Adult family members and friends

The use of adult friends or family members as untrained interpreters in health care settings has been widely reported, although the existing literature has not reached any clear consensus on whether their use in health care is considered to be bad or good practice (e.g. Meyer et al., 2010; Valdés et al., 2003;

Bischoff et al., 2003). However, their use in medical encounters appears to be extremely widespread, frequent, and almost inevitable (MacFarlane et al., 2009). This is mainly due to “structural reasons, as it appears to save time and costs” (Meyer et al., 2010, p. 302). Time constraints seem to be a particularly important reason (Hsieh, 2015b; Jaeger, Pellaud, Laville, & Klauser, 2019) since when a patient urgently needs to communicate with providers, one of the fastest solutions is to use a relative or friend accompanying the person. However, time constraints are more relevant in settings such as emergency departments than mental health care, where sessions are usually planned in advance (Lundin, Hadziabdic & Hjelm, 2018).

The lack of consensus on the use of this category of interpreter can also be explained by the fact that their linguistic skills, health literacy, preparation, and awareness of their interpreting activity in the interaction can vary greatly. It has been reported that these interpreters are often not able to understand and translate specific medical (e.g. anatomical) or technical terms, and that their language skills may be poor or insufficient (Hsieh, 2015b; Jaeger et al., 2019). The lack of health literacy, which is the ability to seek, cater, and process information when communicating with health care providers (Hsieh, 2013), is also an issue that chance interpreters (untrained interpreters who are not family members or friends) face. Chance interpreters may be skilled enough to translate from one language to the other, but they may not be able to communicate effectively with a health provider.

Another issue that may arise is the ability to navigate not just between languages but also across cultures: the concept of “explanatory models”, whose importance is widely recognised in research (Napier et al., 2014). According to Kleinman (1980), the notions of health and disease can vary greatly from one group (or individual) to another, and disease and illness exist “as constructs in particular configurations of social reality. They can be understood only within defined contexts of meaning and social relationships” (p. 73). Providers, especially those in Western countries, use a more biomedical explanatory model, whereas patients from other cultures may have other ways of discussing disease. Since explanatory models of illness are influenced by people’s social and cultural background, patients may focus more on non-physical factors. An untrained interpreter may be unable to identify and appropriately tackle this “shift” in explanatory models when interpreting. This shift, on top of different cultural expectations and social norms, may, unless addressed, become communication barriers for the two main participants (Pöchhacker, 2000).

In addition, the differing relationships between the patient and the relative or friend interpreting for them makes it difficult to generalise about the impact of this kind of interpreter on a health care encounter. While a number of studies show that there are some advantages to this category of interpreter in health care exchanges (Greenhalgh, Robb, Scambler, 2006; Meyer et al., 2010; Hsieh, 2015b) others highlight their drawbacks (Juckett, 2005).

For example, an essential difference between family interpreters (and also other types of non-professional interpreter) and non-professional interpreters is the adherence to a non-professional code of ethics.

Since family members do not abide by any professional code, they are not bound to respect the patient’s right to privacy and confidentiality. With neither professional training nor a code of ethics, it is reasonable to assume that the trustworthiness of family interpreters cannot always be guaranteed (Angelelli, 2015; Faucherre et al., 2010, as cited in Greenhalgh et al., 2006), something that providers should be aware of. Moreover, the patient may feel embarrassed to discuss personal health issues or

other topics deemed sensitive in their culture, and that could affect the family’s reputation (Hansen

& Cabassa, 2012) or risk bringing shame on them. It is worth mentioning, for example, the reported case of a refugee woman who lied to her Australian specialist during a consultation of a sensitive nature that was interpreted by a family member because no professional interpreters were available (Hansen & Cabassa, 2012).

Unfortunately, trust-building between the three participants is even more difficult given the potential sensitivity of a health care encounter. Trust needs to be present not only between patient and interpreter, but also between interpreter and provider (Fidan, 2017), and since family members are not assessed or supervised by a professional agency or the health care system, it is difficult for providers to fully trust them or to feel that they are both part of the same “team” with shared goals and expectations (Foundation House, 2012).

