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Needs of the bilingual patient: a challenge for
the Welsh language in the Health Service
Dr Enlli Thomas, College of Education and Lifelong Learning,
Bangor University
Biography
Enlli Thomas is currently a Lecturer in
Education at the College of Education and
Lifelong Learning in Bangor University. Enlli
graduated with a degree in Psychology from
the University of Wales, Bangor, in 1996. As a
native speaker of Welsh, Enlli was eager to
conduct research on children’s acquisition of
Welsh, and Bangor was the ideal choice. She
was fortunate enough to win a Bookland
Studentship, awarded by Bangor University’s
Development Trust, to follow a three year
post-graduate research degree looking at
children’s acquisition of grammatical gender in
Welsh.
Enlli received a PhD in Psychology in 2001 for that work, aspects of which
have been published. She has been involved as a co-author on a number of
research grants in collaboration with other colleagues at Bangor University,
for example looking at language transmission practices in the home (Welsh
Language Board) and developing Welsh language assessment tools (Welsh
Assembly Government).
Speech
As the title of this presentation suggests, I will be concentrating on the
bilingual patient’s needs in the bilingual context here in Wales. I will
ultimately be asking a question - is there a challenge to the Welsh language
in the health service? That is, are there some things to do with bilingualism
in Wales and the use of the Welsh language in the health service which are
impossible to deal with and to what extent are there other things which are
easy enough for us to address.
In order to try and answer this question, I will look at four main themes in
this presentation. Firstly I will talk a little bit about the importance of
language in health care. I will show a model to explain what Paul has just
said about the importance of communication. Then I will talk a little bit
about the differences between monolingual and bilingual speakers. Getting
to know some of these differences is essential, I believe, in order to
understand the implications of providing monolingual assessment, treatment
and care to bilingual patients. Because usually, of course, it is easier to
provide monolingual care through the medium of English for a number of
reasons. But if we have a better understanding of the differences between
monolingual and bilingual speakers, it will be easier to understand the
implications of doing so. Then, at the end, I will return to the opening
question and try to talk about to what extent it is possible to come to terms
with the Welsh challenge in the health service – how it is possible to reduce
the effect of treatment through the medium of English or treatment through
the medium of an individual’s weakest language – how we can come to
terms with that.
Importance of language in healthcare
To start off, and this is very similar to what Paul was discussing...but if we
can think of the health care context as a type of model. We start with the
patient, who of course, has a problem of some kind and they must, in order
to come to terms with that problem, discuss it with a doctor or whoever.
After that discussion has taken place, it is possible to create an assessment,
and through that assessment it’s possible to understand, or develop a type
of treatment and care for that patient, and that treatment and care will be
subject to further discussion and also further assessments.
So that is the model, and of course, most of that model involves language.
So it’s impossible to get this service without a language commitment. But
of course, on each of those levels, if something goes wrong or doesn’t quite
work in terms of communication, then that has a detrimental effect on the
remainder of those steps. So, for example, if something goes wrong during
the discussion of the problem, if there is a misunderstanding or
miscommunication, that then affects the assessment, and also the
treatment and care. If the assessment then becomes an incorrect
assessment because the initial discussion was not a useful one for that
patient, then that leads to ineffective treatment and care. Of course,
ultimately, if there is ineffective treatment and care, that does not get rid
of the initial problem. The problem continues. So that is the model of
language care and the importance of language within that model.
Therefore, in a way, language has two main roles – ensuring a fair
assessment of a problem and ensuring fair and purposeful treatment and
care following that. So the question we must ask is “To what extent does
the health service succeed with this whilst dealing with its bilingual
patients?”
Difference between monolinguals and bilinguals
In order to look at this in more detail, I will talk to you a little bit about the
obvious differences between monolingual and bilingual speakers in the first
place. One obvious difference between monolingual and bilingual speakers
is that a bilingual speaker has to deal with two very complex systems.
