In many professions, effective communication is essential for a successful provider-consumer interaction. In particular, in mental health counseling, clinicians rely on verbal and nonverbal communication as the primary tool for obtaining a thorough psychiatric and psychosocial history and forming a therapeutic relationship with the client. Language barriers can lead to miscommunication, which can further lead to under- or overdiagnosis and inappropriate treatment.
Overcoming language discrepancies between the patient and clinician is not an easy task. Both parties interpret cues based on a set of culturally determined beliefs and values. The cultural rules underlying how they respond to each other determine the course of their communication in the therapeutic encounter. Research demonstrates that considerable complexity can arise due to differences in social class, even when the patients and clinicians share a common language (Pendleton & Bochner, 1980) and gender (Felton, 1986). Few studies document how differences in culture and primary language affect the direct provision of counseling. Studies that do exist highlight several negative effects when a common language is not shared: diagnoses of more severe psychopathology, low ratings of clinicians' empathy and therapeutic rapport, and lack of patients' self-disclosure (Belton, 1984; Doolgin, Salazar, & Cruz, 1987; Erzinger, 1991; Marcos, 1979, 1988).
There are few studies documenting the positive effects on treatment outcomes if a common language between the clinician and patient is shared. One recent study indicated that when Asian clients and therapists shared either a common language or a common ethnic origin, there was a significant increase in the number of client sessions with the primary therapist (Flaskerud & Liu, 1991). If we assume that language match can bring more beneficial effects to treatment outcome, we need to have many more bilingual mental health professionals. In our current culturally diverse population with a dramatic increase of immigrants whose primary language is not English, it is next to impossible to staff an organization competent in so many languages and dialects. Therefore, the use of interpreters is necessary to bridge the language and cultural gap, even though it may not be the ideal communication medium. Although many organizations already use interpreters, at least three problem areas exist: (1) Most interpreters are not properly trained in the art of interpreting, particularly in the mental health setting; (2) most clinicians are not skilled in the use of interpreters; and (3) most patients are ill-informed as to their rights to receive services in their own language and often find it difficult to express themselves through interpreters.
The purpose of this chapter is to provide clinicians with knowledge and skills to develop their competency in working with interpreters. This chapter provides a practical guide to identifying common problems in interpreting, the role of the cultural interpreter, interpreting formats and stages, and effective communication skills in working with non-English-speaking patients. The therapeutic triad model is introduced as an effective tool in working with interpreters.
The term "translation," in general, refers to written work. It is judged by its denotative accuracy. The translator must have excellent command of the two languages. The term "interpretation" refers to the transfer of connotative as well as denotative meaning and usually applies to dialogue rather than written materials (Westermeyer, 1989).
A "cultural interpreter" is an active participant in a cross-cultural/lingual interaction, assisting the provider in understanding the beliefs and practices of the client's culture and assisting the client in understanding the dominant culture, by providing cultural as well as linguistic links. This model of interpreting service was developed out of an awareness that communication is seriously impaired by insensitivity to the role of culture in the content and manner of communication, particularly in formal interactions (Cairncross, 1989).
Institutions vary in their arrangements for meeting the needs of monolingual patients. Even in urban cities with large numbers of immigrants who do not speak English, many facilities have not dealt with language and cultural barriers in a formal operational sense and systematic way.
Providing interpreters is not seen as an institutional responsibility. With the financial crisis facing many health care facilities, funding for formal interpreting services is not seen as a priority.
Models of interpretation currently being used in mental health settings broadly fall into five different categories:
- The "approximate-interpreting model" applies when the responsibility for interpretation falls on the shoulders of the nearest person who is bilingual and convenient to the scene. This person is sometimes the relative of the patient or a stranger who happens to be in the vicinity (e.g., janitorial staff or bilingual worker in another department). In some hospitals, other patients are used as interpreters. There are major problems with this substitute for a trained interpreter. Persons put into this position usually do not have the level of dual fluency needed and it is unlikely that they have the necessary technical vocabulary. Another problem is the inability to adhere to the confidentiality ethic. The patient may not be willing to share many personal and often private thoughts with a stranger from the same ethnic community or with other family members. When children are used as interpreters, the conflicts resulting from the reversal of roles between the parent and the child can have a lasting negative effect on the family relationship (Cairncross, 1989).
