Language and symptom recognition

Reference FosterFoster (1992) defined bilingual people for whom English is their second language as those ‘who function with varying levels of proficiency in the English-speaking work-a-day world, but who may dream, express surprise, count their change, make love or soothe a child in their mother tongue’. Psychoanalytic work with bilingual people through their second language appears to be less effective than through their first language (Reference GreensonGreenson, 1950), possibly because using the former does not allow access to important areas of the intrapsychic world.

Language has been found also to have a significant influence on presenting symptoms. Work with bilingual Spanish patients found more-obvious evidence of psychosis in subjects when they were interviewed in their mother tongue than when they were interviewed in English, their second language (Reference Del CastilloDel Castillo, 1970). In a further study, of bilingual Spanish patients with schizophrenia, interviews that used a single set of questions but asked them in both Spanish and English, were rated by experienced English- or Spanish-speaking psychiatrists as showing more psychopathology in the part of the interview conducted in Spanish (Reference Marcos, Alpert and UrcuyoMarcos et al, 1973). More-frequent misunderstandings, briefer answers and higher occurrences of speech disturbance were rated in the English section of the interview. From this it has been inferred that bilingual people are more likely to experience psychotic symptoms in their own native language, possibly because this allows a freer association of ideas. These studies suggest that, even when the use of the patient's native language is not apparently strictly necessary to ensure understanding, the information gathered from an interview in the native tongue is likely to be more meaningful and to give a clearer representation of the patient's psychopathology.

Interpretation and translation

Many hospitals and local authorities maintain lists of interpreters. Working through an interpreter provides an opportunity for patients to present symptoms in their own language, but it also adds other dimensions to the interview process. It must be remembered that interpretation is a very much more complex process than is word-for-word translation. Rather than the simple substitution of one language for another, it calls for the deciphering of two linguistic codes, each with its own geographical, cultural, historical and linguistic traditions. Furthermore, possible complications introduced by adding two more relationships to the interview (interpreter–patient and interpreter–interviewer) should not be underestimated.

The accuracy of meaning is lost where an unskilled interpreter simply translates. This is well illustrated in the cases of two suicides by Spanish-speaking patients who had been managed by English-speaking psychiatrists working through interpreters. It was concluded that the patients’ emotional suffering and despair were underestimated in the interpretation process (Reference SabinSabin, 1975). The few studies (reviewed below) which have attempted to examine the role of interpreters in psychiatric interviewing have been based largely on analyses of audiotapes of interviews. Although a range of difficulties has been identified, there have been many methodological problems, including a lack of control groups, use of unqualified interpreters and unstructured interviews. Furthermore, the studies failed to relate errors in interpretation to outcome of the interview. These issues were addressed in a study by Reference Farooq, Fear and OyebodeFarooq et al(1997), which recognised the following categories of error (examples of which are given in Table 1).

Table 1 Examples form the literature of interpretor error

Error category (reference)	Examples of error
Omission (Reference MarcosMarcos, 1979)	Clinician: ‘Do you feel sad or blue; do you feel life is not worth living sometimes?’
	Interpreter: ‘The doctor wants to know if you feel sad or if you like your life.’
	Patient: ‘No. Yes. I know that my children need me. I cannot give up, I prefer not to think about.’
	Interpreter: ‘She says that she loves her children and that her children need her.’
Addition (Reference LaunerLauner, 1978)	Patient: ‘When I go to the toilet, I pass stools with difficulty.’
	Interpreter: ‘He has severe pain when passing stools.’
Condensation (Reference Farooq, Fear and OyebodeFarooq et al, 1997)	Patient: ‘When I was born I have left land, land of India, Handsworth and Bengal. Prime Ministers sign, nations kept fighting, Rajah came to me …’
	Interpreter reported this as reflecting grandiose delusions of involvement with the Prime Minister of India to prevent war.
Substitution (Reference PutchPutch, 1985)	In the following example, the interpreter could not translate the word ‘allergy’ as there is no equivalent in the Navajo language.
	Physician: ‘M., would you ask her if she is allergic to any medication?’
	Interpreter: ‘Does white man's medicine make you vomit?’
Role exchange (Reference PutchPutch, 1985)	In this example, the psychiatrist was preparing to prescribe medication for a Vietnamese patient with a generalised anxiety disorder.
	Psychiatrist: ‘Ask her how long she thinks she will need to take medication.’
	Interpreter: ‘He says you should take this medication for two weeks and then come back and see him.’
Closed/open questioning (Reference Farooq, Fear and OyebodeFarooq et al, 1997)	Psychiatrist: ‘Do you feel happy or sad in your spirits?’
	Interpreter conveys this accurately.
	Patient: ‘If I am not unhappy or sad … [pause] … then I am happy.’
	Interpreter (without relaying the response): ‘Do you feel sad now?’
	Patient: ‘Yes.’
	Interpreter: ‘She is unhappy.’
Normalisation (Reference MarcosMarcos, 1979)	Psychiatrist (through interpreter): ‘Is there anything that bothers you?’
	Patient: ‘I know, I know that God is with me, I am not afraid, they can't get me … I am wearing these new pants and I feel protected. I feel good, I don't get headaches any more.’
	Interpreter: ‘He says that he is not afraid, he feels good; he does not have headaches any more.’

