Health care systems may vary significantly, but the need for interpretation in health care encounters is ubiquitous around the world. Recent waves of migrants and refugees travelling to high income countries have compounded this need, creating new challenges for their health care systems regarding the provision of care to patients who do not speak the local language. It is therefore of vital importance that we continue to deepen our understanding of how health care systems can respond to the needs of increasingly diverse, multicultural and multilingual populations to keep pace with our rapidly changing world.
To this end, this paper will focus on the influence of different kinds of interpreter working in community health care settings in high income countries, with a specific focus on mental health care.
It will explore how different kinds of interpreter can affect the unfolding and outcome of interpreted mental health care encounters.
This question is particularly topical given the critical moment in history that we are currently witnessing; the mass movement of people is increasing at a rate never before seen in contemporary human history. It is therefore of paramount importance that we keep pace with our rapidly changing world by continually reviewing and renewing our understanding of the needs and challenges that humankind faces. The ongoing arrival of migrants (many of whom are refugees) in host countries, with particular reference to Europe, underscores the relevance of a paper focussed on mental health care interpreting; many refugees face traumatic, distressing experiences, be it before, during or after their journey.
Interpreters in health care can influence the lives and wellbeing of patients facing language barriers.
Research on this topic can therefore be of practical use to policy makers and health care providers.
Health care interpreting and, to a lesser extent, the sub-field of mental health interpreting have garnered the interest of several scholars (Giacco & Priebe, 2018; Liu & Zhang, 2019; Pöchhacker, 2006). Just a few researchers have narrowed their focus to comparing the impact of different kinds of interpreter on a health care encounter (e.g. Hsieh, 2016; Meyer, Pawlak & Kliche, 2010), and fewer still have focused on the influence of different categories of interpreter on mental health care encounters. This topic – in particular, with an emphasis on the relationship between patient, interpreter and provider – remains little studied. This thesis therefore aims to contribute to this rather neglected area of research.
Community health care interpreters form a quintessential link between patient and the provider (Tribe, 2007) and play an essential role in overcoming one of the most evident obstacles to health care for allophones: language and cultural barriers (Priebe et al., 2011). However, their impact can vary greatly according to which of the many different kinds of interpreter interprets the exchange. A small but growing number of studies – which will be analyzed in Chapter one – have shed light on the not-so-uncommon use of untrained interpreters (also known as “informal interpreters”), a reality as widespread as it is unexpected. Unlike the world of conference interpreting, where interpreters are expected to have undertaken specific training in specialized schools or universities (Diriker, 2015), the requirements for medical interpreters are far less uniform. In certain instances, these requirements are completely non-existent meaning that non-professional interpreters can provide interpretation services.
According to Hale (2015), the wide variety of different kinds of interpreter present in health care settings can be attributed to several factors. One of the most obvious reasons is the vast array of languages spoken by patients, and for which interpreting may be required. This may vary depending on the location of the hospital or clinic, and on the specific migration waves towards this area. The presence of different foreign languages varies from country to country and from region to region;
even in European countries, the most prevalent languages spoken by migrant communities vary to a surprising degree (Hsieh, 2013). The language demographic of migrant communities can shift rapidly, which can create challenges for health care institutions; it is often difficult – if not impossible – to find a professional interpreter speaking the language or dialect of a newly-establishing community (Gartley & Due, 2017).
The large number of language combinations required is not the only reason for the wide variety of different kinds of interpreter: budgetary restraints and financial issues (or perceived financial issues) in health care mean that professional interpreting services are sometimes perceived as an additional, unwelcome cost (Hof, 2013), so it is not uncommon for interpreting services to be provided by members of an NGO, volunteers or other migrants who may not have the fluency or interpreting skills required for this demanding task. Moreover, even when there is a budget allotted for professional interpreting services, there is still resistance to the use of interpreters. The reasons for this low use of professional interpreters even when a budget is available is sometimes not fully understandable, not even for some researchers (Gray, Hilder, & Donaldson, 2011), whereas other studies attribute this reticence to the fact that hospitals still prefer to use family interpreters or members of the non-medical staff to tackle language barriers, and that clinicians are not aware of the importance and availability of interpreters (Kirmayer, Groleau, Guzder, Blake, & Jarvis, 2003).