Those two systems have to co-exist in the mind and the brain has to cope
with recognising elements from those two systems and keeping them
separate as two different systems. One big question in the field of
bilingualism is “Where are the two systems represented in the mind? Are
they both together – a mixture of some sort?” Some researchers, especially
in the eighties, believed that bilingual speakers’ two language systems are
together at the onset. Or are they separate? That is the most recent
opinion in the field - that the two systems are represented and built
separately, but despite the fact that they are separate, of course on some
levels, the two languages will overlap and will influence each other and that
will have an effect on how an individual expresses himself in one language
or the other. The important thing to remember is that the way a bilingual
speaker expresses himself in one of his languages is never the same as the
way a monolingual speaker does so.
That, of course, leads to a number of differences. To begin there are
neurological differences. That is, the brain has to process the language
somewhere within the brain and research has shown that there are
differences in the Broca part of the brain which mostly deals with the
grammatical structure of language – depending on the age at which the
person learns their second language. So there is a different type of
production in the brain for the first language and the second language of the
bilingual speaker in terms of grammatical structures. But the differences
are not of the same nature in the Wernicke part, it is more to do with the
meaning of words and so on. So there are differences depending on the age
of learning the second language and the individual’s experiences with his
two languages.
Of course, there are also a number of cognitive differences. That is, where
and how does someone store the information in the brain. Are there
connections between concepts and labels for concepts in the two languages?
Is there an overlap with those labels? Does a person make a lot of mistakes
because of the way the two languages are structured in the mind? Of course
all of those differences lead to language differences as I said. So the
linguistic nature of the use of the bilingual speaker of one language or the
other is different to the nature of the monolingual speaker. One obvious
example, of course, is code exchange. A bilingual speaker can use one
language to slot words in from the other language. So all of these are big
differences between monolingual and bilingual speakers.
But the extent to which those differences occur depends on a number of
factors. Firstly, as I’ve mentioned, it is to do with the age of learning the
second language but also experiences and how often a person uses and hears
the two languages. The monolingual speaker has one system to locate in
the brain and the monolingual speaker spends a hundred percent of his time
sorting through that system. When we talk about bilingual speakers, we are
usually referring to two types, in general – simultaneous bilingual speakers
who build two systems at the same time, whether they are stored together
or separately. But because that speaker builds two systems at the same
time, one language is likely to influence the other whilst developing in the
mind. But not one bilingual speaker receives exactly the same input as the
other nor uses the two languages the same amount of time either, and that
type of bilingual speaker is different to the second main type, which is the
late bilingual speaker. In this context, the speaker has already started
building one system almost fully, but usually not completely, and then adds
an extra language on top of that.
So the late bilingual speakers tend to make mistakes that are similar to how
the structure of the first language operates. So there are a lot of
differences between the different types of bilingual speakers. But of
course, no two bilingual speakers have had exactly the same experiences,
and this leads to great differences within the population of bilingual
speakers. When we talk about bilingual speakers, we are not just talking
about one type, we are talking about several different types and Li Wei has
recognised 36 different types of bilingual speakers within the references he
was looking at, including things like scribed bilingual, consecutive bilingual,
insipient bilingual, horizontal bilingual, recessive bilingual, simultaneous
bilingual, vertical bilingual and so on. So there are big differences, we
can’t put bilingual speakers all in one box.
There are differences, not only in terms of languages and how the two
languages are different to each other but there are also cultural differences
that affect the way an individual uses language. But the very important
thing to remember, going back to what the first speaker was suggesting in
terms of the number of different first languages that are in the United
States for example, when we talk about bilingual speakers, we are referring
to most of the world’s population. This map shows where most people live
in the world and as you can see most people live in areas like Asia, South
America, Africa and Europe, where there are hundreds or thousands of
languages. So all these languages come together and develop a number of
bilingual speakers, if not multilingual speakers. So it is a crucial issue and it
affects most of the world’s population.
