同理心、態度中立和醫療口譯員角色

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(1)國立臺灣師範大學翻譯研究所碩士論文 A Thesis Presented to the Graduate Institute of Translation and Interpretation National Taiwan Normal University. 指導教授：陳子瑋博士 Advisor: Dr. Tze-wei Chen. 同理心、態度中立和醫療口譯員角色 Empathy, Neutrality and Roles of Medical Interpreters. 研究生：廖婉如 Advisee: Wan-ju Liao. 中華民國一 0 二年七月 July 2013.

(2) Acknowledgment This thesis is dedicated to my parents, who have always supported and loved me unconditionally. Your encouragement and tolerance has helped me lead a fulfilling and meaningful life. My gratitude goes beyond any words or actions. Thank you so much! I would also like to express my sincere thanks to my thesis advisor, Dr. Tze-wei Chen, for your wisdom, patience and guidance. Thank you for all of your support and encouragement throughout this process, particularly given your hectic schedule! My heartfelt thanks also go to Dr. Li-fei Wang, who didn’t hesitate to assist with this thesis. I’m very grateful for your guidance and patience. Your contributions are much appreciated. Thank you, Dr. Jung-hui Yeh, for your kindness as a member of the thesis committee and for sharing your valuable comments. Special thanks go to Dr. Po-sen Liao for your guidance in format and structure of thesis writing. I would also like to thank Alice Chi and Michelle Fan for your generosity in sharing your experiences. Your contributions have added greatly to the depth of this work. To my dearest friend, Jessie Wu, thank you for sharing your professional opinions and giving me full support that helped me reach this point. Thank you, Shane Lin, for always being a good companion and supporter. I’ve been fortunate to have you and Jessie by my side during this journey. To Gina Chang, Ted Ho and Tasha Chang, thank you for being great friends and giving me valuable advice that helped me complete this work. Thank you, Mark McVicar, for your advice both as a professional and as a friend. I’ve learned a lot from you. I would also like to thank all of my fellow classmates at the NTNU’s Graduate Institute of Translation and Interpretation (GITI), particularly Tina Shih, Valeria Chen, Gina Kuo and Donna Hu, for working and learning together with me over the past several years. Finally, I would like to thank the teachers at GITI, particularly Damien Fan and Elma Ju, who have taught me so many things. To the administrative staff at GITI, thank you for helping answer my constant barrage of questions. My time here at GITI has been truly special and I am thankful to you all..

(3) Abstract This study aims to understand how empathy is demonstrated in medical interpreting and explain the inconsistent views of medical interpreting service users on different medical interpreters’ roles. Among the four roles adopted by medical interpreters, surveys on service users and interpreter’s codes of ethics show that some tasks taken by an advocate are regarded controversial while behaviors of a conduit, a clarifier and a culture broker are considered appropriate. Comparing settings, communicative skills and attitudes of neutrality between medical interpreters and empathizers, great similarities are identified. Based on the confirmation that medical interpreters empathize with service users, this study expands levels of expressed empathy and empathy cycle models in a monolingual two-way setting to a bilingual three-way setting. Published cases of medical interpreting are analyzed to find that:  Roles of conduit, clarifier and culture broker perform interpreting and express empathy while an advocate neither performs interpreting nor expresses empathy in most of the cases. Roles of conduit, clarifier and culture broker are thus neutral while an advocate is mostly not neutral;  A culture broker also empathizes with the receiver of the rendition and thus expresses advanced empathy with the speaker by making implicit culture. . factors explicit in rendition or domesticating the source utterance in the way the receiver is used to; A clarifier and a culture broker prioritize their tasks of communication facilitation over merely linguistic transformation like a conduit while an advocate values on defending service users’ rights or more often on expressing personal opinions.. Findings of this study can be utilized to provide a theoretical framework of roles for medical interpreters in practice. Medical interpreters therefore can have a clearer awareness of role switching, the possible negative consequences of adopting the non-neutral role and how to demonstrate empathy. In addition, to establish an independent organization of medical interpreting is suggested. The organization should be responsible for medical interpreters’ training and supervision, dispatch of medical interpreting services, mediation between interpreters and stakeholders of medical services when conflicts arise and so forth. Through this system, medical interpreters are more likely to maintain a neutral stance. In terms of training medical interpreters, results suggest that the content of training should include clear i.

