by ongoing reflection, regular reference to the original papers, and discussion in supervision to ensure fidelity to the source material. Conceptually, the recommendations are organised according to their relevance within the therapeutic journey and the individuals responsible for implementing them in practice. This structure was informed by the authors’ professional experience as a CBT therapist previously working within the NHS and now within private practice.
These recommendations were across three interconnected levels: Individual, service, and organisational (see Fig. 3). While each level addresses distinct areas, they are interdependent, reflecting the need for a cohesive approach to interpreter-mediated therapy.
Illustration of how recommendations for working with interpreters align with the therapy process.
Individual level
Before the appointment
Reflective practice. Three papers referenced therapists engaging in reflective practice as an important component of their preparation. Wardman-Browne (Reference Wardman-Browne2023) and Gerskowitch and Tribe (Reference Gerskowitch and Tribe2021) emphasise the importance of reflective practice for therapists focused on their experiences, biases, and the dynamics of the therapeutic relationship, particularly when working with interpreters. Costa and Briggs (Reference Costa and Briggs2014) further noted the importance of reflecting on how therapy is shaped by the triadic nature of interpreter-mediated sessions.
Existing guidance. Two papers made reference to familiarisation and the use of existing guidelines. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) noted that in their survey of services, all reported that interpreters followed professional guidelines; however, these were not specific to the NHS, the service context, or CBT, highlighting a lack of standardised, context-specific practices. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) recommended that both interpreters and clinicians familiarise themselves with relevant guidance to ensure they are well-prepared for the challenges that may arise during therapy sessions. Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) further emphasised the importance of interpreters working according to guidelines tailored to interpreter-mediated CBT as these create a structured environment where both interpreters and clinicians can operate within a clear framework.
Sharing materials/resources. Two papers referred to interpreters reviewing session materials and measures beforehand. To enhance their understanding and ability to support the therapeutic process effectively (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). Ideally, these should be translated materials and other relevant resources, as this preparation can significantly improve the fluency and accuracy of interpretation (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021). This might include materials such as handouts, terminology lists, or therapeutic tools that allow interpreters to familiarise themselves with specialised terms and concepts, thereby reducing the risk of miscommunication. Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) emphasise that such preparation makes therapy more accessible and impactful by enhancing the clarity and consistency of communication throughout the session.
Extra time. Five studies referred to allowing additional time for sessions. d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a), Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006), and Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019), while exploring the feasibility and efficacy of interpreter-mediated CBT, noted that sessions typically took longer because of the different pace of communication. d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) reported that interpreter-mediated CBT sessions required up to 50% more time compared with non-interpreter-mediated sessions.
This aligns with Tutani et al. (Reference Tutani, Eldred and Sykes2018), who found that interpreter-mediated sessions often took longer, with guided self-help lasting up to 60 minutes and CBT lasting up to 90 minutes, due to the need for accurate interpretation, engagement, and clear communication. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) further recommend that therapists should also plan for additional time for briefings with interpreters to ensure the session runs smoothly. They emphasise the importance of arriving punctually to avoid delays.
Briefing. Five studies made reference to briefing sessions between therapists and interpreters prior to a therapy session. Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) emphasised the importance of these briefings to ensure interpreters understand the session’s goals and potential challenges. Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) noted that using this time beforehand to discuss therapeutic techniques and client-specific concerns is beneficial. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) noted that interpreters requested briefings to support emotional preparedness and potential trauma, cultural, or linguistic issues, as well as to coordinate practical aspects like seating and eye contact. Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) also advocated for pre-session meetings to help interpreters prepare for difficult content and support therapist–interpreter collaboration. Tutani et al. (Reference Tutani, Eldred and Sykes2018) and Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) further recommended using the briefing to review written materials, clarify CBT-specific tools and terminology, and provide interpreters with handouts in advance – particularly those containing complex language – to support accurate and effective interpretation.
Agreeing on the interpreting model. Six studies referenced the importance of agreeing on the model of interpretation used, noting that the choice or absence of a defined model can significantly impact the therapeutic process and the clarity of expectations and roles. With some leading interpreters to act as literal translators, others convey meaning, and some also explain cultural nuances. Wardman-Browne (Reference Wardman-Browne2023) draws attention to inconsistencies in how interpreters are perceived, with roles ranging from literal language conveyors to co-therapists or cultural mediators. Such variability underscores the need for clear agreement on the interpreting model to ensure aligned expectations and effective collaboration. Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) also emphasise that interpreters are not neutral conduits, but rather facilitators of the therapeutic relationship, helping to build trust and understanding. This aspect is critical in any therapeutic interaction. Similarly, d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) highlight the added value interpreters bring through their cultural insights, noting that they can advise clinicians when appropriate to help contextualise client experiences. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) further emphasise the importance of agreeing on an appropriate interpreting model, which would be the best fit, and also ensure that both the interpreter and therapist are working in accordance with that model. However, that is not to say that it cannot change through a course of treatment, as Tutani et al. (Reference Tutani, Eldred and Sykes2018) suggest that rigid adherence to a single model may not be suitable for all clients or contexts. Instead, this approach should be adapted based on the therapeutic setting and client needs, ensuring their involvement is supportive without being intrusive.