Problems peculiar to psychiatry

There are also more-subtle ways in which interpretation may affect the quality of a psychiatric interview. Many questions asked by psychiatrists could be considered to be presumptuous, at best, if presented without the benefit of empathic expression, and this may damage the quality of the rapport or, worse still, provoke a hostile response. In dealing with a lengthy response, background information may be excluded, distorting the context and making the answer appear illogical or tangential, and this can lead the interviewer to consider the possibility that the patient has thought disorder.

Cultural issues are of huge importance in these situations – both those of the patient and of the interpreter. Both Reference PutchPutch (1985) and Reference WestermeyerWestermeyer (1990) give examples of situations in which interpreters actively dissuaded patients from disclosing vital information which was seen as stigmatising their culture or religion. In other situations, patients’ views concerning traditional practices and therapy may be withheld in the interests of ‘protecting’ the patient from medical authorities.

Finally, the indirect nature of an interpreter-mediated interview is an interruption of the process of psychiatric assessment, which combines form and content of speech, facial expressions and bodily movements to reach an impression of mental state. In these circumstances, the process of using an interpreter has been likened to first watching television without sound, then receiving the sound without the pictures, and later trying to combine the two (Reference Kline, Acosta and AustinKline et al, 1980).

Other sources of error

So far, we have concentrated on sources of error arising from the actions of the interpreter. However, it should be remembered that the clinician's competence and familiarity with the use of interpreters are also extremely important. In the first meeting with a new patient, there is an understandable desire to obtain as much information as possible as quickly as possible to allow an early assessment of mental state. This may lead to the recruitment of the patient's friends, or even other patients, to help out. It is a widespread misconception that being bilingual automatically qualifies a person to be an interpreter. Apart from confidentiality issues, any deficient linguistic or translating skills of the individual, his or her lack of understanding of the clinical situation, and of mental health in particular, and his or her relationship with the patient are likely to magnify any of the errors of interpretation already discussed. Further complications arise from role conflicts (e.g. for a patient's friends or family) or an inadequate understanding of cultural values, as distinct from language.

The process will be further complicated if a clinician speaks quickly, uses long sentences or fails to use ‘laymen's’ language. Talking to the interpreter about the patient using the third person invites a conversation about them rather than with them, and raises the interpreter from the position of facilitator to participant, distorting the process still further. A clinician conducting an interview involving two or more people with an alien language and culture may feel threatened by the situation and easily become overwhelmed. In such circumstances, the interpreter may lose sight of his or her role and the situation of ‘role exchange’ becomes more likely, with the interpreter taking over the interview.

Interviewing through an interpreter is difficult enough in simple history-taking exercises, but the problems experienced in conducting a mental state examination are formidable. Using a methodology which employed both qualitative and quantitative measures, Reference Farooq, Fear and OyebodeFarooq et al(1997) recorded many errors in translation that muddied the meaning of the verbal responses. Interviews were conducted both in English, through an interpreter, and in the patient's own language by a psychiatrist fluent in that language. Errors were also found in the rating of symptoms and these could be minimised by the use of an experienced interpreter.

It has been suggested that unfamiliarity with psychiatric work makes even the most sophisti-cated medical interpreter an emergency translator (Reference WestermeyerWestermeyer, 1990). Moreover, in states of anxiety, delusion, depression or thought disorder, patients frequently lose their ability to communicate freely in an acquired language, making an interview with a bilingual patient in their second language unreliable (Reference Marcos, Alpert and UrcuyoMarcos et al, 1973). Significant factors affecting this reliability include the age at which the second language was acquired, its day-to-day use at home and work, the patient's attitude to primary and secondary languages and the clinical picture.

Similar considerations should be applied to health professionals who are bilingual, particularly if their second language was acquired in the classroom, as they are likely to use too learned a ‘register’, the linguistic term defining the social/intellectual level at which a language is pitched. This can result in discomfort, causing a patient to see their own speech as unpolished or rustic and may interfere with effective communication.

The interpreter in psychiatric practice

For clinician and interpreter to work together effectively, each requires a knowledge of the other's style of work and of what can reasonably be expected (Box 1). This improves with practice, so that the doctor learns to ask translatable questions and the interpreter to render ‘nonsensical’ responses verbatim. It is important that interviewer and interpreter meet before the interview, to clarify the goals of the psychiatric assessment, the main areas to be assessed and any sensitive issues that are to be explored (e.g. relationships or suicide). It may be necessary to discuss the importance of confidentiality, the need for translation of documents and the problems that can arise if the interpreter tries to ‘make sense’ of a patient's verbalisations. It should be remembered that an interpreter-mediated interview will take up to twice as long as a standard clinical interview and will require considerable skill and patience from clinician and interpreter alike.