(4) framework of roles, concept and skills of empathy, the demonstration of neutral attitudes and how to work with the organization. Key words: medical interpreting, roles of medical interpreters, empathy, neutrality. ii.

(5) 摘要本研究的目的有二：了解同理心如何融入醫療口譯，以及試圖解釋為何醫療口譯服務使用者對不同醫療口譯員的角色看法不同。本研究整理醫療口譯服務使用者對醫療口譯員的觀點調查和醫療口譯員的倫理守則，發現醫療口譯員的四種角色中，傳聲筒、澄清者、文化中介者的角色行為被視為恰當行為，倡議者的角色行為則有許多爭議。本研究假設這個現象和口譯員的態度中立與否有關，由於中立態度非常抽象，但剛好是同理心的必備條件，因此本研究用同理心理論來檢驗各個口譯員角色的態度，以驗證研究假設並達成第二個研究目的。同理心理論同時用以探討同理心融入醫療口譯的方法，並達成第一個研究目的。本研究比對醫療口譯和同理心，發現在情境、口譯員和同理者的溝通技巧與態度中立上有很多相似處，並由此驗證口譯員也有同理口譯服務使用者。本研究因此依據單語醫療情境中的同理心理論模型，加入雙語情境的特性，發展雙語醫療情境中的同理心理論模型，包括表達同理心模型和同理心環模型。用這些理論模型以及同理心的表達技巧檢驗各醫療口譯員角色的態度，研究結果發現： 1. 傳聲筒、澄清者、文化中介者都忠實翻譯使用者的語意，並表達對講者的同理心給聽者聽，但倡議者的多數角色行為既非翻譯，也沒有表達同理心。因此傳聲筒、澄清者、文化中介者的態度是中立的，而倡議者的態度多為不中立，此發現驗證本研究的假設。 2. 擔任文化中介者的醫療口譯員在翻譯講者的語意時，因為同理聽者和講者的文化差異，而表達對講者的高層次同理給聽者聽，亦即在譯文中顯化 (explicitation)講者未明確說出的文化意涵，或歸化(domestication)講者的表達至符合聽者文化背景的表達方式，以增進雙方對彼此的了解並協助溝通。 3. 傳聲筒角色只負責語言轉換，澄清者、文化中介者則認為協助溝通是他們的首要工作，倡議者則最重視捍衛醫療口譯服務者的權利或表達其個人意見。本研究提出醫療口譯員的角色架構，並強調同理心和態度中立的重要，應用至醫療口譯理論中，能幫助口譯員清楚覺察角色轉換、了解採取非中立角色行為可能的負面影響，並學習如何在醫療口譯中融入同理。本研究建議政府建立醫療口譯中介機構，由該機構負責培訓口譯員、提供口譯員諮詢、媒合口譯服務、協調服務使用者和口譯員的溝通、提供客訴服務…等，倡議者角色的非中立行為即可由該中介機構負責，讓口譯員的角色功能更一致。本研究結果亦可運用至口譯員訓練課程，幫助口譯員了解自己的角色及功能、同理心的概念與技巧、態度中立的重要，以及和中介機構的合作與角色分工。關鍵字：醫療口譯、醫療口譯員角色、同理心、態度中立 iii.

(6) Table of Contents Abstract ........................................................................................................................... i List of Tables ................................................................................................................vii List of Figures ............................................................................................................ viii. Chapter One－Introduction 1.1 Research Motivation and Purpose ................................................................... 1 1.2 Research Scope ................................................................................................ 2 1.3 Research Questions and Method ...................................................................... 3 1.4 Research Structure ........................................................................................... 3 1.5 Definition of Terminology ............................................................................... 4. Chapter Two－Medical Interpreting 2.1 What Is Interpreting? ....................................................................................... 8 2.1.1 Interpreting as a Process ....................................................................... 8 2.1.2 Categorization of Interpreting ............................................................. 10 2.1.2.1 Interpreting by Mode ............................................................... 10 2.1.2.2 Interpreting by Setting ............................................................. 12 2.2 Roles of Medical Interpreters......................................................................... 17 2.2.1 Conduit................................................................................................ 19 2.2.2 Clarifier ............................................................................................... 21 2.2.3 Culture Broker .................................................................................... 22 2.2.4 Advocate ............................................................................................. 25 2.2.5 Summary ............................................................................................. 27 2.3 Medical Interpreter’s Roles and Neutrality.................................................... 27 2.3.1 User-Centered ..................................................................................... 30 2.3.2 Preference Free ................................................................................... 31 2.3.3 Non-Judgmental .................................................................................. 32 2.4 Conclusion ..................................................................................................... 34. Chapter Three－Empathy 3.1 Introduction to Empathy ................................................................................ 37 3.2 Empathy as a Process ..................................................................................... 41 3.3 Basic Empathy and Advanced empathy......................................................... 43 iv.

