Frame of Reference
Can diagnoses depend on your doctor’s mother tongue?
My passion for the nuances of language has deep roots in who I am as a person. I study intercultural communication: it’s about how people from different cultures interact with each other. About how compatible their communications are, and what happens when they aren’t.
The real moment things fell in place for me, however, can be traced to a single story a lecturer told in my second year.
It was about bilingual people. Being diagnosed by a doctor. The results were different depending on which language they used.
When I started university, I took a course called General Linguistics. The course is cold, clinical and objective; I always thought about it as the maths of languages. Grammar calculus, if you will. I hated it.
But the next year, I was able to take a class called Applied English Language Studies, and that class illuminated my path in life. Applied linguistics is all about how people use language. About teaching and assessing and translating, and how people learn a second language, or even many at once; about speech therapy, language policy, and more.
If General Linguistics was languages caged and categorised in a zoo, then Applied Linguistics was actually seeing those languages in the wild. I was fascinated.
My lecturer had been to a local mental-health hospital. She was doing studies in schizophrenia, the condition including things like false beliefs, confused thinking, and seeing things that aren’t really there.
But this time, the focus was a bit different from what you might expect. Since this was Applied Linguistics, my lecturer was looking at “schizophrenia presentation in first and second languages”. That means seeing how people with schizophrenia display their symptoms, and how it shows up differently when using the mother tongue versus a language that was learned later.
She went on to tell us about an interview where the patient showed very few symptoms in their first language, while presenting far more in their second language. The patient even seemed unaware of their diagnosis in their second language but discussed how the medication was helping in their first!
Now, I have a feeling that this lecturer may have been excited to tell us something so interesting and embellished slightly. But there are definite, proven connections between schizophrenia diagnoses and the language of the doctor, patient and interview.
For those of you who are unaware of how psychiatrists diagnose, they use the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short.
The most recent version is the DSM-5, published in 2013, lists five categories of symptoms for schizophrenia. Don’t try hard to remember them all, but here they are:
- delusions: believing something that’s obviously false
- hallucinations: seeing, hearing, or otherwise sensing something that’s obviously not there
- disorganized speech: jumping across topics, spewing a “word salad” of random words, or otherwise “messy” speech
- grossly disorganized or catatonic behavior: being too physically rigid, or too flexible, or too sluggish, or too something else that shouldn’t be happening
- negative symptoms: behaviours that are conspicuous in their absence, like not showing feelings, not enjoying things, or not doing something else that most people normally would
To be diagnosed with schizophrenia, the patients should have at least one symptom from the first three categories, and one more from anywhere in the list.
There have been thousands of studies on schizophrenia over the years, with many of them focusing on language and language use. However, very few have focused on non-native speakers of a language: people using a language that they didn’t grow up speaking.
The study that really stood out to me was published in 1973. I won’t bore you with the technical details, but the basic idea is that patients answered recorded questions. They did this twice: once in Spanish, their home language, and then once in English, which they had learnt later.
Multiple psychiatrists — both English and Spanish — listened to the answers. And then, they rated these patients using the tools at their disposal.
The results of this study blew me away.
On the most basic level, the doctors totaled up the pathology (think indicative symptoms) for each language. Look at the graph below: the black lines are how much each patient was graded for the English interview, and the white for the Spanish.
As you can see in the figure, all of the patients were scored considerably higher in English. In other words, when interviewed in English the patients were judged to be demonstrating more pathology: they were either showing more symptoms, or those symptoms were deemed to be more severe.
Why did the patients’ symptoms seem more prominent when interviewed in their second language? There are several possible reasons.
To start with: although they did their best to control it, perhaps there was some sort of prejudice from the raters.
Or maybe the patients themselves are the cause: people suffering from schizophrenia often find it difficult to describe their experiences anyway, and they may have reached a point in this experiment where they just tensed up further and gave up.
And, there’s a third option. Maybe the interviewers’ frame of reference for the world was not the same as the patients.
One of the (many) linguistic indicators for depression in a native-English speaker is taking longer pauses. If they keep pausing for too long, it’s possibly because they’re depressed.
But some languages use longer pauses than English and this could very well carry over to their second language. People also naturally use longer pauses when they’re not confident in a language, because they are planning their speech or trying to think of the right words.
Speakers of different languages could have different frames of reference: different ideas of what’s normal, or, in this case, of how long a “normal” pause should be.
But here’s the thing: interviewers and doctors have frames of reference too. And their frame of reference will influence how the pauses are interpreted. Are these people really depressed? Or are they just used to a language where pauses are longer?
I want you to take a moment and think about the patients throughout history who have been interviewed and diagnosed in their second language. How many were misdiagnosed? How many would never find the correct medication dosage? How many were lobotomized?
And that’s just for schizophrenia.
How many sick people have not been able to get the treatment they need because of a language barrier and the assumptions that come with it?
If you have one, think about your second language. Sure, you might be able to get by day-to-day: order a meal, get directions, chat with a friend. But now imagine you are ill, you are anxious and you are sitting in a room with a doctor, a doctor who wants detailed descriptions of what you’re going through, a doctor who uses technical language and expects some of the same from you, a doctor who does all of this in your second language.
And that’s all it takes. To put yourself in someone else’s shoes. Take a moment and think about a person you have met that you thought was dumb, uneducated, rude, untrustworthy.
Sometimes, those gut reactions from you have to do with intercultural communication. Norwegians have longer pauses in their native tongue that carry to their English, English speakers believe Norwegians to be ‘stupid’ or not fluent.
A young Zulu boy is taught that not looking his elders in the eye is respectful, his English teacher thinks he’s lying when he says he did his homework but won’t look at her.
A Chinese business man follows his cultural norms of saying no to second helpings several times before he accepts, his German business partner thinks he doesn’t like the food.
Intercultural communication is vital to us living peacefully, and it doesn’t just have to be between different languages.
Think about how you speak and act in your country, your area, your town, even your own family! Being aware of how you communicate, and that it might be different from other people, could make your interactions smoother and more enjoyable.
But importantly, carry that awareness over to people you meet. The next time you meet someone who won’t make eye contact, or laughs too loud or is brusque, don’t jump into assuming negative things about them.
Instead, start by asking yourself if perhaps they’re just different.
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Curious for more? Sources and references for this article can be found here.
