There is increasing recognition of the need for cultural mediation – an approach that goes beyond purely providing translation or interpreting services – to meet the needs of migrants, asylum seekers and refugees. Cultural mediators work with a wide variety of organisations including NGOs, hospitals, health centres and the police, and provide assistance to displaced populations in areas including medical and para-medical services, health promotion, psychological services and legal advice.
Médecins Sans Frontières (MSF), which has provided a range of support to migrants throughout Italy since 1999, conducted a study to understand the role of cultural mediation in facilitating mental health provision and the challenges faced by those providing cultural mediation services, and to learn more about the experiences and support needs of cultural mediators themselves. Twenty-five in-depth interviews were conducted with cultural mediators, MSF staff and key informants from academic institutions and organisations who were experts in the use of cultural mediation with displaced populations.
Pivotal role of cultural mediators
Communication and translation are the main tasks of any cultural mediator’s work, enabling meaningful exchange and helping to build trust. The three-way communication that occurs between cultural mediators, their clients and other team members (such as psychologists) is an extremely important triangular relationship which helps beneficiaries to access and benefit from essential services. This relationship helps to build trust between the cultural mediator and the client, in turn improving communication between the client and the service-provider.
Cultural mediators are often the first point of contact that people have with mental health services. The mediators are often able to facilitate a more adequate and earlier understanding of needs and prevent mistakes being made or avoid missed opportunities for timely access to care and services. This initial contact was beneficial in assessing the immediate needs of displaced populations, particularly relating to acute psychological distress.
Some cultural mediators assist clinicians or mental health staff during individual consultations, or work with survivors of torture and women who have been trafficked. Others work with legal and security agencies, providing information and translation during legal hearings. They translate both words and concepts between clients and service providers, ensuring that the client is understood and can access the care and support they need.
Emotional and challenging work
The work is also challenging for the mediators themselves. Often they are drawn from the refugee community and many of them have been through similar, often traumatic, migration journeys and experiences as the people they are trying to support; it is more difficult therefore for them to establish a proper, objective and professional distance. Where they have been through a difficult asylum process in Italy themselves, they can be unsure if – or how – they should share these experiences with their clients. They are sometimes accused of bias or are asked to lie or conceal information, which puts them in a very difficult position.
On the other hand, as an MSF staff member said, the fact that some of the cultural mediators had travelled the same way and were in a stable situation “was a positive message for the people… the very fact of being there, even sometimes without speaking, was already of added value in this situation, to decrease the tension, the fear...”
Clients do not always want assistance from, or close proximity to, a cultural mediator, and do not always want to speak their home language during psychological or clinical sessions. As one expert in cultural mediation explained, “it’s the language of their torturers”. Some prefer expressing themselves in French or English without a cultural mediator to assist with translation. Although MSF clients already have the right to decline the support of a cultural mediator during their sessions, more work is needed to inform (and thereby reassure) them about codes of conduct and confidentiality to help in deciding whether or not to have the assistance of a cultural mediator.
While familiarity with their experiences provides reassurance for clients, the shared experience between cultural mediators and those whom they assist makes their work emotionally challenging and the risks for them of vicarious trauma and burnout are extremely high. Cultural mediators may adopt personal coping strategies, but well-integrated psychological support and supervision are necessary to fully protect cultural mediators, particularly those exposed to extremely sensitive issues around mental health, violence or torture.
Regular meetings between cultural mediators and their counterpart colleagues – such as psychologists, physiotherapists or clinicians – need to take place before and after interactions with clients. However, as many cultural mediators do not work full time, or may be working with different organisations simultaneously, such meetings can be challenging to attend. In addition, this precarious employment status adds further to the challenges they face.
Timely access to mental health services for refugees and asylum seekers is a fundamental component of essential medical provision, in Italy as elsewhere. Cultural mediators are essential to this but the pressures on them in that role are many. A greater focus on training and skills development for cultural mediators and for those staff working with them would also help ensure an improved clarity of roles and quality of service provision, and would reduce the potential for increased trauma.
Emilie Venables firstname.lastname@example.org
Luxembourg Operational Research Unit, Médecins Sans Frontières (MSF) Luxembourg; Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town
Katherine Whitehouse email@example.com
Luxembourg Operational Research Unit, MSF Luxembourg
Caterina Spissu firstname.lastname@example.org
Italy Mission, MSF
Lilian Pizzi email@example.com
Italy Mission, MSF
Ahmad Al Rousan firstname.lastname@example.org
Italy Mission, MSF
Stefano di Carlo email@example.com
Italy Mission, MSF
 We use the terms ‘cultural mediation’ and ‘cultural mediators’ to reflect MSF’s guidelines at the time when the study was conducted. Subsequently updated job descriptions refer to ‘inter-cultural mediation’.
 The research team would like to acknowledge the invaluable contributions of the study participants as well as the support of MSF Italy. We would particularly like to thank Francesca Zuccaro and Adeline De Gratet for their support and input into this research study.
 See presentation at https://f1000research.com/slides/5-1331.