(7) 3.4 Communicative Skills of Empathy ................................................................ 47 3.4.1 Attending and Active Listening .......................................................... 47 3.4.2 Paraphrasing ........................................................................................ 50 3.4.3 Emotional Reflection .......................................................................... 52 3.4.4 Therapeutic Interpretations ................................................................. 53 3.4.5 Summary ............................................................................................. 55 3.5 Empathy Cycle ............................................................................................... 57 3.6 Conclusion ..................................................................................................... 59. Chapter Four－Medical Interpreting and Empathy 4.1 Similarities between Medical Interpreting and Empathy............................... 63 4.1.1 Settings ................................................................................................ 63 4.1.2 Communicative Skills ......................................................................... 65 4.1.2.1 Active Listening ....................................................................... 66 4.1.2.2 Paraphrasing ............................................................................. 67 4.1.2.3 Therapeutic Interpretations vs. Explicitation and Domestication .............................................................................................................. 68 4.1.3 Neutrality ............................................................................................ 72 4.2 Expressed Empathy in Monolingual and Bilingual Medical Settings ........... 75 4.3 Empathic Process in Medical Interpreting ..................................................... 81. Chapter Five－Case Studies 5.1 Cases Categorization ...................................................................................... 87 5.1.1 Cases Collection.................................................................................. 88 5.1.2 Expert Analyses .................................................................................. 89 5.1.3 Expert Categorization and Results ...................................................... 90 5.1.4 Reliability and Validity ....................................................................... 92 5.1.5 Results Compilation ............................................................................ 93 5.2 Medical Interpreters’ Roles, Empathy and Neutrality ................................... 95 5.2.1 Conduit................................................................................................ 96 5.2.2 Clarifier ............................................................................................. 100 5.2.3 Culture Broker .................................................................................. 107 5.2.4 Advocate ........................................................................................... 114 5.3 Conclusion ................................................................................................... 126. v.

(8) Chapter Six－Conclusion and Implications 6.1 Research Findings and Implications to Theories ......................................... 132 6.1.1 Demonstration of Empathy in Medical Interpreting ......................... 132 6.1.2 Empathy Models in Medical Interpreting ......................................... 133 6.1.3 Neutrality of Medical Interpreters’ Roles ......................................... 133 6.2 Implications to System ................................................................................. 135 6.3 Implications to Training ............................................................................... 137 6.4 Limitations and Recommendations for Further Studies .............................. 138. Bibliography ......................................................................................................... 140 Appendix: Medical Interpreting Cases ....................................................... 146. vi.

(9) List of Tables Table 2.1 Differences between Community and Conference Interpreting ................... 14 Table 2.2 Neutrality in Medical Interpreting and Empathy ......................................... 30 Table 3.1 Differences between Empathy and Sympathy ............................................. 41 Table 3.2 Levels of Expressed Empathy ...................................................................... 46 Table 4.1 Levels of Expressed Empathy in Bilingual Medical Settings ...................... 80 Table 5.1 Collected Cases of Medical Interpreting ...................................................... 88 Table 5.2 Experts’ Categorization ................................................................................ 91 Table 5.3 Analyses Results of All Cases .................................................................... 127 Table 5.4 Empathic Understanding and Expressed Empathy of Neutral Roles ......... 129. vii.

