Impact case study database

Costa and Dewaele’s research and its active dissemination of the main findings through clinical training has raised awareness about multilingualism and multilingual identity as a therapeutic asset, leading to improved practices of UK therapists dealing with LX users of English and ultimately benefiting some of the most vulnerable and traumatised groups in society.

New training and forms of clinical supervision have been developed as a direct result of Dewaele and Costa’s research (A, E). The training reinforces the importance of allowing the clients’ languages in the therapy session, even if these are unknown to the therapist, and the realisation that this does not constitute a threat to the authority of the therapist. By allowing clients to use their full linguistic repertoire, therapists allow clients who may struggle in English to maintain their dignity and to show their multicultural identity. Finally, it emphasises the importance of recognising that language switching happens at critical emotional junctures (A; 1) in a session and these instances deserve particular attention.

2 types of training for different target groups were developed based on studies by Costa and Dewaele (A, B, C, E, F). The first type of session was for psychological therapy practitioners in general and focused on the assumptions of psychological therapists about their ability to work in English with a multilingual client for whom English is an LX and whether the client’s multilingualism is significant to the therapy. This training was the first time that these issues have been included in psychological training curricula. The second type of training built specifically on the findings of (B) and led to greater confidence in multilingual practitioners to work effectively in a language in which they have not trained.

The training has helped to build the confidence of practitioners to consider, for instance, incorporating a linguistic history into the assessment process; discussing linguistic privilege and power with regard to the concept of “native speakers” and foreign accents; initiating a conversation about identity and language; evaluating when, how and if to invite a client to use their different languages in the therapy room when processing trauma; and the therapeutic value of speaking in one language or another.

Between 2013 and 2020, Costa trained in the region of 3,640 practitioners through her support services Mothertongue and Pásalo CIC (2). This figure represents all of the training discussed below. The importance of these therapeutic skills should not be understated – LX clients are often extremely vulnerable; empowering them to speak in the language in which they feel safest and most comfortable is vital. Findings demonstrate that some multilingual clients may struggle to express themselves in their LX (C), while others feel safer to do so due to the ‘detachment effect’ of speaking in a foreign language. Each individual is unique and benefits from services that are adaptable. Although this case study broadly describes the impacts on therapists, the ultimate beneficiaries are the clients, who through Costa’s training have been empowered by their therapists to work through their emotions and trauma as individuals with unique linguistic needs.

Mothertongue: Costa established Mothertongue as a charity in 2000 to provide culturally and linguistically sensitive counselling and mental health intervention to people from black and minority communities in the languages of their choice. Costa and Dewaele’s research led to a greater awareness of and respect for Mothertongue’s culturally-sensitive professional counselling services, and in improved training practices for interpreters and psychotherapists. A comprehensive training programme was developed for psychotherapists and counsellors working in the NHS, private therapy and the voluntary sector. Clients who used Mothertongue directly were referred by the NHS Migration and Domestic Violence Services, and by Probation and Social Services.

Beyond this, through Mothertongue Costa has trained therapy trainees and qualified therapists practicing in IAPT, Child and Adolescent Mental Health (CAMH) teams, clinical psychology, and trainees on psychotherapy training programmes (3), who consistently demonstrate greater confidence and understanding in working with LX clients.

Clinicians reported higher levels of patient satisfaction and appreciation when their multilingual identities were acknowledged and respected.

Mothertongue’s model of practice has now been integrated into the Berkshire NHS IAPT (Talking Therapies) psychotherapy services, employing Mothertongue-trained interpreters as NHS workers, resulting in easier access to services for speakers of non-English languages. Trust clinicians have gained invaluable insight and knowledge, enriching staff experience improving the client experience. New practice resulting from this intervention is now firmly embedded at the Trust in which senior clinicians either lead or attend supervision sessions (4). The frontline work of the charity Mothertongue was concluded in 2018 after the successful integration of its interpreter service and elements of its therapy model into the Trust’s Mental Health Service.

Pásalo CIC: Costa launched the Pásalo Project in 2017 as a Community Interest Company (CIC). A CIC is a more nimble and dynamic organisational structure than a charity; this structure suits the non-frontline dissemination and expansion of the learning from the work that Mothertongue initiated. In 2018, Pásalo was awarded funding by the Big Lottery to provide cultural and linguistic training and supervision to small organisations which would otherwise be unable to afford the training. Spaces were filled months prior to the start date of March 2018, while requests for multilingualism in therapy training continue.

Practitioners working with the terminally ill and bereaved family members were trained through Pásalo to work with multilingual clients. Case workers and clinicians from five refugee organisations, working with the most traumatised members of our communities, have been trained. This model of training is easily replicated and available to the least well-resourced workers working with a highly vulnerable client group. Due to its success, funding was awarded again in 2019, while additional funding to work with organisations in Wales was awarded, also in 2019. The impact of this model is particularly significant because of the overall lack of resource for vulnerable client groups. In 2020, Pásalo CIC was awarded funding by the Paul Hamlyn Foundation to create a free online CPD training resource on mental health and multilingualism. This includes six short films from psychological therapy with multilingual clients. The resource will ensure the widest possible reach for practitioners to work with multilingual mental health clients https://www.pasaloproject.org/multilingualism-mental-health-and-psychological-therapy---course-content.html.