During the appointment
Confidentiality. Two studies highlighted the importance of confidentiality in interpreter-mediated CBT, particularly in terms of ensuring and clearly communicating it to clients to build trust. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) emphasise that interpreters must adhere to strict confidentiality standards and avoid working with clients they know personally. They also recommend logistical measures such as providing separate waiting areas for clients and interpreters to prevent inadvertent disclosures and maintain professional boundaries. d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) further note that interpreter involvement can raise concerns about trust, particularly when clients are uncertain about how their information will be handled. This issue may be heightened if the interpreter shares the client’s cultural or ethnic background, potentially leading to fears of judgement or breaches of privacy (Tutani et al., Reference Tutani, Eldred and Sykes2018). Mofrad and Webster (Reference Mofrad and Webster2012) reinforced this point in a case study by ensuring that the interpreter and client did not share a social relationship, a step they identified as critical for maintaining trust.
Clarifying roles. Four studies noted clearly defining and communicating the roles of therapists and interpreters to clients. Before therapy begins, therapists should introduce the interpreter, agree on roles, and establish practical arrangements such as seating (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) emphasise the importance of explaining the interpreter’s role and limitations to clients to set appropriate expectations and avoid confusion. Similarly, Tutani et al. (Reference Tutani, Eldred and Sykes2018) note that clarifying roles and dynamics helps reduce misunderstandings and improves therapeutic outcomes. Ensuring both the client and interpreter understand their roles and boundaries can enhance engagement and trust in the process. Because interpreters often focus on word-for-word translation, this may limit their direct interaction with clients. To address this, therapists are encouraged to strike a balance between the interpreter’s linguistic role and opportunities for meaningful client engagement (Tutani et al., Reference Tutani, Eldred and Sykes2018). Role expectations may also need to be revisited throughout therapy, as mismatches between client expectations and the interpreter’s actual role can lead to confusion or dissatisfaction. Costa and Briggs (Reference Costa and Briggs2014) point out that some clients may perceive interpreters as overly rigid if their role does not align with previous experiences of interpreters providing more personal or emotional support in other contexts.
Communication. Seven studies noted adaptation to communication in interpreter-mediated CBT. Therapists should use simple, clear language and adjust their pace to support accurate interpretation (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b; Wardman-Browne, Reference Wardman-Browne2023). Strategies such as using common codes, repeating key terms, and developing shared terminology can improve understanding (Mofrad and Webster, Reference Mofrad and Webster2012). However, this must be carefully balanced as interpretation may interrupt the natural flow of conversation, slow the session pace, and reduce direct engagement between therapist and client (Costa and Briggs, Reference Costa and Briggs2014; Mofrad and Webster, Reference Mofrad and Webster2012).
The communication of empathy can be challenging; therefore, therapists must rely more on non-verbal cues and work closely with interpreters to ensure both emotional tone and content are conveyed effectively (Tutani et al., Reference Tutani, Eldred and Sykes2018). Therapists are also encouraged to observe verbal and non-verbal interactions, pause sessions when needed, and seek feedback from clients to address and refine communication issues (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). There is a risk of miscommunication when feedback lacks clarity or emotional nuance, which can potentially disrupt therapeutic rapport (Tutani et al., Reference Tutani, Eldred and Sykes2018). Therefore, communication quality is essential for avoiding misunderstandings and ensuring therapeutic effectiveness (Costa and Briggs, Reference Costa and Briggs2014).
Interpreters are encouraged to translate in small, direct segments, remaining as close to the original language as possible – except when dealing with idioms or figures of speech, where conveying intended meaning is prioritised (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). They are also advised to pause sessions to clarify uncertainties and must accurately convey all nuances, including repetitions, pauses, ambiguities, and sensitive material (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). Psychological terminology can be particularly challenging to translate, especially when unfamiliar or inconsistent with terms used in medical contexts (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021). The interpreter’s linguistic proficiency and understanding of therapeutic language can significantly influence the quality of communication (Sander et al., Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019).
Careful preparation further supports effective communication. Tutani et al. (Reference Tutani, Eldred and Sykes2018) note that therapists who planned sessions thoughtfully seemed better able to navigate linguistic and cultural challenges. This includes preparation, such as considering terminology, avoiding idioms and jargon, and selecting words that are culturally appropriate and more easily translatable.
Therapeutic relationship. Eight of the studies made reference to the dynamics of the therapeutic relationship. The involvement of an interpreter inherently alters the traditional one-to-one therapy model, introducing a triadic structure that changes the interpersonal dynamic. Therapists often reported discomfort with this shift, describing feelings of being under pressure or scrutinised, which could hinder their ability to engage fully with clients (Schulz et al., Reference Schulz, Resick, Huber and Griffin2006; Mofrad and Webster, Reference Mofrad and Webster2012). In contrast, clients generally appreciated the interpreter’s presence and reported no issues with having a third person in the session, suggesting a more positive perception of the therapeutic environment (Costa and Briggs, Reference Costa and Briggs2014).
To navigate this altered dynamic, the development of relational and interpersonal skills was seen as essential for both therapists and interpreters. Strengthening the three-way relationship between therapist, interpreter, and client was viewed as crucial for fostering a collaborative and effective therapeutic environment (Tutani et al., Reference Tutani, Eldred and Sykes2018; Mofrad and Webster, Reference Mofrad and Webster2012). When interpreters were able to mirror the therapist’s empathy, therapy outcomes improved, highlighting the importance of alignment in therapeutic attitudes (Tutani et al., Reference Tutani, Eldred and Sykes2018). However, some therapists expressed concerns that working with interpreters might compromise their ability to build a strong therapeutic bond. In some cases, they felt marginalised when the client appeared to form a closer relationship with the interpreter, particularly if personal concerns were shared more openly with them (d’Ardenne et al., Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a; Mofrad and Webster, Reference Mofrad and Webster2012). These experiences were linked to issues of trust, role ambiguity, and power dynamics, with some therapists reporting anxiety, feelings of powerlessness, or a loss of control, while others sought to share power more equitably within the triad (Tutani et al., Reference Tutani, Eldred and Sykes2018; Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021; Wardman-Browne, Reference Wardman-Browne2023). Therapists were also encouraged to reflect on how the interpreter’s presence might influence transference and countertransference processes, which are important for understanding the client’s experience and facilitating therapeutic progress (Costa and Briggs, Reference Costa and Briggs2014).