(10) List of Figures Figure 1.1 Research Scope ............................................................................................. 2 Figure 2.1 Different Types of Interpreting and Medical Interpreters’ Roles ............... 35 Figure 3.1 Schematic Outline of the Empathy Cycle .................................................. 59 Figure 3.2 Empathy Cycle, Levels and Communicative Skills ................................... 62 Figure 4.1 Process of Expressed Empathy in Monolingual Medical Settings ............. 75 Figure 4.2 Process of Expressed Empathy in Bilingual Medical Settings ................... 76 Figure 4.3 Interpreters’ Empathic Process in Bilingual Medical Settings ................... 85 Figure 5.1 Study Process of Cases Categorization ...................................................... 87 Figure 5.2 The Medical Interpreter’s Empathic Process of Case 9………………......97 Figure 5.3 The Medical Interpreter’s Empathic Process of Case 19 ......................... 103 Figure 5.4 The Medical Interpreter’s Empathic Process of Case 23 ......................... 109 Figure 5.5 The Medical Interpreter’s Empathic Process of Case 11 .......................... 120 Figure 5.6 The Framework of Roles of Medical Interpreters .................................... 128. viii.

(11) Chapter One Introduction 1.1 Research Motivation and Purpose This study is motivated by the interest in empathy, which has been said to be relevant to medical interpreting (Gentile et al., 1996; Hale, 2007). Nevertheless, there has been no in depth discussion about the reasoning behind this relevance and how to demonstrate empathy in medical interpreting. Empathy and medical interpreting literature share similar vocabulary but the interactions among these terms are not clear. If they use similar terms, can the two topics be integrated and may be reinforce the theoretical foundation of each other? For example, neutrality, an important factor that is influential to medical interpreting (Wadensjö, 1998; Hale, 2007; Roat, 2011), is a term used in both topics (VandenBos, 2007; Wadensjö, 2009); however, it is unclear whether neutrality refers to the same meaning in the two topics. Another motivation is that different roles the medical interpreters play are mentioned (Pöchhacker, 2000; Roy, 1993/2002) but no systematic analysis has been conducted to investigate how the roles relate to each other. If a theoretical foundation can be established, can it be applied to categorize roles that are mentioned in the literature? To sum up, the motivation of this study is to clarify the relevance between empathy and medical interpreting with interpreters’ roles being the sub-category. This study is also motivated to understand how neutrality relates to these two topics. The purpose of this study is thus to identify the similarities between empathy and medical interpreting so to understand how empathy can be incorporated into the process of medical interpreting. In addition, this study also aims to explore how different medical interpreters’ roles demonstrate empathy and neutrality in the hope of having a clearer understanding of the differences among these roles. The ultimate goal is to propose a systematic framework of these roles as the theory foundation of 1.

(12) medical interpreters’ appropriate level of involvement.. 1.2 Research Scope Empathy. Medical Interpreting. Empathic Understanding Role. Language. Communicative Empathy. Figure 1.1 Research Scope Source: compiled by this study. The scope of this research is empathy demonstrated under the setting of medical interpreting. Empathy is a concept that can be applied to various contexts (Gladstein, 1983; Duan & Hill, 1996). It is widely used in psychotherapy (Rogers, 1975; Egan, 1975,1998) and contains several components in the process (Truax & Carkhuff, 1967; Barrett-Lennard, 1981,1993). In this study, only the parts that are related to a mediated bilingual setting will be studied. On the other hand, medical interpreting refers to interpreter-mediated medical conversations between the healthcare provider and the patient (Hale, 2007). There are studies focusing on various aspects of medical interpreting. For example, medical interpreters’ roles, job satisfaction, training, credentials, quality of interpreting (Fan, 2011), etc. This study aims to investigate how empathy is demonstrated when a medical interpreter assumes different roles. Therefore, certain aspects of medical interpreting, such as issues of language, power structure and service quality, will not be discussed. The research scope is visualized as Figure 1.1. 2.

(13) 1.3 Research Questions and Method Based on the research motivations and scope mentioned in previous sections, the research questions are compiled as the following: 1. Can empathy theory be applied to medical interpreting? If yes, how empathy is demonstrated in medical interpreting? 2. What are the empathy models in the context of medical interpreting? 3. Can neutrality distinguish appropriate roles of medical interpreters from the controversial one? The method adopted to answer the first question is to compare the similarities between empathy and medical interpreting, which gives a clear picture of how to incorporate empathy in medical interpreting. To find the answer for the second question, two-party empathic interaction is compared with three-party communication. Empathic models in medical interpreting are developed based on the two-party empathic process model (Carkhuff, 1969; Barrett-Lennard, 1993). Answer to the third question is found through case studies by examining the neutral attitudes of different medical interpreters’ roles with empathic theories and models in medical interpreting.. 1.4 Research Structure Subsequent to this introductory chapter, Chapter Two reviews the literatures concerning the essence and categorization of interpreting as well as the roles and neutral attitudes of medical interpreters. Chapter Three reviews the literatures related to the essence, process and communicative skills of empathy. In Chapter Four, similarities between medical interpreting and empathy are identified. It is followed by the development of empathic models in medical interpreting. These models as well as communicative skills of empathy are used in Chapter Five to examine medical interpreting cases performed by different roles. Chapter Six sums up the answers to 3.

