InterpreterInterpreter--mediated mediated interaction in healthcare interaction in healthcare settings: an analytical settings: an analytical

frameworkframework

Claudio Claudio BaraldiBaraldi(University of Modena and Reggio Emilia, (University of Modena and Reggio Emilia, ItalyItaly))

claudio.baraldi@unimore.itclaudio.baraldi@unimore.it

This presentation is aboutThis presentation is aboutinteraction, in healthcare settings, interaction, in healthcare settings, between speakers of different between speakers of different languages talking to each other with the languages talking to each other with the help of a mediator/help of a mediator/translatortranslator

While this type of communication could While this type of communication could be considered be considered ““intrinsically intrinsically interculturalintercultural””, we pose two questions: , we pose two questions:

(1) in what way is this type of (1) in what way is this type of communication communication in factin fact interculturalintercultural? ? (2) what is (2) what is culturally relevantculturally relevant in this in this type of communication?type of communication?

We observe: We observe:

1) the relationship between evidence of 1) the relationship between evidence of ““culturescultures”” in communication and in communication and facilitation of intercultural facilitation of intercultural communication.communication.

2) the relationship between mediation 2) the relationship between mediation and translation.and translation.

The relationship between evidence The relationship between evidence of of ““culturescultures”” in communication and in communication and facilitation of intercultural facilitation of intercultural communicationcommunication

Interaction is basedInteraction is based onon cultural cultural presuppositionspresuppositions ((GumperzGumperz, 1992: , 1992: 230): 230): presuppositions the participants presuppositions the participants ““must rely on to maintain must rely on to maintain conversational involvement and assess conversational involvement and assess what is intendedwhat is intended””

Cultural presuppositions may be Cultural presuppositions may be conceived as conceived as generalised expectations in the social systems(Luhmann, 1984)

For example, in For example, in healthcare systemshealthcare systems, , cultural presuppositions of interaction are cultural presuppositions of interaction are provided by: expectations about the value of provided by: expectations about the value of patientspatients’’ health, the specific roles of doctors health, the specific roles of doctors and patients, the need of medical treatments and patients, the need of medical treatments and patientsand patients’’ adaptation.adaptation.

Following this general cultural pattern, two Following this general cultural pattern, two main types of more specific cultural main types of more specific cultural presuppositions have been observed in presuppositions have been observed in doctordoctor--patient interactionspatient interactions

1.1. Patients adapt to the Patients adapt to the ““Voice of MedicineVoice of Medicine””((MishlerMishler, 1984): , 1984): theythey respond to doctorsrespond to doctors’’questions and accept doctorquestions and accept doctor’’s s recommendations. There is a hierarchical recommendations. There is a hierarchical relationship between doctors and patients relationship between doctors and patients based on difference in competence (doctorbased on difference in competence (doctor--centred medicine)centred medicine)

2.2. Doctors support the patientsDoctors support the patients’’ lifewordlifeword ((Barry Barry et al.et al., 2001), 2001). Patients are expected to be . Patients are expected to be competent interlocutors and are encouraged to competent interlocutors and are encouraged to

express their problems and needs in the express their problems and needs in the interaction. There is an interpersonal interaction. There is an interpersonal relationship between doctors and patients relationship between doctors and patients based on attention for patientsbased on attention for patients’’ needs (patientneeds (patient--centred medicine)centred medicine)

1.1. In doctorIn doctor--centred medicine, centred medicine, expectations are mainly cognitive expectations are mainly cognitive (expectations of patients(expectations of patients’’ adaptation adaptation and doctorsand doctors’’ performance) and performance) and normative (hierarchical relationships)normative (hierarchical relationships)

2.2. In patientIn patient--centred medicine centred medicine expectations are mainly affective expectations are mainly affective (expectations of patients(expectations of patients’’ and doctorsand doctors’’

selfself--expressions expressions in interpersonal in interpersonal relationships)relationships)

In the interaction, cultural presuppositions In the interaction, cultural presuppositions may be different and tmay be different and the differences between he differences between them may embody the differences between them may embody the differences between ““culturescultures””. .

