Cult Med Psychiatry (2014) 38:700-711 DOI 10.1007/s11013-014-9394-7 ORIGINAL PAPER

The Invisibility of Informal Interpreting in Mental Health Care in South Africa: Notes Towards a Contextual Understanding Leslie Swartz • Sanja Kilian

Published online: 16 September 2014 Ó Springer Science+Business Media New York 2014

Abstract Despite South Africa’s constitutional commitment to equality, represented by 11 official languages and the promotion of South African Sign Language, many users of the public health system receive treatment from people who cannot speak their language, and there are no formal interpreting services. This is a legacy of service provision from the apartheid era, and interpreting is currently undertaken by nurses, cleaners, security guards, and family members of patients, amongst others. We provide a preliminary outline of proximal and distal issues which may bear upon this situation. Changing understandings of the nature of careers in the health field, international trends in mental health theory and practice toward crude biologism, and ongoing patterns of social exclusion and stigma all contribute not only to a continuing state of compromised linguistic access to mental health care, but also to processes of rendering invisible the actual work of care in the mental health field. Keywords Interpreting  Mental health  South Africa  Psychiatric Services  Language diversity

Introduction In this article, we discuss the question of how it can be that, 20 years into democracy in South Africa, access to mental health care services is compromised by the fact that few psychiatrists and psychologists speak indigenous languages—the languages spoken by the majority of South Africans. People who act as informal interpreters in the context of psychiatric hospitals, though they may have a personal L. Swartz (&)  S. Kilian Alan J Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Private Bag X1, Matieland 7602, South Africa e-mail: [email protected]

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commitment to patient welfare, are ill-equipped to interpret complex clinical sessions (Kilian et al. 2010; Hagan et al. 2013; Smith et al. 2013). This holds potentially serious consequences for how patients are diagnosed and treated (Kilian et al. 2014). Before turning to the current situation, we provide some background to the current situation, going back some 30 years.

Some Historical Background About 30 years ago, our research group started exploring the question of language access to care in large psychiatric institutions in South Africa. We found that most clinicians—psychologists and psychiatrists—could not speak any local languages apart from Afrikaans, and that nurses were often called upon to conduct informal interpreting. During our years of research, we noted clinicians’ concerns about the violations of the rights of patients and about their own ability to provide proper care, particularly in wards, where in the Western Cape for example, there were no nurses, let alone doctors or psychiatrists, who could speak isiXhosa, the dominant African language in the province (Drennan et al. 1991; Drennan and Swartz 2001, 2002; Swartz 1998; Swartz et al. 1997; Swartz and Drennan 2000). Clinicians expressed their frustration and shame at their own practice of what they termed ‘veterinary psychiatry,’ a term borrowed from debates in transcultural psychiatry (Littlewood 2001). By this they meant that they were forced, as a result of not being able to speak with their patients, to treat them as though they were animals—to observe their behavior, and on the basis of this, to make important decisions about treatment (including medication and other procedures) and about how long patients would stay confined in hospital. Though the term ‘veterinary psychiatry’ is emotive and well describes the frustrations of clinicians in South Africa, it is important to note that South African clinicians have somewhat restricted the meaning of the term as it used in transcultural psychiatry. For the clinicians, we interviewed at the time of the transition to democracy in South Africa in 1994, for example, an important solution to ‘veterinary psychiatry’ would have been if clinicians could have spoken the languages of their patients, or if they could have had access to good trained interpreters. To proponents of transcultural psychiatry, however, the practice of veterinary psychiatry means much more—it means the practice of psychiatry which seeks for common universals of psychopathology under the epiphenomenal cultural accretions. In what Kleinman in 1977 called the ‘old transcultural psychiatry’ (Kleinman 1988), the fact that people may experience emotional or affective distress in different ways in different contexts was seen as a form of ‘noise’ getting in the way of revealing the true, universal disorders which underlie all human experience and which, not coincidentally, just happen to have been revealed through the science of psychopathology to psychiatrists in the USA and Europe. It is not necessary here to rehearse the multiple issues associated with this depiction of psychiatry as a form of cultural imperialism, but this broader understanding of ‘veterinary psychiatry’ is very important to what we see in the practice of psychiatric care today (Swartz 1998, 2012a).