Concerning the positive contributions of family interpreters, Hsieh (2015b) states that untrained family interpreters constitute a “unique category due to their knowledge of the patients and special relationship of trust, which providers can draw on in certain circumstances” (p. 182). With proper training for providers, the use of family interpreters can be appropriate and effective. Another study conducted by Greenhalgh Robb and Scambler (2006) adds that friends and family members are sometimes a preferred choice because of their specific relationship of trust with the patient, as well as the fact that they share the “lifeworld agenda” (p. 1180), and act in the patient’s interests. When interviewed, some family interpreters expressed the view that the high degree of trust between them and the patient and the ability to keep health problems safely “in the family” made them preferable to professional interpreters. This shows how important trust is to a patient; linguistic skills may become of secondary importance. Greenhalgh et al.’s study draws the conclusion that the lower level of linguistic skill of family interpreters could be weighed against their positive contributions (better advocacy, greater trust, deeper knowledge about the patient and viewpoint) to determine the

appropriateness of their use on a case-by-case basis. Another recent study (Zendedel, Schouten, van Weert, & van den Putte, 2018) confirms that a patient may prefer to have a family member interpret for them. For some patients, the fact that their family member knew them (and therefore, their illnesses) and, crucially, that they could trust them, were more important factors than interpreter training or skill. Other authors have also illustrated observed positive aspects of having a family member or a friend as an interpreter (Hsieh, Ju, & Kong, 2010; Messias et al., 2009). Although their linguistic skills and health literacy are usually poorer than that of professional interpreters, in some cases such interpreters can act as active information providers for the patients, advocate for them if needed, and shorten the time needed for a consultation by talking directly to the medical providers (Meyer et al., 2010).

In mental health care, however, the use of adult family interpreters is generally viewed as being unacceptable in the literature (Bot, 2005a, Hsieh, Ju, & Kong, 2010; Fidan, 2017; Boss-Prieto, 2013).

Their use is often seen as being problematic, unethical and in some cases even counterproductive, leading to translation errors and misunderstandings. In mental health care, where dialogue between the two main participants is often the main diagnostic tool, an interpreter’s insufficient language skills and training are potential hindrances to the session (Fidan; Boss-Prieto; Miller, Martell, Pazdirek, Caruth, & Lopez, 2005).

Unsurprisingly, language proficiency is not the only common issue. As explained by Pauwels (1995), ethics is also key, especially the concepts of trust, privacy and confidentiality. Unlike other health care sectors (Greenhalgh et al., 2010) where views on the use of family interpreters are more heterogeneous, researchers have highlighted that the use of family and friends as interpreters in mental health care is contra-indicated to protect the patient’s confidentiality and to avoid the emergence of trust issues during sessions (Juckett, 2005; Fidan, 2017).

For instance, privacy was identified as a recurring issue in mental health encounters, since a patient may not feel safe or free to share private information while in the same room as their relatives. This has been reported in the literature to be a cause of distress for the patient (Juckett, 2005). It is not unlikely that information shared during a session will be disclosed to other members of the same small immigrant community (or other relatives or friends). This can provoke further trauma for the victim, potentially turning “a healing session into a traumatic experience” (Suzuki & Ponterotto, 2008, p. 225). A reverse situation arises when the relative who is interpreting does not want to report the patient’s utterances because they fell they are too embarrassing, or may lead to “loss of face” and honour for the family or the minority community as a whole (Bot, 2005a). Even without the conscious censorship of words or phrases, this may lead to an “obfuscation” of the translation and further distortions of the original message (Bot).

Another potential problem is the existing relationship between the family interpreter and the patient.

The two individuals already know personal information about one another, and already share an alliance that does not relate to the content of a therapy session. This pre-existing relationship may impede the establishment of a therapeutic relationship with the provider (Boss-Prieto, 2013). While this may not be as problematic in other medical sectors, mental health care requires caution in even the most innocent of interactions; even casual interactions may have “serious clinical consequences”

for patients suffering from conditions such as paranoia or PTSD, and should not be taken lightly (Hsieh & Hong, 2010, p. 7). The family or friend interpreter could, in such a case, undermine the already delicate therapeutic relationship (Mirdal, Ryding, & Essendrop Sondej, 2012).

Overall, one could argue that interpreting by an adult family member is more successful in less complex situations, where linguistic skills are sufficient, and the patient feels safe and satisfied with their choice. Their use in mental health care requires more caution, since the complexities and detail of dialogue take on a new level of importance. It is worth stressing once again that a family member

or close friend should not be the only option for allophone patients during an interpreted consultation (Gray, Hilder, & Donaldson, 2011), especially in mental health settings.