The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter

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Master

Reference

The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter

MORI, Anita

Abstract

Recent waves of immigrants pose new challenges to the health care system of host countries, and one of those challenges is related to language barriers. One solution is the use of health care interpreters, an essential link between patients and providers. In health care, it is common to find different individuals acting as interpreters. Recently, researchers have focused on this aspect, however, few studies illustrate how different interpreters affect specific health care settings. In this study, the categories of interpreters will be analyzed with regards to the sub-field of mental health. The categories are family interpreters, chance interpreters, bilingual providers, bilingual medical staff, on-site professional interpreters and technology-based interpreters. This study aims to find out how these individuals influence a mental health interaction. It identifies several factors affecting the encounter, going beyond the concept of “trained and untrained interpreter” and showing the role played by non-language related differences.

MORI, Anita. The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter. Master : Univ. Genève, 2020

Available at:

http://archive-ouverte.unige.ch/unige:146389

Disclaimer: layout of this document may differ from the published version.

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The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter

Anita MORI

Mémoire présenté à la Faculté de Traduction et d’Interprétation pour l’obtention du MA en Interprétation de Conférence

Directeur de mémoire : Prof. Lucía Ruiz Rosendo Jurée : Manuela Motta

2020

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STUDENT INFORMATION :

Anita MORI

Faculté de Traduction et d'Interprétation Université de Genève 40, boulevard du Pont-d'Arve,

CH-1211 Genève 4, Suisse

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Abstract :

Recent waves of immigrants and refugees pose new challenges to the health care system of host countries, and one of those challenges is related to language barriers. One solution is the use of health care interpreters, an essential link between patients and providers. In health care, it is common to find different individuals acting as interpreters. Recently, researchers have focused on this aspect, however, few studies illustrate how different interpreters affect specific health care settings.

In this analytical study, the categories of interpreters will be analyzed with regards to the sub-field of mental health. The categories described are family interpreters, chance interpreters, bilingual providers, bilingual medical staff, on-site professional interpreters and technology-based interpreters.

This study aims to find out how these individuals, through their similarities and differences, influence a mental health interaction. It identifies several factors affecting the encounter, going beyond the concept of “trained and untrained interpreter” and showing the role played by non-language related differences.

Key Words: interpreting, migrants, patients, mental health care, untrained interpreters, professional interpreters

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Acknowledgements

I would first and foremost like to thank my supervisor, Lucía Ruiz Rosendo, for her invaluable help and guidance.

I wish to express my deepest gratitude to my friend and colleague Claire for helping me through each stage of this process. Without her support and kindness, this work could not have reached its goal.

I also wish to acknowledge the unconditional support and patience showed by my parents Daniela and Giorgio, as well as the support of Francesca, Sara and Jan.

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1. Introduction

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.

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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;

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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;

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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).

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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,

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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

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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

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– 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.

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1. Literature review

Health care interpreting is a field that allows researchers to adopt a number of different perspectives.

While some researchers focus on categorizing and studying the consequences of interpretation mistakes in an interpreted health encounter (Flores, 2005; Laws, Heckscher, Mayo, Wenjun, &

Wilson, 2004; Vasquez & Javier, 1991) or on comparing the respective performances of professional interpreters and bilingual staff (Elderkin-Thompson, Cohen Silver, & Waitzkin, 2001; Laws, Heckscher, Mayo, Wenjun, & Wilson, 2004; Moreno et al., 2007; Vasquez & Javier, 1991), other researchers prefer to focus on the whole interaction between patient, provider and interpreter, as well as its relative challenges (e.g. Hsieh, 2006). The interpreter’s language proficiency is just one of many elements to take into consideration for successful linguistic mediation; other equally important factors include the interpreter’s ability to build a triadic relationship by gaining and maintaining the trust of the other two participants. The vital importance of the creation of trust between interpreter and clients during bilingual healthcare encounters is underscored by several scholars (Greenhalgh, Robb, &

Scambler, 2006; Meeuwesen & Twilt, 2011). However, few scholars have taken into account how different categories of interpreter may affect its construction (Hsieh, Ju, & Kong, 2010), or the particular importance of interpreter-client trust in the domain of mental health care (Fidan, 2017;

Boss-Prieto, 2013).