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Before turning to what we do see today, we want to note one other feature of local practices in the 1980s. Most of the people doing informal ad-hoc interpreting in the Western Cape at that time were Xhosa-speaking nurses who, it seemed to us, engaged in a complex set of practices with three interlocking aims (Swartz 1991a, b). First, it appeared, they wanted the patients to get the best care available. Second, they wanted to make sure that the wards functioned smoothly and without disruption. Thirdly, or so it seemed to us, they wanted to present themselves in a particular way—both as health professionals in a hierarchy where medicine was dominant, and as representatives of a particular racial or ‘cultural’ group. During our data collection, we observed one particularly skilled nurse who appeared to the psychiatrist to be interpreting his words while, in reality, she was conducting a different interview on her own, ensuring that the patient got what in her view was the appropriate care while at the same time never engaging with the psychiatrist to say she thought his questions were wrong or inappropriate. During the 1980s and early 1990s, many South Africans concerned with equitable health care access held the belief that when the country was democratic and there was a consolidation of the apartheid folly of 14 ‘ethnic’ health departments in one country into one national health department, funds would be released to allow for a system of health care which was accessible to patients in their own language. There are many reasons why this has not happened, and amongst well-documented successes of the post-apartheid health care (in the area of primary health care in particular), there have also been many disappointments in a range of areas (Mayosi et al. 2012). Let us continue our focus specifically on psychiatric interpreting, remembering the complex and clinically important job nurses were doing in the 1980s in this area, despite the fact that interpreting has never been part of their work.

The Current Situation: the Past in the Present Kilian et al. (2010) reported on the current situation regarding interpreting in a psychiatric institution in South Africa. The first author of that article interviewed people whose informal role in the hospital in which they worked was to interpret in situations where patients could not speak English and clinicians could not speak isiXhosa. These informal interpreters regularly performed the role of being the only conduit by which English-speaking clinicians could communicate with their patients. Here are two excerpts from interviews, the first author of that article conducted these informal interpreters, and reported in that article: Interviewer (SK): What I first want to know from you is how long have you been doing interpreting? (No response from the participant.) SK: While working, I know you are not a professional interpreter, but for how long have they been asking you to do the interpreting? Participant (P1): The first time now I interpret. Are you asking about the job?

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SK: Would you encourage other people that work here or wherever to do interpreting? P1: When interpreting to the patients? SK: Ja, would you encourage other people to do that? (No response from the participant.) SK: Would you maybe say to them, ‘‘Yes, I think I would tell them to do interpreting’’ or ‘‘No.’’ Out of your experience? P1: No, the doctor inform me why he call me. And: SK: So, what do you understand by psychotic? P1: Ok, I then, as I told I just have little bit of basic. SK: Ja, no, I’m not looking for a right or wrong answer. I just want to know how you understand it. P1: Ok, I understand when the patient is psychotic because sometimes he can say just imagining and then you must understand there is sometimes the mind that she is thinking and not the mind she have before. It’s just the other mind now. SK: Ok. P1: What’s going on to the head it’s just up in the head, in her head. (Kilian et al. 2010) It is clear that this person, who fulfilled the role of isiXhosa-English interpreter in clinical settings, did not meet the requirement of basic fluency in English. This was not an isolated case. In a recent replication of the Kilian et al. (2010) study, Hagan et al. (2013) report a similar problem with fluency in English on the part of informal interpreters at another South African psychiatric hospital, with people who act as informal interpreters struggling to understand and express themselves in English.

Understanding the Continued Invisibility of Language Issues in Psychiatric Care in South Africa The above examples from recent research are echoed in data which are currently under analysis as part of a broader project regarding language access and informal care work in South African health care. Despite a constitutional requirement of equal access to service and an on-paper commitment to nondiscrimination based on language, 20 years into democracy, things have remained the same, or, if anything, got worse for people who cannot speak English or Afrikaans and are admitted to psychiatric institutions. This is clearly a failure of care at a number of levels, as language is at the heart of mental health care. If users of services cannot understand and be understood by those treating them, they cannot receive adequate care. Clinicians, too, are forced into situations where they feel unable to assist their patients properly (Kilian 2013). They experience considerable shame and distress at the fact that they adopt ad-hoc arrangements to try to communicate with patients, making use of cleaners and security guards, amongst others, to interpret for them. Clinicians have enormous