- The "tele-active model" uses the telephone dial to select from a menu offering different languages/dialects. The patient interacts with computer and software without human interaction. This mode of service may be used during emergencies or crises after hours when an interpreter is not available. Such machine contact should not replace face-to-face communication on a regular basis.
- The "bilingual worker/interpreter model" works as a "clinician's assistant" who sees the patient alone under supervision or functions as an interpreter if needed. If the worker is not professionally trained, this model may present certain legal and ethical problems. If the worker is experienced and well trained, this model can be quite effective. Many refugee clinics and mental health clinics serving large number of monolingual patients are using this model.
- The "volunteer interpreter pool model" recruits a pool of volunteers to provide services upon request. They usually have not received formal training in interpreting skills.
- The "staff interpreter model" employs paid staff to provide interpretation. Most of them have received formal training.
Table 32.1 provides a listing of competency criteria for the interpreter.
TABLE 32.1. Competency Criteria for the Interpreter
- Good command of English in both speech and reading
- Proficiency in language of origin in both speech and reading
- Ability to translate fine shades of meaning
- Familiarity with and understanding of the terminology and procedures used in different organizational settings
- Ability to translate not only verbal communication but also such nonverbal communication as body language, facial expressions, and speech patterns
- Intimate knowledge of his or her ethnic community, including migration history, cultural values, social and power structures, community healers, and cultural views of health and illness
- Ability to make cultural connection and rapport with patient
- Familiarity with U.S. culture
- Ability to act as cultural broker-to interpret with linguistic and cultural perspective and to explain why a suggestion from the clinician may be unacceptable or unrealistic to patients
- Ability to understand the culture of the organization
- Good awareness of personal values, attitudes, and personal biases
- Good understanding of own communication style
- Ability to assess areas of incompatibility with clinician or patient and to react appropriately
- Ability to get along with peers and other staff members
- Ability to deal with conflicts arising from role confusion or unrealistic expectations from clinician or patient
A professional ethics code that includes confidentiality, impartiality, proficiency, and general rules with respect to conflicts of interest
- Ability to be an effective advocate for patient
- A good memory
- Careful attention to detail
- Flexibility in handling different situations
Note. Adapted From Cairncross (1989).
STAGES OF INTERPRETING
Using interpreters correctly requires time, planning, and experience. Generally speaking, for the clinician, an ideal interpreting session should consist of four stages.
Language Assessment and Interpreter Assignment
The clinician makes an initial assessment of the patient's country of origin, language, and dialect and matches these characteristics with those of the interpreter. There are dialectical differences even for patients from the same country or same region. For example, a Chinese patient from Vietnam may not speak Vietnamese. Also, the Chinese speak many different dialects (Cantonese, Mandarin, Chiuchow, etc.). It is important to find an interpreter co match the exact dialect. For the patient who speaks "some English," it is advisable to provide an interpreter to avoid language and cultural misunderstandings. It is quite difficult for patients whose primary language is not English to express their emotional states in English. On the other hand, unless the monolingual provider is thoroughly effective and fluent in the patient's language, he or she should always use an interpreter. In addition to language match, it is also desirable to assign an interpreter of the same sex in some cases. Very often, an age match is useful.
It is also important to assess the interpreter's knowledge and understanding of the organization. The interpreter should know about the mission of the agency, range of services provided, terminology and institutional language used, legal forms required, roles of different professionals, and types of patients served.
Preinterview Meeting with the Interpreter
The clinician should take time to prepare the interpreter before the actual interview. Questions to consider include the following:
- What are the objectives of the interview?
- What topics are to be covered?
- What is the patient like (background, symptoms, behavior)?