(14) the research questions and discuss the implications of these findings to the field of medical interpreting in theory, system and training. Research limitations and recommendations for further studies are also given.. 1.5 Definition of Terminology Due to that it is a pioneering study applying empathic theories to medical interpreting, definitions of terminologies are compiled in this section for readers to have an overview in advance. The section that explores a certain terminology in detail is also given in brackets for readers’ reference. . Interpreting: To deliver the speaker’s meanings to the addressee in another language (Hale, 2007). [Section 2.1.1]. . Medical interpreting: It is a communicative event that takes place in private practice and healthcare institutions and participated by the healthcare provider, the patient and the medical interpreter (Hale, 2007). [Section 2.1.2.2] . Narrow-sense of interpreting: The rendition that is based simply on primary parties’ explicitly expressed utterances. [Section 2.4]. . Broad-sense of interpreting: Medical interpreters make clarifications or include primary parties’ explicitly and implicitly expressed utterances, such as unclear messages and social background of the primary parties, in the rendition. [Section 2.4]. . Non-interpreting: Expressions that are not based on the source information given by the primary parties and are delivered without the presence of both primary parties. [Section 2.4]. . Role: It is a social position performing certain behavior patterns that are subject to expectations held by participants within the context (Borgatta & Montgomery, 2000). [Section 2.2] 4.

(15) . Conduit: A role that converts verbal and non-verbal information into another language faithfully, accurately, without omission, addition and edition. [Section 2.2.1 & Section 5.1.5]. . Clarifier: A role that facilitates primary parties’ mutual understanding of non-cultural related factors and alerts primary parties of possible misunderstanding. [Section 2.2.2 & Section 5.1.5]. . Culture broker: A role that bridges the culture gap between primary parties to facilitate level of understanding. [Section 2.2.3 & Section 5.1.5]. . Advocate: A role that acts on behalf of a user, provider or patient, for his/her benefits and rights either within or outside of medical encounters. [Section 2.2.4 & Section 5.1.5]. . Empathy: To accurately perceive another person’s internal meanings and feelings as if one were the person, but without losing one’s awareness that the meanings and emotions belong to the other (Rogers, 1959). Then this perception is communicated back to the other without prejudice to check one’s accuracy of the understanding (Rogers, 1975). [Section 3.2] . Empathy Cycle: The process of empathy involves five steps, Empathic Setting, Empathic Resonation, Expressed Empathy, Received Empathy and Feedback (Barrett-Lennard, 1981, 1993). [Section 3.5]. . Basic empathy: One of the levels of Expressed Empathy indicating that what person B expresses is interchangeable in meaning and feeling with what person A responses (Carkhuff, 1969). [Section 3.3]. . Advanced empathy: One of the levels of Expressed Empathy indicating that implicit and deeper meanings and feelings in person B’s expressions are added to person A’s responses (Carkhuff, 1969). [Section 3.3] Person B’s implicit meanings and affect can be derived from his/her verbal and 5.