These different cultural presuppositions may These different cultural presuppositions may be observed in the interaction through be observed in the interaction through specific specific contextualization cuescontextualization cues, which, which are are linguistic cues which linguistic cues which highlight, foreground or highlight, foreground or make cultural presuppositions salient in make cultural presuppositions salient in communication (communication (GumperzGumperz 1992).1992).

The emergence in the interaction (the The emergence in the interaction (the cues) of a difference between cultural cues) of a difference between cultural presuppositions creates the conditions presuppositions creates the conditions for intercultural communication.for intercultural communication.

Intercultural communicationIntercultural communication is a is a type of communication in which cultural type of communication in which cultural diversity is observed diversity is observed and treatedand treated as a as a meaningful phenomenon meaningful phenomenon

In intercultural interactions, In intercultural interactions, mediationmediationmay facilitate both: may facilitate both:

(1) reproduction of the mainstream (1) reproduction of the mainstream cultural presuppositions (cultural cultural presuppositions (cultural reproduction of a specific cultural system) reproduction of a specific cultural system)

and and

(2) cross(2) cross--cultural adaptation (Kim, 2001) cultural adaptation (Kim, 2001) by which the parties can acknowledge by which the parties can acknowledge their own expectations about cultural their own expectations about cultural presuppositions presuppositions

The relationship between The relationship between mediation and translationmediation and translation

In healthcare systems, when the In healthcare systems, when the parties do not understand each other parties do not understand each other for linguistic reasons, intercultural for linguistic reasons, intercultural mediation requires mediation requires translationtranslation as a as a fundamental activity. fundamental activity.

In these situations, translation is In these situations, translation is essential at least in:essential at least in:

(a) assuring common understanding (a) assuring common understanding and and

(b) facilitating a (b) facilitating a directdirect communication communication between the parties. between the parties.

This means that the very activity of This means that the very activity of translating is an activity of mediating translating is an activity of mediating

Consequently, cultural presuppositions Consequently, cultural presuppositions and intercultural meanings are produced and intercultural meanings are produced through translationthrough translation

Here we suggest that: Here we suggest that: Coordination of participantsCoordination of participants’’ turns in turns in interactions involving the provision of interactions involving the provision of translation has consequences for the translation has consequences for the achievement of cultural reproduction or achievement of cultural reproduction or crosscross--cultural adaptation.cultural adaptation.

More precisely we suggest that: More precisely we suggest that:

1.1. InterpretersInterpreters’’ actions are projected by actions are projected by other actions, presenting the cultural other actions, presenting the cultural presuppositions of a specific social system presuppositions of a specific social system (e.g. medical treatments). (e.g. medical treatments).

2.2. InterpreterInterpreter--mediated interaction mediated interaction produces a reproduces a re--interpretation or interpretation or rere--contextualisationcontextualisation (Baker, 2006) of these (Baker, 2006) of these cultural presuppositions, promoting the cultural presuppositions, promoting the participantsparticipants’’ understanding and understanding and responsibility for their actions. responsibility for their actions.

To sum up: To sum up: 1. Interpreter1. Interpreter--mediated interaction is mediated interaction is contextualized by a set of cultural contextualized by a set of cultural presuppositions (e.g. forms of medical presuppositions (e.g. forms of medical culture)culture)2. Such contextualization derives from 2. Such contextualization derives from embedding social systems relevant in embedding social systems relevant in society (e.g. healthcare system)society (e.g. healthcare system)3. Interpreter3. Interpreter--mediated interaction can mediated interaction can possibly change these cultural possibly change these cultural presuppositions, that is it can represuppositions, that is it can re--contextualize the embedding systemcontextualize the embedding system4. Contextualization and re4. Contextualization and re--contextualization are made evident contextualization are made evident through particular linguistic cuesthrough particular linguistic cues

Mediation/translation is not the mere result of the Mediation/translation is not the mere result of the mediatormediator’’s actions.s actions.