The transition to remote therapy introduced further complexity, as therapists found it more challenging to apply key interpersonal skills and maintain relational depth in online sessions (Wardman-Browne, Reference Wardman-Browne2023). Finally, the potential for therapeutic ruptures was noted, with one client reporting distress when an interpreter laughed at painful material – an incident that significantly disrupted the therapeutic relationship (Costa and Briggs, Reference Costa and Briggs2014). Addressing such ruptures was considered vital to preserving trust and ensuring clients felt respected and understood throughout the therapeutic process.
Collaboration. Four studies made reference to collaboration, with it being a key aspect within the relationship between the therapist and interpreter, as effective communication and therapy rely on their interdependence (Costa and Briggs, Reference Costa and Briggs2014) and shared accountability (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). Building a collaborative alliance with interpreters is crucial to support the therapeutic process (Tutani et al., Reference Tutani, Eldred and Sykes2018). Client perceptions of this relationship varied; when collaboration was lacking, interpreters were often seen as interruptive; when collaboration was strong, clients appreciated the shared effort and trusted both professionals in their respective roles (Costa and Briggs, Reference Costa and Briggs2014). Rather than treating it as two separate collaborative relationships, it may be better viewed as a three-way partnership. Gerskowitch and Tribe (Reference Gerskowitch and Tribe2021) advocate for a collaborative approach involving the therapist, interpreter, and client. Similarly, Costa and Briggs (Reference Costa and Briggs2014) noted that clients valued a sense of teamwork when all three parties worked together cohesively.
Culturally adapted therapy. Five studies referred to aligning the therapeutic approach with a culturally adapted approach. Wardman-Browne (Reference Wardman-Browne2023) stresses the importance of adapting CBT principles for diverse clients while preserving the core structure of the therapy. Therapists are encouraged to be flexible, tailoring their approach based on the client’s cultural context, history, and current circumstances. This should be in collaboration; for example, d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) recommend jointly selecting metaphors and idioms that are meaningful within the client’s cultural framework. Tutani et al. (Reference Tutani, Eldred and Sykes2018) similarly advise therapists to check the cultural relevance of language and values during sessions to minimise miscommunication and enhance therapeutic impact. In cases where complex language may be a barrier, Mofrad and Webster (Reference Mofrad and Webster2012) suggest using behavioural interventions that emphasise learning through action rather than relying heavily on verbal explanation. Additionally, Costa and Briggs (Reference Costa and Briggs2014) highlight the importance of understanding a client’s culture and typical stress responses, as this insight can inform more tailored and effective interventions.
Routine outcome measures. Five studies made reference to the use of psychological outcome measures. Due to the frequent unavailability of such measures in other languages, interpreters are often asked to assist in administering psychological assessments. Tutani et al. (Reference Tutani, Eldred and Sykes2018) reported that therapists often rely on interpreters to directly translate English-language questionnaires during sessions, which raises concerns about the consistency and validity of the measures used. Similarly, d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) and Mofrad and Webster (Reference Mofrad and Webster2012) emphasise that interpreter involvement in administering assessments can inadvertently influence how questions are understood and answered, potentially compromising the reliability of the results. In response to these concerns, d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) recommend that therapists carefully review psychometric data for accuracy and be mindful of how the interpretation process may have impacted client responses.
After the appointment
Debriefing. Four studies made reference to post-session debriefing between therapists and interpreters. Interpreters have expressed a strong need for post-session debriefings to help process the emotional and cognitive demands of the session, clarify content, and provide feedback (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). These debriefs are also viewed as a valuable opportunity for therapists to gather insights, address any misunderstandings, and assess whether the session’s objectives were effectively met. Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) further underscore the role of debriefing in refining the therapeutic process and enhancing collaboration between therapists and interpreters. Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) recommend that clinicians prioritise debriefings to reinforce mutual understanding and improve communication. In addition, Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) found that interpreters often use these sessions to share cultural insights or perspectives, which can be invaluable for therapists navigating sensitive or unfamiliar cultural dynamics. However, despite these clear benefits, debriefings are not consistently implemented in practice. A telephone survey conducted by d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) found that only about half of the services allocated additional time for debriefing.
Supporting interpreters. Three studies made reference to supporting interpreters with any potential emotional reactions after the session. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b), Costa and Briggs (Reference Costa and Briggs2014), and Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) highlight the emotional and psychological demands placed on interpreters, particularly within trauma-focused therapy. Interpreters often report personal distress due to the content they must convey, especially when interpreting traumatic material using first-person language and non-verbal expressions (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b; Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021). Given these potential risks, it is crucial that, as part of the debrief, this is considered and support is offered, along with signposting as needed.