(16) non-verbal information as well as context, such as cultural expectations, register and education background. (Hill, 2009). [Section 3.4.4] . Communicative skills adopted in empathy and medical interpreting: . Active listening: A concentrating state of mind (Gentile et al., 1996; Egan, 1998) to grasp the meaning of and connections in the other person’s expressions (Jones, 1998; Hill, 2009). [Section 3.4.1 & Section 4.1.2.1]. . Paraphrasing: To rephrase the other’s meanings in one’s own words without alteration of meaning (Robinson, 1998; Smaby & Maddux, 2011). It is adopted to demonstrate basic empathy (Huang, 1991). [Section 3.4.2 & Section 4.1.2.2]. . Emotional reflection: To rephrase the other’s feelings derived from his/her verbal and non-verbal information as well as the context (Hill, 2009). It is adopted to demonstrate basic empathy (Huang, 1991). [Section 3.4.3]. . Therapeutic interpretations: Give new meanings or explanations to the other’s experiences based on the other’s past experience, culture and so forth (Hill, 2009). It is adopted to demonstrate advanced empathy (Huang, 1991). [Section 3.4.4 & Section 4.1.2.3]. . Explicitation: To explain the implicit meanings in the source utterance explicitly in the target utterance (Klaudy, 2009). [Section 4.1.2.3]. . Domestication: To render the source language in a way the receptor of target language is used to (Munday, 2008). [Section 4.1.2.3]. . Neutrality: It is demonstrated by user-centered, preference free and non-judgmental attitudes (VandenBos, 2007; Hornby, 2010) to all service users. [Section 2.3 & Section 4.1.3] . User-centered attitude: No suggestions are given by the neutral person and thus the client’s autonomy is respected. [Section 2.3 & Section 4.1.3] 6.

(17) . Preference free attitude: The neutral person does not imply agreement or side with any of the participating parties in a communicative activity. [Section 2.3 & Section 4.1.3]. . Non-judgmental attitude: The neutral person expresses neither judgments nor prejudice and is emotionally detached. [Section 2.3 & Section 4.1.3]. 7.

(18) Chapter Two Medical Interpreting. 2.1 What Is Interpreting? 2.1.1 Interpreting as a Process Interpreting is resulted from language varieties and the demand for communication between speakers of different languages throughout the history; it is therefore one of the oldest forms of human communication (Gentile et al., 1996). The goal of interpreting is that the message expressed by the speaker creates same influence on an audience whose mother tongue is either the same as or different from the speaker’s (Angelelli, 2000). For a long time, interpreting had been considered a branch of translational activities (Hale, 2007). Practitioners later create a distinction between translation and interpreting, in which interpreter converts oral messages while translator converts written texts from one language to another (AIIC, 2012). The immediacy of interpreting is one of the major features that makes it different from translation (Pöchhacker, 2004). Interpreters are demanded to immediately comprehend and analyze the oral message that is presented only once “without the opportunity to consult references…or correct and edit their final product” (Hale, 2007, p.8). The communication between the participants – speakers, addressees and interpreters – is also immediate in contrast to the indirect contact between the author and reader of a written text (AIIC, 2012). According to Hale (2007), various scholars define interpreting from different perspectives, but the general principle is to mediate the transformation of speaker’s message to addressee in another language. The relation between source/input and target/output language is often described as equivalence; however, there have been 8.

(19) different arguments about levels of faithfulness to the source utterance, ranging from literal rendition to interpreting the meaning of the source utterance. The denotation of the word “interpreter” in Latin, referring to the person explains the meaning or facilitates others’ understanding of the things they find difficult (Pöchhacker, 2004), supports the idea that it is the meaning instead of form equivalence between input and output utterances. Interpreter’s professional organization, International Association of Conference Interpreters (AIIC, 2005) also states that interpreting is neither word-for-word or verbatim conversion nor parroting, but meaning transformation. In addition, recognized by the field of interpreting as one of the influential theories (Angelelli, 2000), Seleskovitch (1978) proposed that interpreting is a process in which interpreter comprehends and produces the “sense” of source utterance. The process involves three stages: perception, comprehension, and expression. At the stage of comprehension, interpreters de-verbalize the source text to understand the sense. “Sense” is “(1) “conscious”, (2) “made up of the linguistic meaning aroused by speech sounds and of a cognitive addition to it,” and (3) “nonverbal”, that is, dissociated from any linguistic form in cognitive memory” (Seleskovitch, 1978b; cited from Pöchhacker, 2004, p.97). To understand the sense, she emphasized the importance to relate the meaning of source utterance with “background knowledge, familiarity with the speaker, the topic, and the purpose for delivering the message” (Roy, 1993/2002, p.348). Other prominent scholars provide explanations of the knowledge that interpreters access to in performing accurate interpreting. Moser-Mercer (1997/2002), based on information processing theory, compiled the knowledge being stored in and extracted from interpreter’s long-term memory to short-term working memory during interpreting, including phonologic, syntactic, semantic, contextual and general knowledge. Hale (2007) highlighted the importance of the contextual knowledge such 9.