The mediatorThe mediator’’s and the other participantss and the other participants’’ (doctor (doctor and patient) actions are always strictly and patient) actions are always strictly coordinated.coordinated.

The interplay among these three participantsThe interplay among these three participants’’actions permits the actions permits the interactionalinteractional construction of construction of cultural reproduction or intercultural contact.cultural reproduction or intercultural contact.

WeWe’’ll see this better tomorrow, in Laurall see this better tomorrow, in Laura’’s s presentation.presentation.

In our research (In our research (BaraldiBaraldi, 2006; , 2006; BaraldiBaraldi, , GavioliGavioli, 2007; , 2007; BaraldiBaraldi, , GavioliGavioli, in press; , in press; GavioliGavioli, , BaraldiBaraldi, 2005), we have observed , 2005), we have observed some forms of mediation.some forms of mediation.

In this presentation, I will introduce one In this presentation, I will introduce one ““sideside”” of our observation, while Laura of our observation, while Laura GavioliGavioli will present the other will present the other ““sideside””tomorrow morning. tomorrow morning.

I will introduce three forms of reI will introduce three forms of re--contextualisation through mediation.contextualisation through mediation.

Mediation as assessment of WeMediation as assessment of We--IdentitiesIdentities ((normativenessnormativeness expanded expanded beyond medical culture; overbeyond medical culture; over--adaptation adaptation of the patientsof the patients’’ actions to the medical actions to the medical culture; non renditions of prescriptions)culture; non renditions of prescriptions)Mediation as dyadic separationMediation as dyadic separation(instructions; questions; answers; (instructions; questions; answers; responses; reduced translations; feedback responses; reduced translations; feedback channel; affective support) channel; affective support) Mediation as affective formulation Mediation as affective formulation (affective support combined to translation (affective support combined to translation as formulation)as formulation)

The dataThe data

-- 120 audio120 audio--recorded interactions recorded interactions involving Italian healthcare providers, an involving Italian healthcare providers, an immigrant patient and a bilingual immigrant patient and a bilingual mediator. mediator. -- Patients are African English, Arabic and Patients are African English, Arabic and Chinese speakers.Chinese speakers.-- The mediators are, respectively, The mediators are, respectively, Nigerian/Ghanaian, Jordan/Moroccan, and Nigerian/Ghanaian, Jordan/Moroccan, and MandarineMandarine Chinese bilingual professionals. Chinese bilingual professionals. -- 40 interactions are examined per 40 interactions are examined per linguistic group.linguistic group.

Mediation as assessment of WeMediation as assessment of We--IdentitiesIdentities (extract 1)(extract 1)

1 D Well, very well! Everything is all right, all okay. We saw before that it was all okay, didn’t we?

2 M How many girls do you have? You have two, maybe the third one? Is okay eh?

3 D Has she got two?4 M Eh!5 D Two more?6 M Yes (.) No, this is number five!7 D Number five?8 M Yes! Is OK eh? You know this problem that you are talking

to – If your husband is going to make love, go and buy condom or…((P smiles)) (?)9 P Yes!10 M You cannot face the baby. You have at this point, this

problem eh? Or you want to pack the children and go to Ghana? Eh?

11 P Ah! ((P sighs))12 M Ok! So if you don’t want to go and live in Ghana with these

children, don’t stop ( ). Go, come to via Padova and we’ll give you what you will be take in, so that you don’t get pregnant. If your husband, I know usescondom (.) I know Africans maybe don’t like condom. If he cannot use, there’s a pill that you can be taking or you come at this point. Do you understand? Don’t stay too long, eh?