Scholars in this field agree that the use of non-professional interpreters is as widespread as that of professional interpreters – if not more prevalent (Hale, Ozolins, & Stern, 2009). However, few have taken this as their focus. Rather, researchers make this observation following a wider exploration of the different kinds of health care interpreter, conducted using a range of different methodologies and approaches. These studies provide a useful insight into the current reality of bilingual health care.

Boss-Prieto (2013), Messias, McDowell, & Estrada (2009), Meyer et al., (2010) and Brisset et al.

(2014) opt to analyze the different kinds of interpreter in health care, with the intention of highlighting

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their respective implications and influence on medical outcomes. Boss-Prieto (2013) and Brisset et al. (2014) further narrow the focus of their research to the sub-field of mental health care.

The study of interpreting in mental health care calls for input and expertise from different fields. It is therefore common to see this topic dealt with in domains other than interpreting studies, and researchers from various fields have taken an interest in the subject: from communication researchers such as Hsieh (2016) and Delizée (2018), to health care providers such as Bot (2005a, 2005b) and Boss-Prieto (2013), who have approached the topic from a more clinical point of view. Although their methodologies and approaches vary, these researchers, with the exception of Delizée (2018), highlight the importance of acknowledging the significant differences between different kinds of interpreter.

Hsieh’s prolific body of research, which has contributed to the visibility of this matter in several areas of study, was a particularly valuable source of information for this project (Hsieh, 2009, 2010, 2013, 2015b, 2016; Hsieh, Ju, & Kong, 2010; Hsieh & Hong, 2010). Hsieh was one of the first researchers to expressly highlight the existence of different kinds of non-professional interpreter, after observing the conflicting findings and unclear conclusions of bilingual health care studies that did not take this into account. Her 2006 study (updated in 2016) is of particular interest since Hsieh examines the different characteristics of each type of interpreter. By explaining the reason why she focused on the categorization of different kinds of interpreter in the first place, Hsieh (2016) indicates how necessary it was for her to increase awareness of the intercultural context and the challenges posed by “the blurred boundaries between culture, language and medicine” (p. 254). In her 2010 study, Hsieh conducted in depth-interviews with interpreters and providers to explore the notion of trust in an interpreted encounter. This work is particularly relevant because although it does not take different types of interpreter as its focus, the kind of interpreter present is identified as a factor influencing the construction of trust. In her 2015 qualitative study, Hsieh analyzed the factors that influence

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providers’ choice of interpreters, pointing out how a provider’s wrong (or uninformed) choice of interpreter could contribute to compromised care. This shows yet again the importance of the awareness concerning the existence of different interpreters. The study illustrates that strategies adopted by providers and the outcome of health care encounters can vary greatly depending on the kind of interpreter present (Hsieh, 2015b).

Boss-Prieto’s (2013) study on the development of the therapeutic alliance in a cross-cultural setting takes an approach similar to that of Hsieh. The work finds that human qualities, moral values, and the quality of communication in a “triadic setting” (itself determined by the type of interpreter present), are fundamental for building a positive therapeutic relationship. For Boss-Prieto (2013), the interpreter underpins the relationship between the three parties. The same study observes that according to some professionals “the bond with the interpreter depends on his type” (p. 115), going on to conclude that in light of the above, patients would benefit from being more aware the pros and cons of using each kind of interpreter.

While not directly focusing on mental health, Messias, McDowell and Estrada's (2009) study, based on in-depth interviews with professional and non-professional health care interpreters, explores how the manner in which different types of medical interpreter carry out their role may differ from their

“technical role definition” and “role expectations” (p. 140). The study shows that professional and non-professional interpreters may perceive their roles differently, and that an interpreter’s approach towards the patient or the situation as a whole can vary according to their understanding of their role.

Like Hsieh (2015b), Messias et al. note that health care providers did not expect the same service of all kinds of interpreter. They conclude that health care interpreting would benefit from there being a greater level of understanding of the strengths and weaknesses of each group of interpreter, since this would promote a perception of health care interpreting as not just a language service, but rather as an activity encompassing patient advocacy and, by extension, social justice.