- What are the particularly sensitive topics?
- What are the interpreter's experiences with patients with emotional problems?
- How much time will the interview require?
- What are the preferred translation formats?
The preinterview meeting gives the clinician an opportunity to build a relationship of trust and team spirit with the interpreter and to get across to the interpreter the concept of "I need your help" or "I need your input." In the event the clinician finds that the patient's culture is unfamiliar, he or she might give the interpreter permission to bring up cultural issues.
Actual Interview with the Patient
During the actual interview, the clinician should be aware of translation problems, verbal and nonverbal communication styles of everyone in the interview, different types of translation formats, and cultural misunderstandings. More details will be covered later in the chapter.
Review of the Session
After the interview, the clinician and the interpreter should review the session to clarify any confusion that may have arisen, to discuss any cultural issues, to vent any feelings about working with each other, and to plan future sessions.
Clinicians have different role expectations for the interpreters, depending on the resources available in the organization and the training received by the providers. Generally speaking, there are three major types of relationships:
- Treating the interpreter as a "robot" or voice machine. The only task of the interpreter is to pass the message verbatim from one person to the other. The interpreter is not expected to give any input, cultural or otherwise. This type of interaction may work well in court settings or in multilingual conferences but may not be the most effective model for mental health interviews.
- Treating the interpreter as a "clinician." The clinician lacks confidence in working with the patient from a very different culture and hands over the clinical judgment to the interpreter.
- Treating the interpreter as a "team partner." The clinician understands that he or she brings professional expertise and knowledge in the helping process. At the same time, the clinician recognizes and respects the interpreter's expertise in language, culture, and community resources.
THERAPEUTIC TRIAD MODEL
When three persons work together within a limited physical space, using two different languages in a structured task, three distinct interactions are occurring. What develops is a triangle with three sets of pairs, or dyads, each one operative at a given point in time (see Figure 32.1). The clinician, the interpreter, and the patient form a "therapeutic triad" with three interlocking sets of relationships. Unlike two-way communication, there is a shift of power balance within the triangle. The interpreter is the only one who knows the two different languages. In this situation, the only means of communication between the clinician and the patient is nonverbal communication. Although only one of these dyads is operative at any one time, nonverbal communication is taking place with each dyad at all times.
1. Word-for-word interpreting gives verbatim or line-by-line translation. The interpreter is expected to act as the "messenger" to translate each word spoken by the provider. This format allows minimal participation by the interpreter, who attempts to be a neutral party whose primary task is to pass information between the patient and the provider. The clinician may find this format to be helpful in situations such as asking factual questions, giving information, and explaining technical procedures. However, this format is not the best if the subject being discussed needs to be expressed in a summary fashion without constant interruption. This
Figure 32.1 Therapeutic triad model
format also does not allow room for untranslatable words or concepts. This process takes at least twice as long.
Concurrent interpreting consists of the interpreter translating and speaking while the clinician or patient is speaking. Although this method saves time, it can have many disadvantages (e.g., more chances for error, greater emphasis on denotative translation at the expense of connotative interpretation, and no room for the interpreter to assist with his or her cultural expertise).
Summary interpreting summarizes the important points without necessarily using the same word or sentence sequences. It is a much faster method than verbatim interpreting but less accurate in terms of reflecting the actual exchanges of the communication. This format is helpful when patients need to tell their stories on emotionally charged topics. This model requires high degree of trust between the clinician and the interpreter.
Consecutive interpreting requires accurate interpretation segment by segment as each party speaks.
Cultural interpreting gives permission to the interpreter to convey the parties' messages in a way appropriate to the cultural background and understanding of the speaker and the receiver. The interpreter acts as the "cultural broker" to minimize cultural misunderstanding.
COMMON PROBLEMS IN INTERPRETATION
There are many problems associated with the utilization of interpreters, especially in the fields of mental health and psychiatry. Interpreting requires three-way dyadic communication in two languages by three individuals (more in the case of family interviews or group interviews). Each member in the session is different in terms of dialect, accent, grammar, and linguistic style. Generally speaking, problems fall into two areas: technical difficulties, and role conflicts.