In the interview, addressing the patient directly instead of through the interpreter helps to establish a better rapport and give control of the interview to the clinician. Questions should be planned in advance so as to make the best use of the time available. Long questions, excessive jargon and use of the passive voice will make an interview more difficult. Breaks while the interpreter is speaking to the patient should be used by the clinician to observe the patient's non-verbal behaviours, helping to gain non-verbal clues to the patient's mental state and enabling the next question to be framed more appropriately. Writing notes during these breaks wastes the opportunity to acquire valuable clinical data and should be avoided. A statement that is inconsistent with a patient's non-verbal behaviour should be explored by changing the wording, breaking down the question or asking about a related issue. A post-interview meeting with the interpreter is essential to clarify the interview material and the dynamics of the interaction.

It has been found that these provisions, coupled with the use of a qualified and experienced interpreter, minimise the occurrence of qualitative distortions. The process provides a reliable method for making clinical observations and results in a reliable diagnosis (Reference Farooq, Fear and OyebodeFarooq et al, 1997). However, while this is the standard for which to aim, the reality of clinical practice may require information to be gathered in less than ideal circumstances, greatly magnifying the potential for error.

Occasionally, a situation is encountered that forces the use of a relative or friend of the patient, or even another patient, as an interpreter. Where possible, these situations should be avoided, given the sensitive and confidential information being captured. Interviews using such interpreters should be confined to essential information and arrangements should be made for a second, more appropriate interview to be conducted using a qualified interpreter. It must be remembered that the use of such emergency interpreters will greatly increase the number of errors, particularly those involving role conflict and normalisation. Responses such as ‘does not know …’ or ‘talks irrelevantly …’ should be explored further to look for errors or psychopathology: in such situations, a verbatim translation should be requested. The interpreter may have his or her own agenda or insecurities in such settings. During the interview, however, it is important to keep a focus on the patient. Interpreters’ questions and insecurities should properly be addressed later.

Where it is not possible to clarify aspects of the patient's mental state, such as where formal thought disorder is suspected and a verbatim translation cannot be given, it is helpful to record the interview on audiotape. This situation may occur however skilled the interpreter is and the recording will allow a more considered view to be taken later, either by the interpreter or by a psychiatrist colleague who is fluent in the language concerned.

Conclusions

It has been claimed that transcultural psychiatry is an applied science, converting research-derived concepts into reliable health strategies (Reference JablenskyJablensky, 1994). To sustain this position, significant advances are needed in research and in training towards overcoming language barriers in an environment where 80% of psychiatric staff consider that their professional training prepares them ‘very little’ or ‘not at all’ for cross-cultural clinical work (Reference Minas, Stuart and KlimidisMinas et al, 1994). Such circumstances demand not only an ability to communicate through an interpreter but also an understanding of an individual's cultural values in a way that has received only limited attention within training programmes for psychiatric staff in multi-cultural settings (Reference LefleyLefley, 1984). It is essential for psychiatrists to recognise the complexity of the task, particularly the power that interpreters have to control the information being relayed back and forth and thus influence the outcome of the interview (Box 2). Interpreters should be selected with care, and supervision by a clinician who is used to working with interpreters is a valuable experience.

Multiple choice questions

1. 1 When bilingual patients are interviewed in their mother tongue:

   1. a psychoanalytic work is less effective

   2. b patients with schizophrenia are rated as showing more psychopathology

   3. c misunderstandings are fewer

   4. d psychotic symptoms are less obvious

   5. e answers are usually briefer.

2. 2 Interpretation:

   1. a is the same as translation

   2. b allows patients to present symptoms in their own language

   3. c complicates a clinical interview

   4. d involves the substitution of one language for another

   5. e is applicable only to spoken language.

3. 3 The following are most likely to be effective interpreters in a clinical psychiatric setting:

   1. a a bilingual social worker

   2. b a qualified interpreter, experienced in mental health settings

   3. c the patient's brother

   4. d a bilingual general practitioner

   5. e a bilingual consultant psychiatrist.

4. 4 When interviewing through an interpreter:

   1. a careful notes should be taken during the interview

   2. b all questions must be directed to the interpreter for translation to the patient

   3. c interviews of depressed patients are less reliable

   4. d technical terms should be kept to a minimum

   5. e a preliminary meeting with the interpreter is essential.

5. 5 Using a patient's relative or friend as interpreter:

   1. a should be avoided if possible

   2. b does not preclude carrying out a comprehensive interview with the patient

   3. c may lead to the distortion of sensitive information

   4. d requires the addressing of questions to the interpreter during the interview

   5. e makes role exchange more likely.