(20) as intention behind the source utterance and cross-cultural differences. The role of both long- and short-term memory is therefore crucial to interpreter’s work.. 2.1.2 Categorization of Interpreting Alexieva (1997/2002) categorized currently existing parameters of interpreting into two broad headings: mode and elements of the communicative situation. Mode distinguishes consecutive interpreting from simultaneous interpreting while elements of communication refer to participants (with speaker and addressee as the primary parties and interpreter as the secondary party), topic, communicative goal and so forth. In this study, her demarcation is adopted and the elements are preserved but the heading of “elements of the communicative situation” is replaced by “setting”. The scope of setting is therefore expanded to include not only the place where interpreting takes place, but also other elements involved during the process of interpreting.. 2.1.2.1 Interpreting by Mode Simultaneous interpreting (SI) and consecutive interpreting (CI) are two basic working modes of interpreting (Gentile et al., 1996). The distinction between the two occurred only in the 1920s when the development of ancillary equipment, such as headphones and microphones, made simultaneous interpreting possible (Pöchhacker, 2004). The major difference between SI and CI is the time when interpreters start to render (Kelly, 2008). CI “entails waiting for the speaker to complete a speech or a segment thereof before the interpreting begins” whereas SI “entails starting the interpretation soon after the speaker begins and continuing until just after the speaker has finished” (Gentile et al., 1996, p.22). In addition, according to Alexieva (1997/2002), the continuous delivery of source and target utterances in SI makes 10.

(21) interactions between the primary parties as well as between primary parties and interpreter indirect, which in turn leads to a more formal and less culturally noticeable type of communication. On the contrary, CI is a direct and face-to-face interaction in which speaker, addressee and interpreter are present in the same room. Furthermore, Pöchhacker (2004) said that interpreters demonstrating CI of longer speeches usually adopt note-taking skills whereas the skills are less used in SI. However, using note-taking skills is labeled as ‘classic’ consecutive, in comparison to “short CI” without notes. The length of the segments of short CI can be considerable but is generally shorter than classic CI (Gentile et al., 1996). It is usually adopted in dialogic mode in community interpreting, which will be given more elaboration in the next section. Referring these features to medical interpreting, the communication between healthcare provider, patient and interpreter is direct, face-to-face, in dialogic form and short segments. Medical interpreter adopts short CI mode to perform rendition. On the other hand, whispering and sight translation are two special types of SI (Pöchhacker, 2004). Whispering is adopted when ancillary equipment is not at hand. In contrast to rendering for large international audience through SI mode, interpreter working in whispering sits right next to one or a few number of addressees so his/her rendition could be heard (Alexieva, 1997/2002). This working mode is sometimes used in medical encounters (Hale, 2007). In terms of sight translation, or sight interpreting as a more correct name, the interpreter renders simultaneously with the reception of the source text in written instead of audio form. This type of interpreting service could be provided either to a large group of audience with the aid of ancillary equipment in a simultaneous mode or to a small group of people in a consecutive mode (Pöchhacker, 2004). According to Roat (2011), medical interpreters sometimes are required to assist sight interpreting of the documents provided by the healthcare institutions for patients to read, fill in or bring home. The purposes of this service are 11.

(22) to make sure that patients have ample information to decide their treatment plans and at the same time protect the healthcare institutions if unexpected negative result takes place. Since these documents and consent forms are legally binding, interpreters should render everything written on the document.. 2.1.2.2 Interpreting by Setting Interpreting, according to Pöchhacker (2004), takes place when people with different background in language and culture communicate for certain goal in inter-social or international settings. Interpreter-mediated communication also occurs in intra-social settings where diverse ethnic groups of people live within one country. Pöchhacker analyzes the features of interactions in inter- and intra-social settings and categorizes these features into different types of interpreting: conference and community interpreting, which as Hale (2007) said is the major classification in the field of interpreting. Conference interpreting service has been applied to international meetings after World War II the Nuremberg war crimes trials, in which technology development enabled interpreters to work in sound-proof booths and conduct simultaneous interpreting with ancillary equipment (Gentile et al., 1996). On the other hand, community interpreting has only become the center of focus after 1980s when the interpreting service demand rises in public-sector institutions under the background of immigration (Pöchhacker, 2004). It often takes place “at police departments, immigration departments, social welfare centers, medical and mental health offices, schools and other institutions” (Wadensjö, 2009, p.43). The goals of conference and community interpreting are as follows: Conference interpreting aims to facilitate addressees of a communicative activity to comprehend a speaker whereas community interpreters help people obtain social services in public institutions (Kelly, 2008). 12.