Implications of monolingual assessment, treatment and care
for bilingual patients
I will talk briefly about some of the differences, or some of the problems
that the Welsh patient, who also speaks English can face. But something to
remember in the Welsh context is that of course, apart from very very
young children, everyone who speaks Welsh is either developing their
English or have English language skills. Therefore the Welsh-English
bilingual speaker’s English is usually quite good, but that is not to say that
the nature of their understanding of English is exactly the same as you
would expect and there are small differences in terms of linguistic
behaviours because they are also bilingual. So I will look at some of those
problems.
But as this quote on the slide mentions, one of the important things which
needs to be considered when dealing with bilingual patients is sensitivity to
culture and language. So “cultural sensitivity implies understanding an
individual’s social values, beliefs and customs as well as understanding the
language in which these factors are expressed”. I will therefore be looking
at some of those problems which cause problems for the Welsh speakers in
English in Wales.
Firstly it is possible that there are problems with expression. If someone is
speaking a second language or a language which is their weakest, because
for many bilingual speakers in Wales, English is not a second language as
such but their weakest language, then if someone is speaking in their second
language, they tend to pay attention to accuracy in expression rather than
the relevance of the content. So of course, in the medical context, the
relevance of the content is the most important thing. But there is a
tendency to pay much more attention to accuracy and that has a lot to do
with cultural factors. For children, of course, it is due to their lack of
language skills, but for adults, especially older adults, it is to do with the
need to please, it is to do with wanting to appear as if they have good
language skills without paying so much attention to the content of the
message they are trying to convey. So that is one cultural issue.
In terms of more linguistic issues, if something is someone’s weakest
language, there is sometimes a lack of relevant idioms which are direct
translations of what someone’s trying to say and this often causes problems.
This first example “Mae fy nghoes i’n cnoi” is something I remember as a
child, I didn’t quite understand how people could communicate this in
English. There are different ways of doing this of course, the translation is,
in a way, “gnawing pain” or “my leg is aching” or something like that. But
the direct translation “my leg is chewing” doesn’t make sense at all, of
course. But you also have problems where there may be a direct translation
and that is what a child would do of course, and would not quite express the
nature of the problem. So if someone has a pain in their stomach, “stomach
ache”, saying that someone has a “stomach ache” is of course different to
saying “I have a pain in my stomach” where that might be a chronic pain of
some sort. So direct translation can be a problem, likewise with “Mae gen i
bigyn yn fy nghlust”. It’s difficult for a child to know how to translate that,
and also of course, another problem is that not every language has a ready
translation for all words in the other language. So “pigyn” - here it’s
“ache”, but in another context it might be “stitch”. So learning in which
context different terms are used depends on the individual’s experiences
and not every individual has a lot of experiences of using these terms in
English, for example.
Here are a few other examples for you. There are some terms where there
is one term in Welsh but you use different ones in English. “Gwddw” is the
only term that a lot of children would know to describe “neck” and “throat”
so that child needs to be aware of the context of using “neck” v “throat”
when speaking English and so on.
Also, because bilingual speakers learn one language in a different context
from the other, sometime the bilingual speaker hasn’t got the exact words
for something specific in that language and only has terms for those things
in the other language, the context language of that learning. According to
the researchers, this is called “distributed characteristic” or “domain
specificity” and a personal example for me is that for a long time I didn’t
know what the translation was for “clun”. I know what “clun” is but I
wasn’t sure that the translation was “thigh”. The same as “gwar”. I know
what “gwar” is but I didn’t know that the translation was “nape”. Similarly I
know that my ankle is an “ankle” but for a long time I wasn’t sure what the
Welsh translation was. So speakers have missing vocabulary as well. What
you will often see is that a speaker may feel more comfortable speaking
Welsh, but maybe with English terms thrown in. That is not to say that they
prefer speaking English or that it’s easier to deal with them in English, that
is just the nature of their bilingualism.
My background is in psychology so I tend to read more about things to do
with mental illnesses and so on. But one thing that is obvious in those
contexts as well is that emotion is something that is closer to an individual’s
first language than their second language and speakers feel that there are
some aspects of their personality that they can express better in their first
language as well. So if they want to communicate something that is to do
with a personal issue of theirs, if it is to do with personality or emotion, it’s
easier for them to do that in their first language than in their second
language. This is probably because the context of learning the second
language is less emotional than the context of the first language and of
course if someone has learned their first language as a child, the second
language a little bit later, then these emotional elements don’t affect the
learning in the same way.