Furthermore, the potentially urgent need to overcome language barriers in hospitals – a typically time-constrained, fast-paced environment – also inevitably leads to the use of non-professional interpreters.
Indeed, their use is so common that it is almost seen as the “norm” for health encounters in hospitals or clinics, and the level of awareness about the differences between professional and non-professional interpreters is generally low. It is therefore not surprising that the use of a broad range of interpreters has been so widely reported in both interpreting studies and health sciences studies (Fidan, 2017;
Carvan, 2018; Hsieh, 2013, 2016; Juckett, 2005; Leanza, 2005; Messias, McDowell & Estrada 2009;
Meyer et al., 2010).
However, it is difficult to gain an overall view of the use of professional and non-professional medical interpreters in high-income countries, even where specific surveys have been carried out to shed more light on the issue. The general confusion surrounding this topic is highlighted by Brisset, Leanza, Rosenberg, Vissandjée, Kirmayer, Muckle, Xenocostas and Laforce’s 2014 survey, which found that 56% of practitioners interviewed were unaware of which type of interpreter they were interacting with during a bilingual health care encounter and, one could argue, by extension unaware of the potential influence of that kind of interpreter on the encounter. This idea is also supported by a study conducted in 2019, which found that healthcare staff tend to be unaware of the repercussions of communicating through different kinds of interpreter, which will be analysed further below (Granhagen Jungner, Tiselius, Blomgren, Lützén, & Pergert, 2019). This lack of awareness is particularly evident – and, one could argue, particularly problematic – when analysing interpreted mental health encounters, where verbal communication rather than physical or objective analysis is the main diagnostic tool (Cambridge, Singh, & Johnson, 2012). If unaddressed, language problems seriously hinder communication, potentially hampering the development of a healthy relationship with the allophone patient, the assessment of symptoms, and the diagnosis. This may have serious and even irreversible repercussions on the patient’s treatment and mental health outcome (Gray, Hilder, & Donaldson, 2011; Kirmayer, Groleau, Guzder, Blake, & Jarvis, 2003). These are by no means the only problems relating to language barriers: migrant patients may hesitate to seek treatment, and if they do access the required services it is common for both patient and provider to experience feelings of frustration about the impact of language barriers on the mental health encounter. This in turn negatively affects their therapeutic relationship (Mirdal, Ryding, & Essendrop Sondej, 2012).
Another set of problems is the presence of cultural barriers, which add another layer of complexities to bilingual health care. The literature clearly shows that cultural misunderstandings negatively affect health care encounters, with issues ranging from poorer assessments and diagnosis to inadequate treatment and, in mental health care, a greater difficulty in establishing a therapeutic alliance between patient and provider (Kirmayer et al., 2003; Napier et al., 2014). Trying to go beyond “sweeping generalizations or cultural stereotypes” (p. 149), Kirmayer et al. identified several recurring cultural issues. Amongst others, they listed identity factors (such as age and gender), the impact of traumatising experiences, the impact, for refugees, of the process of obtaining political asylum, the impact of migration through generations (such as the loss of communal support and of extended families), racism and the importance of religious practices and social support as some of the most frequently recurring issues concerning culture and mental health.
1.1. Methodology
This paper is an analytical study of existing literature. Such an approach was chosen because gathering and analyzing knowledge in this way is of dual benefit: it can be of theoretical use to future researchers who may wish to further study the field of health care interpreting, and of immediate practical use to health care providers and other medical staff members who wish to gain an insight into a topic that can have repercussions on their daily work and the way they relate to allophone patients. After reading the literature on bilingual mental health care, the most relevant studies were analyzed in depth to identify the role played by different kinds of interpreter, the main issues arising from their differences, and the implications of this on a health care encounter.