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workloads, and the time it would take to make more satisfactory arrangements regarding language access may seem an impossible demand in a context in which this issue is not made explicit (Kilian 2013). Security guards and cleaners, though many gain considerable satisfaction from feeling that they are helping patients access care, lack confidence regarding what they are doing, feel distressed by it, and are concerned that what they are doing is not remunerated or formally recognized in any way (Kilian et al. 2010; Hagan et al. 2013). Examining this situation, which endures after centuries of discrimination and, more recently, apartheid, it is all too easy to attribute what is occurring to proximal failures in the health system—we can brand clinicians and hospital administrators as uncaring and unethical. However, if we are serious about wishing to change things (and this is something we will return to at the end of this article), we need to take a far broader range of factors into account. Each of these issues could merit a lengthy discussion on their own; our intention here is to highlight a range of apparently disparate factors which together create a climate in which patient care is compromised through lack of access. Our analysis is tentative, and the issues we raise will require more research. It is also not our intention here to present a purely dystopian view of the situation. We acknowledge that there may be a range of local ad-hoc interpreting arrangements which may facilitate access to care, and it is important to know more about these, but the evidence for the clinical utility of these arrangements is at this stage scanty and not robust (Penn and Watermeyer 2012). We will now briefly discuss a number of apparently disparate issues, showing how each contributes to enabling a situation of poor access to care on grounds of language. We make no claim that this list is exhaustive, but we do suggest that a broad perspective will assist with a deeper understanding of the invisibility of language issues in the South African mental health care context. New South African Elites Speak English and Can Use Private Health Services Democracy in South Africa has brought benefits to many, but the lives of the vast majority of South Africans—the South Africans who access public health services—have not changed substantially. The problem of lack of redistribution of wealth and resources and services has been noted by many as a key challenge for the country (van der Berg 2014). It has been an important achievement of the transition that a new Black elite has been established, but members of this elite can speak English and can access private sector health care—they are not the people who would be forced to seek treatment in the state health system and from clinicians with whom they cannot communicate. In the competition for resources in the new state, language access may be viewed as something of a luxury by those policymakers who do not experience exclusion on the basis of language. Global Psychiatry Continues to View Local Issues as Epiphenomenal to the True Business of Appropriate ‘Scientific’ Care Psychiatry, despite developments in the ‘cultural’ field, continues to expand as a global enterprise, seeking universals and the imposition of epidemiological methods

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which require us to produce bodies to be counted and which defocus from the constructed and interactional nature of all diagnostic processes. Apparently Divergent Traditions Within Psychiatry and Mental Health All Contribute to Making Invisible the Interactional and Highly Personal Nature of Work in Mental Health There are at least three important traditions in psychiatry which have purchase in South Africa and which, despite being rather different in the way they operate, may contribute to obscuring the importance of language to access to care. (a)

The dominant diagnostic system used in South African Psychiatry is the Diagnostic and Statistical Manual (DSM) approach. Since the publication of the third edition of the DSM in the 1980s, up to and including the most recent, fifth edition, there has been an emphasis on an empirical approach to diagnosis—this amounts to the counting of signs and symptoms. The DSM approach reduces the complexity of the German phenomenological tradition on which it is based to the classification sets of signs and symptoms, all of which inhere in the patient. This approach has many advantages, but the cookbook approach to counting supposed universal signifiers of mental disorder is accompanied in practice (though not necessarily in the intention of the DSM system) with a devaluing of the deeply intersubjective nature of mental health care. The empiricism of the DSM approach (as we shall see in the next point) has many advantages, including the advantage of curbing wildly irresponsible diagnostic practices not based on evidence. The attempt to eliminate subjectivity from diagnostic processes, however, may have distal consequences for language access to health care. The German phenomenological tradition, for example, used the concept of praecox gefu¨hl—the feeling that a clinician has in the presence of somebody who has dementia praecox (later called schizophrenia). It is understandable why empiricists in the British and US traditions are skeptical of the concept; it is not clearly explainable, and it is difficult to teach (Wing 1983). But emphasis on the objective creates an environment in which the intersubjective nature of diagnosis and health care may be ignored—it becomes more possible to view patients as objects, as containers of sets of signs and symptoms, rather than as co-constructors of clinical realities. In this context, the work of diagnosis and treatment becomes that of the extraction of signs and symptoms from the patient, and the complexities of conversation do not have to be engaged with. (b) In South Africa there remains a strong tradition of engagement with psychoanalytic theory, including in the training of mental health professionals. At first blush, the psychoanalytic tradition with its hermeneutic emphasis would appear to require a strong engagement with issues of language and communication. Paradoxically, however, as Andreasen (2007) has pointed out, working in the psychoanalytic tradition can be abused, allowing clinicians to bypass issues of phenomenology and communication. The insights of