Cultural consultation. Three of the studies noted interpreters contributing culturally bound understanding. Interpreters often possess a deeper understanding of clients’ cultural backgrounds and the culturally based meanings associated with them. Wardman-Browne (Reference Wardman-Browne2023) and Tutani et al. (Reference Tutani, Eldred and Sykes2018) emphasise that interpreters can act as important sources of cultural knowledge, enriching the therapeutic process by providing context that may not be immediately apparent to therapists. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) recommend that this insight be shared during debriefing sessions, where interpreters can communicate their observations and cultural interpretations, allowing therapists to adjust their strategies accordingly. Therapists are encouraged to actively engage interpreters in discussions about cultural nuances that may affect therapy, as this collaboration can enhance cultural sensitivity, support rapport-building, and lead to more effective and contextually appropriate interventions, particularly when addressing culturally specific concerns.
Consistent interpreter. Six studies referred to the importance of ensuring continuity by maintaining the same interpreter throughout therapy. d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) and Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) report that this is standard practice unless a client specifically requests a change. Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) support this approach, noting that consistent interpreter involvement across treatment sessions fosters trust and familiarity among the client, therapist, and interpreter, which can enhance therapeutic outcomes. From the therapist’s perspective, continuity is essential, with d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) emphasising the therapist’s responsibility to maintain the same interpreter or to facilitate a change if the client requests it. Clients also expressed appreciation for consistency, as it contributed to a more comfortable and trusting therapeutic environment (Costa and Briggs, Reference Costa and Briggs2014). From the interpreter’s perspective, continuity in care was likewise seen as beneficial. Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) recommend that interpreters be assigned to clients they have previously worked with whenever possible, as this familiarity improves communication and supports a more stable and effective therapeutic process.
Service level
Selecting and matching interpreter
Six studies referred to the process of selecting interpreters, with emphasis on ensuring a good fit. This was a consistent feature across studies evaluating the feasibility and outcomes of interpreter-mediated CBT (d’Ardenne et al., Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a; Schulz et al., Reference Schulz, Resick, Huber and Griffin2006; Sander et al., Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019). For instance, d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) employed accredited interpreters with at least one year of experience in health interpreting, aiming to ensure a high standard of competence. Similarly, Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) worked with medically trained interpreters to effectively support the therapeutic process. To formalise standards in this area, Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) advocated for the introduction of an accreditation scheme specifically designed for interpreters working in psychotherapy, helping to ensure consistent quality of service across contexts. Beyond professional competence, studies highlighted the importance of matching interpreters to clients in ways that respect cultural norms and foster rapport. Considerations such as gender, ethnicity, age, dialect, and political sensitivities were noted by Mofrad and Webster (Reference Mofrad and Webster2012) and d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) as important when assigning interpreters, as these factors may significantly influence the client’s comfort and engagement. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) further emphasised the therapist’s role in assessing clients’ specific language support needs to ensure appropriate interpreter selection. In addition, some interpreters requested detailed information about clients’ linguistic and cultural backgrounds before accepting bookings, underscoring the importance of preparation and mutual fit in supporting effective therapy (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b).
Supporting remote delivery
Two studies made reference to remote delivery of interpreter-mediated CBT. Wardman-Browne (Reference Wardman-Browne2023) reported that therapists recognised the potential for remote working with interpreters to significantly expand access to therapeutic services, particularly for communities that face language-related barriers. However, this approach also introduces specific challenges, including heightened therapist anxiety, difficulties in creating a safe and confidential space, and a reduction in non-verbal interpersonal cues critical to therapeutic engagement. Despite these limitations, Wardman-Browne (Reference Wardman-Browne2023) acknowledged the notable benefits and new possibilities that remote interpreter-mediated CBT can offer, suggesting that the flexibility and accessibility of remote delivery may increase its appeal to a broader client base. Similarly, Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) highlighted the advantages of using live interpretation systems through videoconferencing platforms to facilitate therapy. Importantly, Wardman-Browne (Reference Wardman-Browne2023) emphasised that remote delivery should not be imposed; instead, offering clients a choice regarding the format of their therapy is essential for maintaining a client-centred approach.
Supportive service culture
Four studies made reference to services creating the conditions that facilitate the delivery of interpreter-mediated CBT. In part, these relate to service pressures and organisational demands. Interpreter-mediated CBT requires additional time and resources, often increasing the workload for therapists and the perceived burden on the system (Schulz et al., Reference Schulz, Resick, Huber and Griffin2006; Sander et al., Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019).
Therapists who felt supported by their service were more open to collaborative relationships with interpreters, more confident in addressing power dynamics and cultural differences, and better able to navigate feelings of guilt or discomfort related to power and privilege (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021). In contrast, therapists who did not feel supported noted that rigid systems and high organisational demands increased stress. In such contexts, working with interpreters was often perceived as a threat to their competence, resulting in heightened anxiety and a more defensive approach to collaboration (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021).
Moreover, this organisational stress influenced therapists’ perceptions of interpreters. Under pressure, therapists were more likely to view interpreters negatively or as ‘translating machines’ rather than valued collaborators (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021). Wardman-Browne (Reference Wardman-Browne2023) also highlights that therapists reported increased anxiety when working with interpreters due to the additional demands of meeting service expectations. Some therapists noted a mismatch between service provision and client needs, further exacerbating these challenges.
Reducing performance pressures and cultivating a more collaborative, less competitive atmosphere can enhance cooperation between therapists and interpreters, ultimately leading to better care (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021). Part of these recommendations includes allowing greater flexibility with service demands, time constraints, and organisational targets. This flexibility is necessary not only to accommodate the time needed for sessions and preparation but also to ensure sufficient capacity for the additional associated tasks (Wardman-Browne, Reference Wardman-Browne2023).