This project focusses on how different types of interpreter may affect a bilingual health encounter, with a specific focus on mental health care. In previous studies, the main foci of research have tended to be interpreter performance, mistakes, and patient and provider satisfaction (Vasquez & Javier,
1991; Moreno, Otero-Sabogal, & Newman, 2007). These topics were often taken as a “starting point”
for further analysis of the appropriateness and/or effectiveness of different kinds of medical interpreting. However, following careful perusal of these studies, it was decided to base this project on the idea that rather than documenting interpreter performance or categorizing errors that occur during an interpreted meeting, an alternative and perhaps more relevant “starting point” is exploring the different categories of health care interpreter. It is upon this starting point that other more specific studies (for example on mistakes, or the appropriateness of a specific type of interpreter) can be elaborated. Listing the types of error that can occur and the interpreter proficiency are arguably relevant points of focus which merit equal scholarly attention and consideration. However, before such studies can be conducted, it is important to first identify the different kinds of interpreter and their respective impact on the health care session (Bauer & Alegría, 2010). Moreover, the obvious distinction between professional interpreters and untrained (or ad hoc) interpreters is just the first, main differentiation. Stopping here without making further subdivisions would flatten out the diverse, complex reality of health care interpreting. Each category of interpreter, and their respective influence on a health care session, merit separate, in-depth analysis.
It was also decided not to focus on the suitability of interpreters. Although this approach is more common in studies on mental health (professional interpreters being clearly portrayed as the best and most ethical solution), the dichotomy between what is “appropriate” and what should be
“unacceptable” is not the intended focus of this research. As previously stressed, community interpreting in health care is currently so overlooked and unregulated that speaking strictly in terms of interpreter “suitability” or “unsuitability” overlooks the complex reality of the issue. This issue is further laid out in chapter two (the current, urgent situation of refugees and the lack of a clear international legal framework on the provision of professional language assistance). Understanding the ever-evolving situation of refugees, and the sheer scale of the phenomenon, goes some way to
explaining the existence of such a wide variety of “interpreters” and of their differing levels of professionalism.
Last but not least, choosing not focusing strictly on suitability lessens the risk of making misleading generalizations. Indeed, this study adopts a more descriptive, analytical approach, and by describing how bilingual individuals play their role as medical interpreters (and how they can affect the mental health encounter), this research could also be of more practical use to health care providers and medical staff members who use interpreters and would like to understand the potential implications of using a certain kind of interpreter.
1.2. Structure
This analytical study of existing literature aims to answer to the following research question:
1) How do different types of interpreter affect a mental health encounter between a health care provider and an allophone patient?
The aforementioned question will be answered through an analysis of different categories of interpreter.
The body of this thesis is divided into four main chapters. Chapter one analyzes and compares the main relevant studies on this topic of research. Before exploring how different kinds of interpreter can affect an interaction, it is important to the contextual reasons for the existence of such a wide variety of categories. Chapter two will therefore look at the current situation of allophones, with a specific focus on Europe, where migration is currently in continuous expansion. Particular attention will be paid to the most recent waves of refugees arriving in the continent. Exploring the presence of
– helps us to understand why it is so relevant, and even urgent, to analyze the field of bilingual health care interpreting. A list of legal instruments on the right to health will also be provided, with a specific focus on consideration given (or rather not given) to language barriers in such a framework.
Chapter three draws upon existing literature to understand how different kinds of interpreter may influence a mental health encounter. This will be accomplished by first describing each category of interpreter, and then providing an insight into how each category may approach and execute interpreting a mental health encounter. The possible influence of each kind of interpreter on a mental health care exchange will then be discussed based on the aforementioned analysis, and in Chapter four the main factors influencing an interpreted mental health care encounter will be listed and analyzed.