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As far as I am aware, whilst the presence of different kinds of health care interpreter has been quite comprehensively covered by the existing literature, knowledge on their respective impacts on a mental health care exchange remains sparse. Only recently have researchers begun to narrow the scope of their research to this sub-field. Although the aforementioned studies have been a rich source of information, no researcher has taken as their central focus the way in which different kinds of interpreter may affect a mental health interaction. This study therefore aims to narrow this gap by consolidating our knowledge on, and thus contributing to our understanding of, interpreted mental health encounters.

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2. A current issue

2.1. The increasing number of allophones, with a special focus on Europe

The challenges and implications of language barriers are very much a current issue, especially given that the number of allophones¹ in Europe is ever increasing. This is, in part, due to the recent rise in the number of refugees globally, including in European countries. Recent waves of migration have also increased the interest of researchers in conducting bilingual health care studies (Giacco & Priebe, 2018). This explains why health care interpreting in general, and specifically mental health care interpreting, are currently drawing more scholarly attention than ever before. According to the United Nations High Commissioner for Refugees (2019), in the year 2018 alone the number of forcibly displaced people around the world increased by 2.3 million. Globally, almost 70.8 million people have been forced to leave their homes by persecution, conflict, violence or human rights violations, resulting in a record high number of forcibly displaced individuals – double the level of 20 years ago.

Of these 70.8 million worldwide, 41.3 million people are internally displaced (people who are displaced within their own country) whilst 25.9 million people have obtained refugee status after fleeing their country of origin. Another 3.5 million people are asylum seekers awaiting a decision on their application - a process that can be long and complex.

The latest data regarding externally displaced individuals in the area of the European Union (EU-27) gives a detailed insight of the current situation. Moreover, the migration phenomenon in the European Union, illustrated in this section, has a paradigmatic value: the considerations arising from the data

1 Refugees and other migrants. Immigrants are defined as “people born outside of the country of current residence” (Migration Data Portal, 2019).

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in the EU can be useful to further understand what is happening in other geographic areas that are currently experiencing a similar migration phenomenon. The Eurostat asylum statistics webpage (2020) shows that between 2008 and 2012 the increase in the number of asylum applications in EU countries was relatively gradual. Between 2013 and 2014, however, the number of asylum seekers started to rise at a more rapid pace, reaching 1.3 million and 1.2 million in 2015 and 2016 respectively;

more than double the number of applicants in 2014. The number of asylum applications in 2017 marked a significant decrease, and trend that continued in 2018. In 2018 alone, more than 25,000 refugees were redistributed through national and European Union programmes in the year 2018 (Migration Data Portal, 2019). However, in 2019, the trend began to rise once more. A total of 676,300 asylum seekers applied for international protection in the European Union, an increase of 11.2 % compared to the previous year.

Amongst these refugees, there are people who are yet not able to express themselves in the language of their host country. This can, of course, be the case for other regular immigrants too. Refugees, asylum seekers and other immigrants with limited language proficiency may find it difficult to communicate properly with health care providers. They may encounter subsequent difficulties ranging from poor care to hindered access to wider support.

2.2. Refugees and mental health

Understandably, the migration phenomenon – and consequently the arrivals of such a large number of allophones in host countries – has contributed, over the last two decades, to sparking new interest in addressing challenges hampering their access to health care (Giacco & Priebe, 2018; Bradby, Humphris, Newall, & Phillimore, 2015). According to Giacco and Priebe (2015, 2018), a growing number of researchers and institutions are exploring how health care services respond to the needs of immigrants and refugees, with some studies focusing specifically on mental health care.

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This chapter focusses solely on refugees (rather than other kinds of migrant) for several reasons.

Firstly, this permits a deeper analysis of a group of allophones who did not necessarily plan to emigrate, and are thus less likely to have dedicated time to learning the language of the destination country before moving. Moreover, the forced migration of refugees makes them more likely to have been exposed to distressing situations, making a discussion of mental health care and language barriers particularly relevant with regard to this group of people, as explained the next section.