Therapist reflective practice
Three papers noted points related to the importance of reflective practice for therapists within interpreter-mediated CBT. Therapists reported the need to reflect but recognised the need for service support to facilitate reflective practice (Wardman-Browne, Reference Wardman-Browne2023; Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021). Moreover, this could be facilitated by regular supervision, ongoing training, and reflective meetings between clinicians and interpreters to continuously improve the collaborative process (Wardman-Browne, Reference Wardman-Browne2023; d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b).
Address logistical issues
Five studies made reference to services addressing logistical issues that either directly obstruct interpreter-mediated CBT or create less-than-optimal conditions for its delivery. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) and Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) highlight problems related to the physical layout of clinics, including the lack of space for interpreters to meet with therapists for debriefings, and the absence of separate waiting areas for interpreters and clients, both of which are important for maintaining confidentiality and preventing unintended disclosures. Moreover, interpreters reported difficulties in communicating directly with clinic staff in relation to logistics, which was identified as a barrier to efficient coordination (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021).
In addition to logistical concerns, recommendations also focus on addressing process-related challenges within services. For example, rigid and time-consuming room booking procedures were found to increase stress (Gerskowitch and Tribe, Reference Gerskowitch and Tribe2021). To support more effective delivery of care, organisations should establish fair policies for managing late or missed appointments and ensure that both therapists and interpreters are well informed of these procedures (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021).
Regular meetings between clinicians and interpreters are also recommended to review and refine the interpreting process (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). These meetings provide opportunities to raise concerns, discuss challenges, and strengthen alignment in approach. Finally, avoid scheduling back-to-back sessions for either therapists or interpreters and include scheduled breaks to help prevent burnout (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021; d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b).
Interpreters as part of the team
Four studies noted points related to sourcing interpreters from external agencies or being part of the team. In part, this was related to the cost associated with sourcing from external agencies. Wardman-Browne (Reference Wardman-Browne2023) highlights a common perception that working with interpreters is expensive, which can act as a barrier to service provision. In a cohort study by d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a), interpreting services were estimated to cost approximately €100 per session. These additional costs can become significant over the course of treatment, especially when multiple sessions are required for effective therapy.
As well as missed opportunities for integrating them within the team, in response to these challenges, several studies have recommended greater integration of interpreters into the team. For example, Schulz et al. (Reference Schulz, Resick, Huber and Griffin2006) and Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) describe interventions in which interpreters were either employed directly by clinics or contracted regularly from trusted local agencies, supporting continuity and deeper integration. When interpreters are integrated into the clinical team, they become familiar with service procedures and therapeutic goals, thereby enhancing the effectiveness, consistency, and overall quality of therapy.
Value of interpreters
One study explicitly highlighted the importance of interpreters within therapy. Costa and Briggs (Reference Costa and Briggs2014) reported that for clients, the ability to express themselves in their native language is particularly significant during times of emotional distress. Clients also highly valued the interpreter’s contributions, which often exceeded their expectations. Importantly, the presence of a third person in the therapy room was generally not seen as problematic; rather, many clients expressed appreciation for the interpreter’s involvement. This finding underscores the value of creating an inclusive therapeutic environment in which the interpreter’s role is normalised and seamlessly integrated into the process. According to Costa and Briggs (Reference Costa and Briggs2014), interpreters play a vital role not only in supporting communication but also in enhancing both the process and outcomes of therapy. Services should therefore create a culture where interpreter involvement is not simply helpful but essential in ensuring effective therapy for clients who are non-native speakers.
Developing and maintaining therapist competencies
Five of the reviewed studies noted practice related to the development and maintenance of therapist competence, in part through training for therapists to work effectively with interpreters. Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) recommended that therapists receive specific training and gain practical experience in interpreter-mediated therapy to develop competence in this area. Similarly, Costa and Briggs (Reference Costa and Briggs2014) emphasised the importance of training that focuses on effective collaboration with interpreters. Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) advocated for training in practical strategies, such as conducting pre-sessions, speaking in manageable chunks, and preparing materials in advance to support smoother communication during therapy. They further recommended that such training should be ongoing, suggesting annual sessions to ensure therapists’ skills remain sharp and up to date.
Mofrad and Webster (Reference Mofrad and Webster2012) suggested that therapists and interpreters build rapport and develop skills together. They even proposed seconding therapists to services with greater exposure to interpreter-mediated CBT as a way to enhance competence through experience.
Supervision was also identified as a key element in developing therapist competence. Mofrad and Webster (Reference Mofrad and Webster2012) described how clinical supervision in their case study was used to rehearse explanations and simplify language in preparation for interpreted sessions. They noted that supervision should address the specific challenges of interpreter-mediated therapy and offer guidance on communication and therapeutic techniques. Additionally, supervision could serve as a platform for formative feedback or the implementation of competency measures to monitor and support therapist development. However, they acknowledged that the slower pace of interpreter-mediated sessions can make formal competency assessments difficult, underscoring the importance of supervision in compensating for this limitation.
Finally, peer supervision and mentoring were also recommended. Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) suggested pairing less experienced clinicians with seasoned practitioners to model effective use of interpreters. This approach allows new therapists to observe best practices and gradually build their own competence.