Another thing to consider about emotion and language is that it is possible
to misinterpret a problem because of the bilingual speaker’s lack of ability
to express emotion in his first language or second language if they are being
assessed in their second language, for example. There are cases where
patients have displayed a higher rate of schizophrenic characteristics for
example in their second language than in their mother tongue. So of
course, if they are assessed in their second language, they are assessed as
having elements of schizophrenia. Others have shown that less psychotic
characteristics appear when someone is assessed in their second language,
and this is usually because they are misdiagnosed as having schizophrenia.
This is because of the patient’s linguistic nature. In their second language,
especially if it is a weak language of theirs, people tend to speak slowly,
with frequent pauses...searching for the words...which can seem as if they
are unwilling to communicate and the diagnosis might be depression,
anxiety and so on. But where if they were assessed on the same issues in
their first language, they would not display the same sorts of problems. In
terms of being assessed as having less psychotic characteristics in their
second language, perhaps that is due to the fact that the assessments use so
much language and the patient hasn’t got enough language to display those
characteristics, the ones that they look for in an assessment. So all of these
are things that can influence the type of assessment that is undertaken and
the outcome of that assessment.
Dealing with the Welsh challenge in the health service:
minimizing the effect
Finally therefore, in considering some of these differences between
bilingual and monolingual speakers and the need for fair assessment,
treatment and care in both languages, if not in the individual’s strongest or
the language they feel most comfortable in, what is the challenge that faces
us in this context in Wales? Well of course the first challenge is lack of
staff, lack of staff who can speak Welsh, lack of awareness amongst staff
members about the importance and the role of the Welsh language in the
lives of bilingual individuals in Wales, lack of research supporting these
issues and lack of relevant measurements or tests.
So there are ways to cope with this of course. The way to deal with staff
shortage is to recruit more staff but of course that will not happen
overnight. Ideally, the number of staff needs to be increased and so on. As
this is not something that can happen straight away, the most important
thing I think is raising awareness, not only amongst practitioners who can’t
speak Welsh, but also amongst Welsh speakers about the use of the Welsh
language and the purposeful use of the Welsh language within the care that
patients receive. Ideally, this would contain training about the nature of
the bilingual patient. So what the expectations are and where would you
expect an assessment through the medium of English to cause problems, but
also, even if there are tests or assessments available in Welsh and in
English, there would be a need to know what to do with that information.
So how would you interpret the results, side by side or would you interpret
them together or what? We need research to support what needs to be
done in that context.
It might not be necessary to assess and give treatment for different ailments
though the medium of Welsh and English because the speaker is bilingual.
There are researchers within Bangor University - Marie-Josephe Tainturier is
leading this work - who are looking at the possibilities of treatment in one
language for bilingual patients suffering from aphasia in order to see if there
is a way of transferring treatment from one language to help the other
language too, and of course that would save time and money in the field if
it is valuable. But this needs to be looked into by supporting research. Of
course, there are a number of excellent things going on in terms of research
in this field in Wales but we need to ensure that that research is conducted
on all aspects of issues relating to the use of or the provision for bilingual
speakers in Wales. In terms of assessments as well, as I said, we need some
research into the implications of using assessments. Some assessments are
easy to translate and there are purposeful means of doing so but it is
possible to translate something in order to have something in Welsh and in
English to give to the patient. But some assessments are impossible to
translate and translating them is not useful at all. So we need to research
into that as well to ensure that what is being produced for the bilingual
patients is again purposeful.
So to conclude, is there a challenge for the Welsh language in the health
service? Yes, of course there’s a challenge but it is not an insurmountable
challenge. Raising awareness and strengthening the research in the field
will help ensure a better experience for the bilingual patient. Thank you
very much.