The journey of a refugee is not an easy one, and the factors that may influence their mental wellbeing merit a more focused analysis. A number of studies on refugees point to their exposure to “pre- migration factors” such as extreme violence, food deprivation and other causes of distress that may negatively impact a person’s mental health (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005; Priebe, Giacco, & El-Nagib, 2016). Furthermore, the World Health Organization (WHO) estimates that the number of people in conflict-affected areas who suffer from mental disorders is much higher than previously thought (Charlson et al., 2019). According to the WHO, one in five people living in areas of conflict is affected by a mental disorder, and one in ten people suffer from a moderate to severe type of mental disorder (Charlson et al.). Causes of distress do not end once a person decides to flee a conflict-affected area; throughout their journey and upon arrival in the host country, refugees face other factors of stress such as the threat of deportation and unexpected displacement (Chiarenza, Dauvrin, Chiesa, Baatout, & Verrept, 2019). Moreover, once a refugee has arrived and settled in the host country, their mental health may suffer due to “post-migration factors”: long-term social and economic causes of stress such as loss of personal possessions, social networks and roles in a determined society (Kluge et al., 2012; Bogic, Njoku, & Priebe, 2015; Miller et al., 2005). Other factors of stress include the legal instability of a refugee and the process of obtaining political asylum, which have “profound effects on immigrants who often require medical and psychiatric care related to pre-migration physical and emotional traumas” (Chu, Keller, & Rasmussen, 2013, p. 895).

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Concerning the prevalence of mental health disorders amongst refugees, a recent study in those settled in high-income countries indicates that there currently is no evidence of significantly higher (or lower) rates of mental disorders amongst refugees during their first year of resettlement compared to non-refugee people (Giacco & Priebe, 2018). The review finds that being a refugee is neither the sole nor the most significant factor in the risk of developing a mental disorder (Giacco & Priebe, 2018).

However, the same review reports that meta-analyses have shown that the prevalence of post- traumatic stress disorder (PTSD) seems higher amongst adult refugees compared with non-refugee individuals. Moreover, the prevalence of depression and anxiety is reportedly higher amongst long- term resettled refugees than in the host population (Giacco & Priebe).

However, it remains difficult to assess the prevalence of mental health disorders amongst refugees with any degree of certainty. Indeed, “the cultural, political, economic and social contexts and the acceptance of a given refugee group in host countries also vary substantially and change over time”

(Giacco & Priebe, 2018, p. 110). Consequently, one could argue that generalised statements about prevalence of mental health disorders amongst refugees are somewhat problematic and should be considered with caution.

Regardless of the prevalence rates of mental disorders, it is worth noting that the increasing number of allophone refugees and asylum seekers inevitably results in new considerable challenges to the mental health care system, “whether or not the prevalence of all or some disorders differs from the host population.” (WHO, 2018, p. 6). These challenges range from the need for greater service capacity and preventive measures for society as a whole to new, effective and appropriate health interventions, more specifically mental health interventions that are tailored for refugees. Given the fact that many refugees have had neither the time nor the resources to learn the language, another challenge in health care is overcoming linguistic and cultural barriers.

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2.3. Rights to health and to medical interpreting

2.3.1. International legal frameworks on the provision of health care

Over time, the right to physical and mental health has been laid down in various human rights instruments. Access to health is a fundamental human right first internationally acknowledged by the WHO in its 1946 Constitution, which states that:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

(WHO, 1946)

The right to health was also acknowledged two years later in the 1948 Universal Declaration of Human Rights. Article 25 states that:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (UN General Assembly, 1948)

Under article 12.1 of the 1966 International Covenant on Economic, Social and Cultural Rights adopted by the UN General Assembly, all state parties “recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The explicit mention of mental as well as physical health in the Covenant puts the former on a par with the latter, recognizing

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the equal importance of both for a person’s wellbeing. The Covenant further highlights how States have an obligation to prohibit and eliminate all kinds of discrimination regarding access to health, and to ensure equal access to health care for all (The United Nations General Assembly, 1966).

Many countries, however, only recognize migrants’ right to “essential care” or “emergency health care”. As explained in Human Rights Fact Sheets 31: The Right to Health, published by the Office of the High Commissioner for Human Rights (OHCHR), these terms carry different meanings from country to country and their interpretation is “left to individual health-care staff”. According to the OHCHR publication, “practices and laws may therefore be discriminatory” (OHCHR, 2008).