Mediation as dyadic separation Mediation as dyadic separation (extracts 2 and 3)(extracts 2 and 3)

55 P55 P Why people have told me is not too much Why people have told me is not too much dangerous. So I want to try.dangerous. So I want to try.

56 M56 M Yes:, the coil eh?Yes:, the coil eh?57 P57 P Yes.Yes.58 M58 M Yeah, itYeah, it’’s not dangerous.s not dangerous.59 P59 P Before I was afraid about that.Before I was afraid about that.60 M60 M It needs that you normally come for It needs that you normally come for

control, control, thatthat’’s all.s all.61 P61 P O:k.O:k.62 M62 M No, (No, (sweat tonesweat tone) don) don’’t worry.t worry.

14 D:14 D: A hard job, A hard job, isnisn’’t t itit??15 M:15 M: YesYes yesyes yesyes..

(8)(8)16 M: Oka:y. (16 M: Oka:y. (°°??°°).).

((D ((D touchestouches PP’’s s handhand))))17 P: 17 P: °°Ah:::Ah:::°°18 M: It18 M: It’’s painful eh? s painful eh? Mm.Mm.19 D:19 D: °°DonDon’’t t hurthurt me, me, hehe says.says.°°20 M:20 M: Eh Eh yesyes hehe saidsaid hehe feelsfeels painpain

((((smilessmiles)).)).

In these examples, mIn these examples, mediation promotes ediation promotes selfself--referential cultural reproduction in the referential cultural reproduction in the interaction, through: interaction, through:

1. Substitution of the parties and their 1. Substitution of the parties and their cultural identities (cultural identities (assessment of weassessment of we--identitiesidentities))

2. Separation of the parties and their 2. Separation of the parties and their cultural identities (cultural identities (dyadic separationdyadic separation))

MediatorsMediators’’ initiatives create shared initiatives create shared normative or cognitive expectations normative or cognitive expectations with one party with one party

MediatorsMediators’’ translations project translations project confirmationsconfirmations and enforcementsand enforcements of of these expectations in the interaction these expectations in the interaction with the other party with the other party

Mediation as affective formulationMediation as affective formulation(extract 4)(extract 4)

Heritage defines formulation as Heritage defines formulation as ““summarising, glossing, or developing the summarising, glossing, or developing the gist of an informantgist of an informant’’s earlier statements earlier statement””(1985: 100). (1985: 100).

1717 D D Now (.) if sheNow (.) if she’’s alright (.) s alright (.) doesndoesn’’t have problems (.)t have problems (.)her period is normal: her period is normal: --

18 M 18 M MmhMmh19 D 19 D Normal (.) ok (.) we can also stop hereNormal (.) ok (.) we can also stop here20 M 20 M OkOk21 D 21 D If instead she wants me to see her (.) ok (.) willingly If instead she wants me to see her (.) ok (.) willingly

(.) I have time I can control her(.) I have time I can control her22 M 22 M she asks you now are you alright or you feel she asks you now are you alright or you feel

something? Because she says have you got any something? Because she says have you got any problem? Normally when one fixes a coil about every problem? Normally when one fixes a coil about every year they have a check upyear they have a check up

23 D 23 D becausebecause alternativleyalternativley itit’’s s JulyJuly AugustAugust (.) I (.) I meanmean thisthissummersummer

24 M Eh24 M Eh25 D 25 D after a after a yearyear

26 M 26 M You wait for the seventh month to do the yearly controlYou wait for the seventh month to do the yearly control27 P 27 P Now Now --28 M 28 M NowNow ––29 P 29 P I havenI haven’’t got anythingt got anything30 M 30 M if everything is fine and your period is regular you donif everything is fine and your period is regular you don’’t need t need

doing doing any controlany control31 31 P P now itnow it’’s a month and I havens a month and I haven’’t got itt got it32 M 32 M a month and you havena month and you haven’’t got itt got it33 P 33 P preciselyprecisely a a monthmonth34 M 34 M She says that pain (.) something strange She says that pain (.) something strange –– there isnthere isn’’t any (.) t any (.)