Technical Difficulties in Interpretation
The following common problems are drawn from both the literature (Putsch, 1985) and my personal experiences in working with interpreters. Any of these problems may prevent the clinician from obtaining accurate and pivotal information.
- Deletion/omission of information. For example: Patient [in Vietnamese]: "I decided to escape by boat but I did not tell my mother about my plan. I did not want her to worry so much since my father was still in the educational camp." Interpreter: "Mr. L says he came by boat."
- Bad paraphrasing. For example: Patient: "It is my right leg that's bothering me for the past three weeks. My back hurts if I stand up too long." Interpreter: "Mr. Y has problems with both his leg and his back."
- Lack of translatable words or concepts. For example: A psychiatrist asks a newly arrived woman from Laos during a mental status examination: "What does `A rolling stone gathers no moss' mean to you?" Interpreter: "???"
- Inaccurate translation of words and concepts. For example: Clinician: "Mrs. W, do you hear voices?" Interpreter: "The doctor asks you whether you hear any noises?" ("Voice" and "noise" are the same word in Chinese.) Patient: "Yes, I hear noises all the time. I live on a busy street."
- Blocked verbal communication. For example: Mrs. C and the interpreter engaged in a 10-minute dialogue, and then the interpreter tells the doctor: "Mrs. C does not want to take the medication."
- Distortion of meaning. For example: Physician: "Are you allergic to any medications?" Interpreter: "Does the Western drug make you vomit?" Patient [in Cantonese]: "No."
- Exaggeration/adding. For example: Patient [in Cambodian]: "I am glad I have decided to come to this country." Interpreter: "Mr. B is excited that he and his family are in the United States. They are now receiving welfare and living in an apartment with a new television."
- Lack of familiarity with professional terminology. For example: Clinician: "What kind of mood have you been in recently." Interpreter: "How have you been feeling?" Patient: "Well, you see my head used to ache all the time.... "
- Inability to interpret the cultural meaning of the symptoms and behavior. For example: Patient [in Cantonese]: "I took the whole bottle of 60 po chia pills last night." The interpreter used word-for-word format to repeat the statement without giving a cultural explanation that this pill is a popular Chinese medicine that usually requires the user to take the whole bottle. Psychiatrist: "Mrs. D, were you trying to kill yourself last night?"
- Inability to detect paralinguistic or nonverbal behavior. For example: A young medical student in a refugee clinic: "Mrs. P, are you having regular sexual intercourse with your husband?" The patient appears embarrassed and looks at the floor after the translation. The medical student consults the chart and repeats the same question.
- Overidentification of patient with the interpreter due to cultural and language bonds.
- Overdependence of provider on the interpreter due to unfamiliarity of language and culture.
- Rejection of the interpreter by the patient due to fear of breach of confidentiality.
- Overexercising the power and authority by the interpreter in relating to patient due to social class difference.
- Role conflict faced by the interpreter as community advocate and institutional employee. Over- or underexpectations by professional of interpreter lead to frustration for both parties.
ISSUES AND PROBLEMS IN CLINICAL ASSESSMENT
Using an interpreter for such clinical assessments as mental status examination poses more complications. Even the sophisticated interpreter and trained clinician face difficulties in pursuing topics such as hallucination, delusions, suicide, mood changes, sexual dysfunction, and so on. Presentations of psychiatric patients, such as flight of ideas, illogical thinking, poverty of speech, thought content, and pressured speech, are difficult to translate. In addition, when the clinician conducts a comprehensive evaluation, there is a constant shifting of contents between history gathering, problem solving, psychotherapy, and education.