2.3.2. Rights to mental health care

As illustrated above, from its founding the WHO recognized that mental well-being is part and parcel of health. This important statement was even voiced by the first Director-General of the WHO, psychiatrist Brock Chisholm, who famously stated that “without mental health there can be no true physical health” (Kolappa, Henderson & Kishore, 2013, n.p.). In its more recent publications, the WHO describes mental health as the “state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”, and affirms that “there is no health without mental health”

(“Mental health: strengthening our response,” 2018, para 1).

In 1991, the United Nations General Assembly adopted the Principles for the Protection of Persons with Mental Illness, a series of non-legally binding provisions promoting the rights of mentally disabled persons. Despite their flaws and the criticism they drew (Harding, 2000), these principles and their adoption demonstrate a shift towards understanding the importance of mental health as a right for every individual. These new international human rights instruments promoted a view of

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mental health as being essential, intrinsically linked to physical health and a fundamental human right.

In 2006 the UN General Assembly then adopted what is considered to be the most important international instrument on the rights of people with disabilities, the Convention on the Rights of People with Disabilities (CRPD) and its Optional Protocol. It encompasses all individuals regardless of whether their disabilities are physical or mental, and aims to eliminate discrimination against all individuals with disabilities. It established international legal standards in this field and requires the signatory states to the Convention to promote, protect and ensure the full enjoyment of human rights by people with disabilities.

At a European level, the “Mental health declaration for Europe: facing the challenges, building solutions” (also called the “Helsinki Declaration”) of 2005 is a non-binding document specifically focusing on the protection of the rights of people with disabilities. In the Helsinki Declaration, the health ministers of the WHO European Region support the implementation and evaluation of

“policies and legislation that will deliver mental health activities capable of improving the well-being of the whole population, preventing mental health problems and enhancing the inclusion and functioning of people experiencing mental health problems” (WHO, 2005).

This non-exhaustive list of international instruments forms the legal foundation of the recognition of the rights of people with mental disabilities. Their purpose is not just to establish a legal framework, but also to reduce stigma and misconceptions surrounding mental illnesses, notably by “encouraging governments to socialize populations on the importance of equal rights for those with mental disability” (Cameron, 2017, para. 5).

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2.3.3. Are there rights to medical interpreting?

Language barriers may hinder an allophone (for example, an immigrant or a refugee)’s access to information on health-related matters and other services available, thus preventing them from realizing their right to preventive, curative and palliative care. Human Rights Fact Sheets 31 “The Right to Health” states that the principle of non-discrimination is a fundamental right. Without it, an individual’s right to health cannot be realized; discrimination leaves the most vulnerable groups of a society facing inequalities, and impedes or nullifies their enjoyment of human rights. Language (along with race, color, sex, language, religion, political or other opinion, national or social origin, property, disability, birth or other status) is identified by the 1966 International Covenant on Economic, Social and Cultural Rights (art 2.2) as possible grounds for discrimination.

While stating that all immigrants and refugees do not speak the host country language would be an unfounded generalization, it is safe to say that not all newcomers to a host country speak its official language. Learning a new language, often from zero, is difficult and takes a great deal of time and energy. Even with intensive language courses, the learning process – up to the point where a newcomer can explain health problems to a health provider – can take months, if not years.

Insufficient proficiency in the language of the host country constitutes one of several barriers that hinder access to care. Experiencing difficulty communicating with health care providers lengthens administrative procedures and, more worryingly, entails risks such as being misunderstood or misdiagnosed (Flores, Abreu, Olivar, & Kastner, 1998; Priebe et al., 2011; Thomas, 2006).

Despite the fact that language barriers may hamper allophones’ enjoyment of their right to health, this issue is not actively taken into consideration by the aforementioned international instruments, meaning that no mention is made of interpreting as a possible solution. There is therefore no legal

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requirement for the provision of health care interpreting. At a European level, unlike the field of criminal court proceedings, for which the European Parliament and the Council of the European Union have issued Directive 2010/64/EU on the right to interpretation and translation through the free assistance of an interpreter (Phelan, 2012), there is no legislative equivalent for health care services.