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psychoanalysis are easily perverted as an unintended (and undisciplined) consequence of the key it psychoanalytic observation that people do not know themselves fully. Because we are driven by unconscious motivations, it may be the case that others (and especially mental health professionals) may be seen to understand us better than we do ourselves. It is a small (though, of course, incorrect) step from here to the view that good mental health professionals do not have to engage deeply with people in order to understand their subjectivity—mental health professionals hold outsider knowledge which patients themselves do not have. We live in a global culture in which it is possible for anyone from psychiatrists to journalists and celebrities to diagnose others on the basis of scant information, and even on the basis of no personal information of the people being diagnosed (One of us reviewed a book recently by a respected psychoanalytic theorist who made a number of claims about George W. Bush’s psychopathological make-up without ever having met Mr. Bush (Swartz 2011)). From here it is a relatively short leap to believing that psychiatrists can diagnose patients by observing them, and with very little engagement with them. The ‘real world’ of both psychology and psychiatry has become that of the ‘brain’; neuroscience is where many of the best minds in the field have gone. In the world of neuroscience there is an emphasis on diagnostic methods which are not available to the patient’s own subjectivity—scanning, neuroimaging, and post-mortem assessments (Sullivan 1986). Though the best neuroscientists do not believe this at all, there is an extant fantasy in the neuroscientific community that we can learn the most about people by using methods which allow us to bypass their subjectivity. There are links here to a crude evolutionary biology in which, in order to explain any behavior from marital infidelity to women’s frustrations in the workplace, we look not to the politics of those situations but to the ‘hard wiring’ of people to do things which they may explain to themselves in subjective terms but which are really part of their brains and their biology. This kind of thinking, as Sullivan (1986) argued many years ago, can render the voice of the patient as ‘noise,’ and a distraction from the ‘real’ evidence which biological sciences provide. In such a scenario it may be an advantagenot to be ‘‘distracted’’ by the voice of the patient.

Changing Patterns in Academic Careers in the Health Field Make Engaging with the Complexities of Patient Care Less Attractive Academic life world-wide has become increasingly dominated by the use of counts of research outputs to determine the success or failure of academic careers (Arum and Roska 2011). In the post-apartheid era, and following the damaging and isolating academic boycott of that time, the pressure on South African academics (including those in the health care field) is also part of a more general national strategy to demonstrate to the world South Africa’s competence in research, science and innovation (Academy of Science of South Africa 2006). South African psychiatrists and psychologists, for example, are expected to publish prolifically in

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high impact journals—journals which generally require quantitative methods and which favor biological psychiatry. Not only does this project take time away from the work of clinical interaction, it encourages, methodologically, the use of scales and measures which can be easily translated and back-translated, and which can produce data which can be presented as directly comparable to data collected in the North. This enterprise views the complex issue of mediated linguistic interactions as ‘noise’, for reasons discussed above. As part of a more general failure of an ethic of care, then, career success in academic psychiatry and psychology is measured, increasingly, not by what happens in the private realm between clinician and patient, but by outputs which can be measured and assessed as having impact in ISI journals. What will be cited (i.e., what will be measured as having ‘impact’) will be that which is ‘universal’—i.e., what appeals to and has use to the readership of such journals. The people who publish in international psychology and psychiatry journals are overwhelmingly situated in North America, Europe and Australasia (Tomlinson and Swartz 2003). Understandably, they will cite what is relevant to their work and academic careers—this is unlikely to be discussions of the detail of challenges in communication in South Africa, despite the fact that migration from lower-income to higher-income countries is a major challenge to health care in wealthier countries. Even within the field of what has come to be termed ‘global mental health,’ academic success may be measured by the transformation of local issues and data into instances of global pathologies and challenges, by the application of standardized technologies of assessment of impact (such as randomized controlled trials), and, crucially, by the overcoming of local difficulties and challenges to care provision through means nearest at hand rather than with detailed discussions of challenges and barriers with the intent of developing most effective solutions (Bemme and D’souza 2014). Nursing as Writing It is well established internationally that nurses spend a substantial proportion of time in their work writing, and that this may be increasing (Mayers 2010). Though there are good clinical reasons for an emphasis on writing and record-keeping in nursing, there may be other reasons, including a wish to be seen as professionals on a similar level as doctors, and a (legitimate) concern that if nurses do not keep detailed records, they may be vulnerable to medicolegal action. Many nurses in South Africa, furthermore, have to keep notes in a language that is not their first language. This process of writing leads to a situation in which nurses have less time for patient care, including less time to speak with patients. Untrained cleaners and security guards, therefore, become an important means by which people are processed through an institutional system when the language of the system and that of the patient are not the same. Task Shifting Globally, within health care (including mental health care) what is termed ‘task shifting’ is seen as a way of dealing with high patient load. Task shifting involves