The Pásalo Project continues to train practitioners, including Speech and Language Therapists at the University of Reading and the Masters programme for Public Service Interpreters at the University of Alcalá, Spain. In 2020, Pásalo created an e-learning resource for the British Association for Counselling and Psychotherapy: The Social Response Cycle - about effective therapeutically framed social action ( https://www.bacp.co.uk/cpd/social-response-cycle-member-resource/) (5).

The British Association for Counsellors and Psychotherapists recommends that practitioners provide around 20 sessions per week with multiple clients. Assuming a thirty-year career for each of the 3,640 practitioners who received training through Mothertongue and Pásalo, and a 48-week working year, this equates to nearly 30,000 sessions per counsellor. For all counsellors Costa has trained, the number of sessions is in the region of one hundred million. The number of people living in the UK for whom English is a second language is around 7%, so assuming that approximately 5% of service users fall into this category, 5% of the overall sessions equates to over 5,000,000 sessions directly benefiting from Costa’s training.*

These sessions often reach the most vulnerable people in society and those most in need of support, including victims of domestic abuse, refugees and asylum seekers. While it is hard to pinpoint exact numbers of those groups that have been reached, we do know that therapists have overwhelmingly benefited from Costa’s training, and that they are passing those benefits on to their clients.

Bager-Charleson: In 2017, Sofie Bager-Charleson (1) published a study with Dewaele and Costa on therapists’ experiences of undertaking awareness-raising training about multilingualism. Analysis showed that clinicians trained to understand multilingualism consistently reported feeling more confident to work with patients’ multilingualism as a therapeutic asset in treatment.

Clinicians trained by Costa consistently report that the techniques developed from Dewaele and Costa’s research are helping patients to use treatment for anxiety and depression - especially trauma - more effectively, aiding their recovery. Indeed, Bager-Charleson’s (1) evaluation of the training programme showed that it raised awareness of how ‘language is a path into “a whole world of understanding and experiences”’ and not using a client’s mother tongue limited access to their world. Bager-Charleson’s positive assessment of Costa’s training holds true in direct feedback, too. Practitioners trained in 2018 and 2019 awarded the sessions an average score of 9.4 out of 10 for usefulness (6), while qualitative comments from IAPT trainees demonstrate the sessions’ impact on clinical practice: ‘I now explore with bilingual clients if they feel a greater connection […] to either language and adapt language chosen’; ‘I [now] invite in client’s first language if they are describing past events’; ‘[I encourage] clients to use phrases or words from their native language’; ‘I have now negotiated with my manager to have more time to write up clinical notes in English when I have been working with a patient in Polish’.

British Association for Counselling and Psychotherapy (BACP): Costa has delivered supervision training across the UK for BACP and has informed the work of numerous small and voluntary sector organisations offering mental health services and counselling to victims of domestic violence, asylum seekers and refugees, and parents of children in hospices. Furthermore, individuals working in these organisations received training directly from Costa (6).

IAPT / Further and Higher Education: Costa taught on Reading University’s IAPT training in 2018-19 and 2019-2020, as part of the School of Psychology and Clinical Language Sciences PYMBAS module, covering foundation skills in Cognitive Behavioural Therapy, as part of the core curriculum to trainee Psychological Wellbeing Practitioners (PWPs). Further sessions were delivered as part of the PWP Supervision training (7). Additionally, Costa has trained clinicians and trainees at further and higher education institutions; IAPT therapists and supervisors have been trained at the Universities of Southampton and East Anglia (7, 8, 9); trainee Clinical Psychologists at the University of Oxford; trainee Speech and Language Therapists at the University of Reading; trainee Counselling Psychologists and Psychotherapists at the Metanoia Institute; trainee clinical supervisors via the BACP; and trainee counsellors at Cardiff And Vale College. Southampton University’s Low Intensity (LI) CBT Programmes Group Manager attested that Costa sessions for PWPs and High Intensity Therapists (HITs) were considered by ‘our programme teams to be an extremely valuable and useful session [there is] an enormous amount of value […] for the students’. Furthermore, Costa also delivered a similar session to PWPs for the Education Mental Health Practitioner (EMHP) training. The Group Manager noted that although it was not part of the national curriculum, the value that it added for EMHPs was indispensable (9).

Costa’s training and new resources have continued to benefit therapists into the latter part of the impact period. Early in 2020, Costa developed a new online training resource on multilingualism and mental health, that included an accompanying film, Language of the Heart, both of which were produced through Pásalo. The course is for therapists, counsellors, trainees, supervisors, trainers, social workers and anyone interested in mental health and multilingualism. The course takes up to 12 hours to complete and participants receive a CPD certificate for on receipt of their evaluation. Because the training is currently in its trial form it is being offered free of charge and is therefore an opportunity to achieve 12 hours of CPD for free. Although the resources were originally due to be trialled earlier in 2020, they were delayed until lockdown restrictions were lifted. Ultimately, the online resource and film were launched on 14 December 2020. In its opening week alone, 115 people accessed it and 22 completed it and sent in evaluation reports, while at the film’s initial screening 100 people attended.