A study conducted by Angelelli (2019) on language assistance in health care in EU law found that none of the four most important documents on European cross-border healthcare address how patients can communicate with medical staff in a different language. In the absence of an official EU legislative framework, decisions on the provision of health care interpreting and other linguistic services in the field are left to member states and their national anti-discrimination laws. Hence, there is no formal framework ensuring systematic access to language assistance for patients, nor are there organizational policies on the provision and use of interpreters in health care.

Moreover, without any legislative framework protecting the budgetary support currently provided to EU countries for interpreting services, this support could be halted at any time. In Denmark, for example, the government decided in 2011 to no longer provide professional health care interpreting services for allophone patients who had been residing for more than seven years in the country (Phelan, 2012). Another similar decision was taken in the Netherlands where, after more than three decades of budgetary support for health care interpreting services, the government announced that as of 2012 it would stop subsidizing this service. Since then, it has been reported that the use of professional interpreters in the country has dropped by 75%, and that they have frequently been replaced by non-professional interpreters (Hof, 2013). These few examples show that the use of non- professional interpreters is often inevitable and all but uncommon, as explained in the following chapter.

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3. Types of interpreter

As already mentioned in Chapter two, the categorization of health care interpreters has been mainly investigated by Hsieh (2006, 2016). Hsieh’s typology of interpreters in bilingual health communication was first proposed by the researcher in 2006 and subsequently updated, revised and clarified in 2016. Hsieh identifies several categories of interpreter in health care settings. The main categories are: non-professional interpreters, bilingual medical professionals, and professional interpreters. These main categories are further sub-divided.

• Non-professional interpreters:

o family interpreters

- children (category added by the author of this MA thesis) - adult family members and friends

o chance interpreters

• Bilingual medical professionals:

o Bilingual providers (who work directly with the patient)

o Bilingual medical employees (professionals interpreting for their colleagues)

• Professional interpreters:

o on-site interpreters

o technology-based interpreters

These categories will be described in greater detail below.

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3.1. Non-professional interpreters

Language brokering in health care can be carried out either by professional (also known as trained) interpreters or by non-professional interpreters. Formal professional training (or lack thereof) can therefore be identified as the starting point for categorizing health care interpreters. Non-professional interpreters are people who have had no training, and who are usually (but not always) not paid to interpret. Common synonyms for non-professional interpreting include ad hoc interpreting, family interpreting, informal interpreting, language brokering, lay interpreting and natural translation or interpreting (Antonini, 2015a).

The use of non-professional interpreters in hospitals is very widespread and well reported by virtually every study analysed for this paper (e.g. Granhagen Jungner, Tiselius, Blomgren, Lützén, & Pergert, 2019).

3.1.1. Family interpreters

Family interpreters are friends, neighbours or relations of the patient (even children) who accompany them to their consultation. They interpret between patient and provider without having received any formal training. Family interpreters may be called upon to interpret for several reasons, such as a lack of interpreters speaking their language, or at specific request of the patient. Unsurprisingly, they do not usually receive any remuneration for their services.

3.1.1.1. Children acting as interpreters

Migrant parents often have to rely on their children to interpret for them in health care settings, and it is not rare for children to play this role, even during therapy sessions (Fidan, 2017; Gray, Hilder,

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& Donaldson, 2011; Greenhalgh, Robb, & Scambler, 2006; Hsieh, Ju, & Kong, 2010; Jacobs, Shepard, Suaya, & Stone, 2004; Meyer et al., 2010; Pöchhacker, 2000; Swartz & Kilian, 2014; Tribe

& Keefe, 2009). Given how widespread and well-documented the use of child interpreters is, it was decided to add this particular category of interpreter to Hsieh’s original typology. It is, however, worth stating that the use of the term “child interpreter” in the literature is somewhat ambiguous. In this project, the word “child” is used as a synonym of “minor”: people below 18 years of age, and not simply the adult sons or daughters of the patient (the latter group will be discussed in the next section).

Children may act as interpreters from a very young age, and soon acquire a nurturing, care-giving attitude towards their parents in a peculiar role-reversal situation. They may perceive this role negatively, feeling that it is an unfair burden and a source of stress and conflict for their family. On the other hand, they may associate interpreting for their parents with positive feelings, perceiving themselves as reliable and efficacious individuals because of the help that they provide to their families (Kam & Lazarevic, 2014).