she says sheshe says she’’s alrights alright35 D Ah35 D Ah36 M 36 M her period is alright(.) the only thing probably this is the her period is alright(.) the only thing probably this is the

reason why she came herereason why she came here37 D 37 D MmhMmh38 M 38 M That she hasnThat she hasn’’t got her period yet this month (..) (t got her period yet this month (..) (((smilingsmiling)) ))

and and sheshe’’s s a bit worrieda bit worried39 39 D D So probably letSo probably let’’s do this (.) lets do this (.) let’’s do a pregnancy tests do a pregnancy test40 M Ok40 M Ok

TThe mediator encourages the patient to he mediator encourages the patient to express her worries (echoes, supporting express her worries (echoes, supporting feedback) which are eventually feedback) which are eventually translated to the doctor through a translated to the doctor through a formulation. formulation.

By formulating the patientBy formulating the patient’’s worries to s worries to the doctor, the mediator promotes the the doctor, the mediator promotes the patientpatient’’s need to be reassured by the s need to be reassured by the doctor and the doctordoctor and the doctor’’s care of the s care of the relationship with the patient.relationship with the patient.

MediationMediation as as affective formulationaffective formulationcan promote the partiescan promote the parties’’ participation participation allowing intercultural contact, in the allowing intercultural contact, in the form of crossform of cross--cultural adaptation:cultural adaptation:

(1) Mediators(1) Mediators’’ initiatives create initiatives create affective expectations allowing one affective expectations allowing one party to selfparty to self--express express

(2) Mediators(2) Mediators’’ translations as translations as formulations give the opportunity to the formulations give the opportunity to the other party to confirm and support this other party to confirm and support this selfself--expression. expression.

ToTo sumsum up, the up, the mediatormediator’’s s initiativesinitiatives, , direct direct answersanswers and and formulationsformulations can can create:create:

(1) (1) sharedshared cognitive and normative cognitive and normative expectationsexpectations withwith one party one party and and thenthenconfirmation and enforcementconfirmation and enforcement of these of these expectations in the interaction with the expectations in the interaction with the other party (extracts 1, 2 and 3)other party (extracts 1, 2 and 3)

(2) affective expectations allowing one (2) affective expectations allowing one party to selfparty to self--express and express and thenthen the the opportunity to the other party to confirm opportunity to the other party to confirm and support this selfand support this self--expression (extract expression (extract 4)4)

ToTo answeranswer the the questionsquestions wewe posedposed at at the the beginningbeginning::

1. 1. in what way is this type of in what way is this type of communication in fact intercultural? communication in fact intercultural? 2. what is culturally relevant in this type 2. what is culturally relevant in this type of communication?of communication?

FirstFirst

Mediation as translation may promote crossMediation as translation may promote cross--cultural adaptation, if it makes culturally cultural adaptation, if it makes culturally relevant: relevant:

(1) patients(1) patients’’ expression and expression and (2) doctors(2) doctors’’ involvement in the interaction involvement in the interaction

promoting a patientpromoting a patient--centred approach in centred approach in medical culture. medical culture.

This happens if translation promotes:This happens if translation promotes:

(a) a balanced distribution of (a) a balanced distribution of participation in the interaction between participation in the interaction between patients and doctorspatients and doctors

and and

(b) an affectively sensitive relationship (b) an affectively sensitive relationship between patients and doctors. between patients and doctors.

SecondSecond

Mediation as translation promotes the reproduction of the Mediation as translation promotes the reproduction of the selfself--referential culture of the system, if it makes culturally referential culture of the system, if it makes culturally relevant a doctorrelevant a doctor--centred medicine, allowing absent or scarce: centred medicine, allowing absent or scarce:

(1) doctors(1) doctors’’ personal involvement personal involvement and and (2) patients(2) patients’’ personal expression personal expression