In psychiatric settings, it is not uncommon that the interpreter attempts to "normalize" the patient's psychopathology to protect the patient from medical authorities. Interpreters may sometimes fall into the trap of trying their best to "make sense" of the patient's disorganized or illogical responses. These efforts to make sense out of nonsense may be motivated by a desire to be an advocate for the patient and trying to help the patient be understood by the interviewer. Interpreters' emotional responses to the questions being asked in the evaluation can add further complications. Many interpreters feel overwhelmed by the responsibility. They may feel embarrassed by some of the interviewer's questions or by some of the things the patient says. Some feel pressured to give more information to the interviewer than the patient actually gave. Some experience frustration about being asked to translate the same questions again and again, or some may feel offended by the "culturally incompetent" questions asked by the interviewer. Unfortunately, many interpreters do not share their feelings openly because of their lower job status and nonassertive communication style. Dynamics such as these interfere with the quality of the interpretation and affect the working relationship.
OVERCOMING THE LANGUAGE BARRIERS: EFFECTIVE COMMUNICATION WITH NON-ENGLISH-SPEAKING PATIENTS
- Clinicians should be aware of their own verbal and nonverbal communication style.
- The clinician should try to find an interpreter who can speak the patient's dialect and understand the patient's cultural background. Clinician and interpreter should convene briefly before meeting the patient to discuss the purpose of the interview, the translation formats, and other clinical information. It is also important to ask about the interpreter's previous experience in working with patients with emotional problems.
- Clinicians must build a relationship of trust with the interpreter. They should interact with the interpreter in a respectful manner and project positive energy.
- The clinician should try to conduct the interview in a comfortable, professional setting. It is helpful for clinicians to organize the seating arrangement in a way that will allow them to engage in face-to-face contact with both patient and interpreter. I recommend a 60-degree triangular arrangement.
- The clinician should always talk to the patient, even if the patient does not understand the clinician's language. Questions should be addressed to the patient directly. Clinicians should address the patient as "Mrs. C" or "you" rather than through the interpreter as "she" or "her."
- It is up to the clinician to explain his or her role and the interpreter's role clearly to the patient.
- Clinicians must demonstrate that they understand the importance of confidentiality.
- Clinicians should be aware of the ethnic/age/sex/class differences of the patient and interpreter.
- Clinicians must be sensitive to and aware of the different cultural assumptions between themselves and the patient. They should use the interpreter as the "cultural broker" to avoid unnecessary cultural misunderstanding.
- Clinicians should practice nonverbal communication skills throughout the interview. Actual spoken words account for only a small portion of emotional expression, while the majority of emotional messages are received nonverbally.
- It is imperative to be aware of the cultural meanings of body language-smiling, nodding, eye contact, touching, foot movement, and other facial expressions. The clinician must maintain "gentle" eye contact when the patient or the interpreter speaks.
- The clinician must be a good listener and must not fake attention.
- The clinician should not take excessive notes during the interview.
- It is wise to use short, simple statements and stick to one topic at a time. When lengthy explanations are necessary, the clinician should break them up into several short sentences.
- A clinician should speak clearly and should not raise his or her voice. Tone and volume should be compatible with the patient's.
- The clinician should speak slowly throughout the session. He or she should conduct the interview in a quiet, unhurried manner and should try to sit down during the conversation.
- The clinician should use words or examples the patient and interpreter are likely to know. He or she must avoid idioms, ambiguous statements, jargon, abstractions, and metaphors. Also, he or she should avoid indefinite phrases that use "would," "could," "if," and "maybe." These can be mistaken for actual approval of a course of action.
- Clinicians must be alert to translation errors. In the event of obvious omission, the clinician should ask gently but persistently that the interpreter make a more complete translation.
- The clinician must try to regulate the flow of the conversation. Clinicians must maintain a good balance between focus on self and on others. They should plan what they want to say ahead of time and avoid confusing the interpreter by backing up, rephrasing or hesitating.
- Clinicians must encourage the interpreter to tell them when he or she is having difficulty. The clinician should ask the interpreter to comment on the patient's word content and emotions. He or she should conduct a postintetview meeting with the interpreter to review the session.
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