The idea of children acting as interpreters is generally disapproved of by professional interpreters, translators and scholars of interpreting (Antonini, 2015b) for reasons ranging from ethical concerns about risking exposing children to psychologically scarring situations, to doubt surrounding the sufficiency of their range of vocabulary (Mead, 2019). However, according to some practitioners, a case-by-case analysis is necessary to determine whether a child interpreter may, in some cases, be beneficial to an exchange. This was highlighted by Fidan (2017), who reports that some practitioners believe that the role of child interpreters can be valuable in certain specific cases, for example when patients ask expressly for a family member to interpret for them. It is not clear, however, whether Fidan is referring to children under the age of 18 years or the adult offspring of the patient.

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Using a child as an interpreter (also referred to as “child language brokering”) in a mental health setting is particularly problematic given the distressing topics potentially addressed during a session.

The most seemingly harmless of topics could give rise to a discussion of disturbing, painful and deeply personal events. The child-interpreter runs the risk of being overwhelmed in particularly complex situations. Moreover, such matters could include private information about the parents that may complicate family dynamics (Fidan, 2017), or traumatic stories including torture and human rights abuses (Ngo-Metzger, Massagli, Clarridge, Manocchia, Davis, Iezzoni & Phillips, 2003). This is particularly true for refugee patients, as illustrated in the previous chapter. Taking into account the high numbers of refugees currently fleeing wars and persecution, these topics remain, regrettably, likely to be discussed in future mental health encounters.

Moreover, the documented behaviour of both child interpreters and their parents during a medical encounter show how challenging it is to achieve trust between patient and provider in such setting.

The effect of the presence of a child interpreter on trust-building between the two main participants should not be underestimated. As shown in other less problematic (but still complex) settings such as paediatrics, some parents feel the need to shield their child from sensitive topics when the child is interpreting for them. This is also true for taboo subjects such as sex and female sexual health: patients were reluctant to talk about these issues in front of child interpreter (Zendedel, Schouten, van Weert

& van den Putte, 2018). Despite the current lack of studies on child interpreters in mental health settings, it is reasonable to conjecture that parents may also try to protect their child from the traumatic, sensitive subjects that are likely to be tackled during a mental health encounter.

Furthermore, according to another study (Valdés et al., as cited in Carvan, 2018), child language brokers may also endeavour to protect their parents from embarrassment by presenting an improved image of the parents to providers and other professionals.

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Regardless of the positive or negative patient outcomes of child language brokering in a mental health setting, one could argue that this activity is problematic and potentially unethical.

3.1.1.2. 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.

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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 professional interpreters is the adherence to a 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

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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

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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).

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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

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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.

3.1.2. Chance interpreters

As mentioned above, it is not rare for hospitals, even ones located in large multicultural cities, to be unable to provide professional interpreting services (Mirdal, Ryding & Essendrop Sondej, 2012).

Patients and providers may instead have to rely on a bilingual or multilingual bystander, or a member of staff of the hospital. Such individuals usually carry out tasks that have little or nothing to do with the activity of professional interpreters; they may work as a cleaner, janitor, household aid, security guard, member of the administrative staff, receptionist or technician. In her updated 2016 study, Hsieh calls individuals belonging to this category “chance interpreters”. The most notable difference between chance interpreters and family interpreters is that the former share no bond with the patient (they are not family members or close friends chosen or who volunteered to help the patient communicate with the provider).

Like family interpreters, chance interpreters typically have no formal training in interpreting, let alone language interpreting in a mental health encounter. In addition, they are often not fully proficient in the two languages (Kilian, Swartz, Dowling, Dlali, & Chiliza, 2014). The quality and accuracy of their renditions can therefore not be guaranteed (Giacco & Priebe, 2018).

Like other aforementioned groups, the use of this category of interpreter brings its own challenges.

A previous study (Messias, McDowell, & Estrada, 2009) suggests that in general, untrained interpreters (also dubbed “informal interpreters”) tend to see their role as that of someone involved in the life of the patient for whom they are interpreting. According to Messias et al., this creates a

The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter

Master

Reference

The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter

The Influence of Different Kinds of Interpreter on a Mental Health Care Encounter

Anita MORI

Table of Contents

1. Introduction

1. Literature review

2. A current issue

3. Types of interpreter