Developing and maintaining interpreter competencies
Six studies made reference to the development and maintenance of interpreter competence, primarily through training, reflection, and supervision. In relation to training, there is a necessity for further and ongoing training programs for interpreters. d’Ardenne et al. (Reference d’Ardenne, Farmer, Ruaro and Priebe2007b) emphasised the importance of interpreters having a clear understanding of mental distress, particularly in relation to the conditions commonly addressed in interpreter-mediated CBT. More in-depth training has been shown to be both feasible and effective. For instance, Müller et al. (Reference Müller, Herold, Unterhitzenberger and Rosner2023) reported that a one-day training not only enhances interpreters’ knowledge base but also positively influences their attitudes and overall effectiveness.
Moreover, competencies can be supported through supervision and reflexivity as these have also been identified as essential for supporting interpreters in navigating the complexities of mental health settings and facilitating effective communication (Tutani et al., Reference Tutani, Eldred and Sykes2018; Wardman-Browne, Reference Wardman-Browne2023). Sander et al. (Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019) and Tutani et al. (Reference Tutani, Eldred and Sykes2018) further highlighted the need for clinical supervision to be extended beyond therapists to include interpreters, recognising their central role in therapeutic encounters.
Importantly, these recommendations align closely with those related to developing and maintaining therapist competence. Mofrad and Webster (Reference Mofrad and Webster2012) advocated for opportunities where interpreters and therapists can build rapport and develop their skills collaboratively. This could be achieved through joint training sessions, shared supervision, reflective practice groups, or co-facilitated skills development workshops. Such integrated approaches not only enhance individual competence but also foster a cohesive therapeutic alliance between therapists and interpreters.
Organisational level
Funding
Two studies made reference to the importance of funding decisions. Whether sourcing qualified interpreters from interpreting agencies or integrating within the team, it is dependent on adequate funding. To achieve this, organisational leadership should secure funding to hire interpreters dedicated solely to the service, ensuring consistency and reducing the strain on therapists (Villalobos et al., Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021). In practice, sometimes interpreters are sourced from external agencies, such as local authorities or private companies, but quality assurance is required (d’Ardenne et al., Reference d’Ardenne, Farmer, Ruaro and Priebe2007b). While this can provide flexibility and access to a broader pool of interpreters, it is essential to ensure that external interpreters are adequately briefed on procedures and supported to maintain consistency and effectiveness in sessions.
Training interpreters
Two of the studies made reference to some interpreters lacking training in mental health, let alone training specific to interpreter-mediated CBT. d’Ardenne et al. (Reference d’Ardenne, Ruaro, Cestari, Fakhoury and Priebe2007a) noted that although interpreters are occasionally briefed on mental health or CBT, most do not hold formal qualifications in these areas. This gap is further underscored by Müller et al. (Reference Müller, Herold, Unterhitzenberger and Rosner2023), who found that two-thirds of interpreters in their sample lacked relevant qualifications in mental health interpreting. Clearly, training organisations and accrediting bodies have a key role to play in ensuring that mental health awareness, along with therapy-specific knowledge and skills, becomes a core component of interpreter training curricula. Additionally, there should be wider provision of continuing professional development (CPD) to upskill interpreters who are already qualified. Wardman-Browne (Reference Wardman-Browne2023) suggests that existing training programs would benefit from regular review and updating to remain effective. In addition, other opportunities and approaches for training could be beneficial.
Training therapists
Four of the included studies made reference to training for therapists to work effectively with interpreters. Recommending therapists receive specific training and gain experience in working with interpreters to develop competence in this area (Sander et al., Reference Sander, Laugesen, Skammeritz, Mortensen and Carlsson2019). Villalobos et al. (Reference Villalobos, Orengo-Aguayo, Castellanos, Pastrana and Stewart2021) recommend that therapists are trained with practical strategies to work effectively with interpreters, such as conducting pre-sessions, speaking in appropriate chunks, and preparing materials ahead of time to facilitate smoother communication during therapy. Costa and Briggs (Reference Costa and Briggs2014) emphasise the need for training that focuses on effective collaboration with interpreters. Universities and accrediting bodies should embed training on working effectively with interpreters into core therapeutic curricula, equipping therapists with practical strategies and collaborative skills essential for interpreter-mediated therapy. Moreover, it should be continually refined. Wardman-Browne (Reference Wardman-Browne2023) suggests that existing training programs would benefit from regular review and updating to remain effective.
Critique of studies
The studies included in the review had small sample sizes, ranging from 1 to 646, which limits the generalisability of their findings. Small sample sizes can lead to the over-estimation or under-estimation of the effectiveness of interpreter-mediated CBT, and may not accurately reflect the broader population. This limitation makes it difficult to draw robust conclusions and suggests that further research with larger sample sizes is needed to provide a more comprehensive understanding of the intervention’s efficacy.
The included studies often provided limited or no information on the specific interpreter models used during therapy. This is notable because the choice of interpreter model or the lack of clarity regarding this choice may influence whether interpreters are perceived as mere word-for-word communication tools or as valued collaborators, as described by Gerskowitch and Tribe (Reference Gerskowitch and Tribe2021). Without detailed information on the interpreter models, it is difficult to assess their impact on the quality or experience of interpreter-mediated CBT. Inadequate reporting hinders the ability to evaluate the effectiveness of different interpreter approaches and to make informed recommendations for best practices.
None of the studies explicitly considered the degree to which cultural factors influence the efficacy or experience of interpreter-mediated CBT, even though language and culture are intertwined but distinct. As culture plays a crucial role in shaping therapeutic experiences and outcomes, failing to account for this factor may obscure important insights into how interpreter-mediated CBT is perceived and its effectiveness. Additionally, the delivery of ‘copy and paste CBT’ (Kunorubwe, Reference Kunorubwe2023) via an interpreter may be misconstrued as ineffective due to language barriers, when in fact the issue may be a lack of cultural adaptation, making the therapy contradictory or unacceptable to the client’s cultural model (Jameel et al., Reference Jameel, Munivenkatappa, Arumugham and Thennarasu2022). Therefore, understanding the interplay between language and culture is essential for optimising therapy and ensuring that interventions are both culturally sensitive and effective.