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the delegation of professional tasks to lower-level personnel (for example, from doctors to nurses, and from nurses to community health workers). Task shifting leads to a useful but narrow understanding of care as a set of procedures which can be manualized but which also require a high degree of surveillance and recording to make sure that the tasks are done (Mayers 2010). But what is left once the measurable tasks have been sieved out is the difficult to contain and messy ‘soup’ of care which may be seen as not real, as not the true work—as an HIV counselor said, commenting on the task-orientation of professional nurses with whom she worked, ‘‘What I’ve noticed what they need is the stats’’ (Rohleder and Swartz 2005; Van der Walt and Swartz 2002). And because this messy and hard to capture ‘soup’ of care is constructed as not part of the real work, or tasks, of health care, it can be done by people who are not health workers (in some senses, in fact, they may be ignored as non-people—people who are not seen as care workers or part of the health system at all). Language translation has come to be seen as part of this ‘‘not true work’’ of public mental health care in South Africa. Resources As has been discussed elsewhere (Swartz and Drennan 2000), there are enormous institutional advantages to not understanding patients. If clinicians do not understand patients, this makes the processing of these patients through the health system much faster and more efficient. When clinicians understand patients and engage with them, this may lead to more complex and time-consuming forms of engagement.

Implications for Changing Care Practices The issues we discuss here are not unique to South Africa, and the scenarios sketched will have resonance for anyone who has worked in or studied health care world-wide. Language issues and lack of access on the basis of language is a global problem (Swartz et al. 2014). It is also true that in health care systems world-wide, much of the more difficult and messy care work is undertaken by informal carers, or by people who have no formal role in health care. Ward and McMurray (2011), for example, have recently highlighted the role of receptionists (commonly women, who are not regarded as significant in relation to the experience of health care) in managing emotions in primary health care in the United Kingdom. The role of informal carers as part of a global economy of care is well documented (Duffy 2011; Fisher and Tronto 1990), particularly in South Africa (Cock 1990; Swartz 2012b). In many contexts, the role of these receptionists and informal carers may well be to improve the experience of health care for some patients, but the lack of attention to and acknowledgement of these roles mirrors the issue of invisibility of informal interpreters in South Africa. We are part of a research group trying to change practices in terms of language access. Amongst other things, we have offered short in-service training courses for clinicians and ad-hoc interpreters on language issues, and we are working closely

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with the health system on a pilot project in which, together with colleagues, we have trained and are supervising a cohort of community interpreters. But as we have shown, the issue of the ubiquity, but at the same time the invisibility, of the language issue in the institutions in which we work is far more complex than simply a question of language expertise. Current problematic practices, which are difficult for clinicians, patients, and ad-hoc interpreters alike, and which can legitimately be seen as highly suspect ethically, are maintained by a web of proximal and distal factors, some of which we have outlined above. If we are serious about effecting change, we need to consider not only the obvious advantages of improving language access, but also the question of how an apparently untenable situation allows for the smooth functioning of institutions, careers and disciplines. Indeed, as we work on our new community interpreting project, we are faced not only with the advantages of our intervention, but also with the ways in which the intervention challenges the smooth running of the institutions concerned and uncovers a range of formerly hidden practices. It is important, then, to engage with these broader and more complex issues if the language access issue is to be adequately addressed. We hope that our tentative comments in this regard will lead to discussion by others who face similar challenges. Acknowledgments We are grateful for the technical support provided by Jacqueline Gamble, and we thank the anonymous reviewers for their very helpful comments. This work is based on research supported in part by the Medical Research Council and National Research Foundation of South Africa (Grant specific unique reference number (UID) 85423); The Grantholder (Leslie Swartz) acknowledges that opinions, findings, and conclusions or recommendations expressed in any publication generated by the MRC- and NRF-supported research are those of the authors, and that the MRC and NRF accept no liability whatsoever in this regard.

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The invisibility of informal interpreting in mental health care in South Africa: notes towards a contextual understanding.

Despite South Africa's constitutional commitment to equality, represented by 11 official languages and the promotion of South African Sign Language, m...
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