The quantitative research on the efficacy of interpreter-mediated CBT was based on standard treatment practices and did not fully report how confounding variables were controlled for. Additionally, there is no information on how closely the delivery of interpreter-mediated CBT adhered to established recommendations for working with interpreters, especially considering some of the qualitative studies highlighting how established recommendations are always implemented. This omission means that the effectiveness of interpreter-mediated CBT cannot be fully understood without knowing whether best practices for interpreter engagement were consistently followed. Consequently, this gap undermines the reliability of the findings and their applicability to real-world settings where adherence to interpreter guidelines can significantly impact therapeutic outcomes.
Another critique of the included studies is that they have predominantly focused on clients who were refugees or asylum seekers, potentially leading to the incorrect assumption that only these groups require interpreter services. This focus may overlook individuals who, although proficient in the majority language, prefer to access therapy in their first language. This narrow view may lead to gaps in understanding the broader need for interpreter-mediated CBT and how it serves various populations beyond refugees and asylum seekers.
Discussion
Summary of findings
Research on interpreter-mediated CBT shows some promise for improving access to therapy for non-native speakers, with studies reporting positive outcomes for PTSD, depression, and phobia. However, the findings are mixed and limited, highlighting the need for further research to address factors such as therapist-interpreter proficiency and client context.
This review also highlights key practice adaptations: comprehensive training and supervision for both therapists and interpreters, supportive service structures, and ongoing reflective practice to address bias and ensure clear communication. Effective interpreter-mediated CBT requires structured preparation, collaboration, role clarity, and adjustments to both communication and core CBT processes to meet clients’ needs.
Relation to previous literature
The results of this review align with and further develop the existing literature on interpreter-mediated CBT. The included research indicates that interpreter-mediated CBT holds promise for improving access to psychological therapies for clients who do not speak the predominant language in a given area. These findings align with the broader literature, which suggests that interpreter-mediated therapy can be effective in bridging language barriers and facilitating psychological treatment for diverse populations. However, the review also highlights some inconsistencies, as one study found less improvement in PTSD symptoms when an interpreter was used compared with sessions conducted without one.
This review sheds light on potential modifications to practice when working with interpreters that align with existing guidance documents on interpreter-mediated CBT (Beck, Reference Beck2016; Beck et al., Reference Beck, Naz, Brooks and Jankowska2019; Costa, Reference Costa2022) and broader guidance on working with interpreters in therapy (Tribe and Lane, Reference Tribe and Lane2009; Tribe and Thompson, Reference Tribe and Thompson2017; Tribe and Thompson, Reference Tribe and Thompson2022).
The review proposes a framework for interpreter-mediated CBT, which can be categorised into three interconnected levels: individual (therapist and interpreter), service, and organisational. This structured approach reflects the influence of these levels, suggesting that effective implementation or improvements in one area requires sustained effort across the levels.
Clinical implications
This review contributes to the discourse on interpreter-mediated CBT by providing a starting point for determining whether interpreter-mediated CBT can be beneficial for mental health problems. To further support best practice, we have drafted a table of recommendations for therapists/interpreters, services, and organisations. Table 7 outlines specific considerations for optimising the delivery of interpreter-mediated CBT, ensuring that the therapeutic process is both inclusive and effective.
Recommendations for interpreter-mediated CBT based on synthesising empirical research
The clinical implications of interpreter-mediated CBT are significant and multi-faceted. Effective implementation requires services and organisations to create optimum conditions and support for both therapists and interpreters. Collaboration between the therapist and interpreter, supported by structured pre-session briefings and clearly defined roles, is essential for maintaining therapeutic relationships, effective communication and a good triadic relationship. Adapting CBT practices to accommodate cultural differences enhances their relevance and engagement, while dedicated funding and improved service coordination ensure the reliability and consistency of interpreter services. Additionally, fostering a collaborative culture, actively seeking client feedback, and promoting reflective practices among therapists and interpreters contribute to better therapy outcomes and client satisfaction. Addressing these clinical implications helps create a more inclusive and effective therapeutic environment, ultimately improving access to psychological support for diverse populations.
Research recommendations
A key research recommendation is to conduct larger-scale studies with more participants, specifically examining the efficacy of interpreter-mediated CBT. This would enhance the reliability and generalisability of findings, particularly if conducted through research trials that are able to control for confounding variables that may influence outcomes. Future studies should also explore the effectiveness of interpreter-mediated CBT across a broader range of mental health disorders, beyond the current focus on PTSD, depression, and phobia, in order to develop a more comprehensive understanding of its applicability to various conditions.
In addition, there is a need to test the proposed recommendations in real-world clinical settings. This would involve implementing the suggested modifications in practice and systematically assessing their impact on therapy effectiveness and client outcomes. Studying the long-term effects of interpreter-mediated CBT on client well-being and therapeutic progress is also essential for a better understanding of the sustainability of therapeutic benefits over time.
Further research should also focus on exploring the experiences of interpreters, clients, and therapists involved in interpreter-mediated CBT. Examining the interactions among these stakeholders can help to improve communication and collaboration, while integrating their perspectives may identify common challenges and potential solutions. This comprehensive approach would provide valuable insights into optimising interpreter-mediated CBT practice and improving outcomes for all parties involved.
Another important area for investigation is the influence of different service delivery models and organisational structures on the implementation and effectiveness of interpreter-mediated CBT. This includes evaluating various models, such as direct employment of interpreters and dedicated funding arrangements, to determine their impact on accessibility and quality of care. Interestingly, the use of existing guidance on interpreter-mediated CBT was not mentioned in many studies; however, it is unclear if this was not reported or if they were not followed.
Although current evidence does not yet conclusively establish the effectiveness and feasibility of interpreter-mediated CBT across all languages and dialects, existing studies have included clients and interpreters working with 44 languages from multiple language families. It would therefore be valuable to investigate whether language-specific factors influence the efficacy of interpreter-mediated CBT.
By addressing these research gaps, the field of interpreter-mediated CBT can continue to develop, ultimately leading to more effective, evidence-based practices that improve access to psychological therapies for diverse populations.
Strengths
This review offers several strengths that contribute to both the academic literature and clinical practice surrounding interpreter-mediated CBT. Firstly, it addresses an under-researched area, providing one of the few focused syntheses of empirical studies on interpreter-mediated CBT. By using a narrative synthesis approach, the review incorporates findings from both quantitative and qualitative studies, allowing for a more comprehensive understanding of the evidence base.
It develops a practical, multi-level framework that organises recommendations into individual, service, and organisational levels. This framework provides clear, actionable guidance that addresses both individual practice and broader systemic considerations necessary to support effective interpreter-mediated therapy.
The review highlights important research gaps, including under-reporting of interpreter models, cultural adaptations, and service delivery approaches. By identifying these gaps, a clear agenda for future research is provided, which is essential for building a stronger evidence base in this area of psychological practice.
Limitations
This review has several limitations that should be acknowledged. One of the most notable is the relatively small number of studies included (n=11). This limited sample size could be a reflection of the scarcity of research on this specific topic, as highlighted earlier in the review. The small number of studies may be related to the potential risks of publication bias, where only certain studies are published, potentially skewing the overall findings of the review. These limitations underscore the need for caution when interpreting the results and highlight the importance of encouraging further research in this area to build a more comprehensive evidence base.
Another issue is the significant variation among the included studies. These studies differ widely in design, ranging from cohort studies to case studies to qualitative studies exploring experiences of interpreter-mediated CBT. Moreover, the diverse samples of therapist, client and interpreter studies, including variations in role and cultural background, can impact the generalisability of the findings.
The review also highlights the variability in the geographical contexts and the healthcare settings of the included studies. Conducted across various countries, the studies reflect differences in cultural norms, healthcare systems, and language proficiency, which can influence both the implementation and outcomes of interpreter-mediated CBT. These cultural and systemic differences complicate the ability to generalise findings across different settings, as what works well in one context may not be applicable in another.
Furthermore, although the review synthesises recommendations based on the available evidence, these have not been tested in real-world settings. Without robust testing, this raises questions about how well these recommendations would perform outside of a controlled research setting. This gap between theoretical recommendations and practical application underscores the need for further empirical testing to validate the effectiveness of interpreter-mediated CBT in diverse, real-world contexts.
The decision to exclude studies in languages other than English, whilst practical, may result in the omission of crucial findings, unintentionally reinforcing the dominance of Western, English language perspectives in the field of CBT. Reflecting a wider pattern seen across the social sciences (Hamel, Reference Hamel2007), science more broadly (Ammon, Reference Ammon2001), despite only around 18.75% of the world’s population speaking English (Eberhard et al., Reference Eberhard, Simons and Fennig2024).
Conclusion
This review contributes to the existing literature on interpreter-mediated CBT for mental health problems. Systematically identifying, evaluating, and integrating the findings of existing empirical literature suggests that interpreter-mediated CBT shows potential. However, further evaluation is necessary to establish its efficacy more robustly. The review has also synthesised the practice points from empirical research into recommendations.
The findings add to the evidence base and provide a rationale for further research. Within the context of practice, this will be a step towards addressing the low access and poor outcome rates for clients from diverse communities.
Key practice points
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(1) Interpreter-mediated CBT shows promise but requires further research to establish its efficacy more robustly.
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(2) When delivering interpreter-mediated CBT, either as the interpreter or as a therapist, reflect on the proposed recommendations and consider how to adapt your practice to ensure safe, ethical and effective therapy.
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(3) All those in positions of authority within services and organisations should reflect on the proposed recommendations and consider strategic actions and development plans to facilitate the optimum conditions for interpreter-mediated CBT.
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(4) Further research is needed to fully evaluate the efficacy of interpreter-mediated CBT and to further explore the experiences of clients, interpreters and therapists.
Data availability statement
The data that support the findings of this study are available on request from the corresponding author.
Acknowledgements
The author wishes to express sincere appreciation to Sam Thompson for his essential support in the quality assessment of the papers included in this review. Additionally, the author acknowledges the contributions of Kate Sheldon, Jenny Lam, Natalie Meek, Michelle Brooks-Ucheaga, Ontonio Dawson, Faithful Odusote, Leila Lawton, and Katy Emerson for their encouragement and assistance with proofreading. Their collective efforts have significantly enhanced the quality and clarity of this work.
Author contributions
Taf Kunorubwe: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Writing – original draft (lead), Writing – review & editing (lead).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The author has no competing interests with respect to this publication.
Ethical standards
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS.
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