(23) Apart from differences in places and goals, Gentile et al. (1996) also mentioned factors that distinguish community interpreting from conference interpreting, such as that a community interpreter renders into both language directions, works by him/herself rather than with a partner in a dialogue with participants often having different social status. The status difference can also be manifested in different linguistic varieties and registers. Moreover, Hale (2007) highlighted the importance of accurate rendition and negative consequences of inaccuracy. Differences of community and conference interpreting are compiled as Table 2.1. Since medical interpreting is one of the major domains under community interpreting (Pöchhacker, 2004), more elaboration of community interpreting will be given. Community interpreting is a three-party interaction, with the bilingual interpreter being the secondary party (Alexieva, 1997/2002) to mediate communication between two monolingual primary parties speaking different languages (Pöchhacker, 2004). Each primary party may consist of an individual or more people (Gentile et al., 1996). According to Alexieva (1997/2002), communication in community interpreting is composed of instinctive, extemporized utterances and personal issues, the intensity of direct interaction between three parties – speaker, addressee and interpreter – is therefore high. In addition, the roles of speaker and addressee are adopted by different primary parties in turn (Gentile et al., 1996). As a result, each party pays close attention to the content and manner of speech of other participants, such as facial and body language (Alexieva, 1997/2002). To work on the message instead of language, the interpreter needs to empathize with the primary parties in turn at each exchange (Gentile et al., 1996).. 13.

(24) Table 2.1 Differences between Community and Conference Interpreting Community Interpreting. Conference Interpreting. Language Directionality. Bidirectional/dialogic. Mostly unidirectional. Form of Communication. Face-to-face. One-to-many. Output Language. Equal amount of work into both languages. Most of the work into one language (interpreter’s A language, generally). Linguistic Varieties. Maximum potential for. Minimum potential for. linguistic varieties of the same code (in both languages). linguistic varieties of the same code (in only one language, the speaker’s). Maximum potential for. Minimum potential for. different registers. different registers. (formal, in general). Consequences of Inaccurate Rendition. High. Medium. Level of Accuracy Required. High. Medium. Backgrounds and Status of Service Users. Maximum potential for different backgrounds and status between the parties. Minimum potential for different backgrounds and status between the parties. Interpreter’s Control over the Flow. Possibility of controlling the traffic flow. Less likely to control the speaker. Number of Interpreters. One (working alone). Two (working as a team). Social Status of Interpreters. Community interpreting remains a low-status profession and have low. Interpreters is recognized a high-status profession and therefore enjoy high levels. levels of remuneration. of remuneration. Register. Source: compiled by this study from Gentile et al. (1996), Angelelli (2000), Hale (2007), Pöchhacker (2004), Wadensjö (2009). The size of the participants and the dialogic form of communication make community interpreters have opportunities to ask the speaker to repeat a segment that 14.

(25) they have not heard clearly or understood comprehensively (Gentile et al., 1996). They may also ask for explanation and clarification (Angelelli, 2000) or point out when they think there has been a misunderstanding (Hale, 2007). As a mediator who shares cultural background with at least one of the primary parties, community interpreter is more likely to discover how differences between primary parties, such as social status and background as listed in Table 2.1, affect the communication (Angelelli, 2000). A great amount of studies therefore suggest that community interpreters should assume broader roles with greater involvement in the communication, comparing to the role of conference interpreter as a conduit, which is only responsible for linguistic transformation (Pöchhacker, 2004). However, community interpreters are demanded to perform “a high level of neutrality and detachment” (Wadensjö, 2009, p.44). While studies show that community interpreters should adopt broader roles, it is also interpreter’s duty not to involve to the extent that may weaken professional performance (Gentile et al., 1996). Professional community interpreters and trainers of community interpreting have diverse opinions about the roles and proper level of involvement of community interpreters; therefore, debate about interpreters’ neutrality and detachment has been one of the major issues of the field (Wadensjö, 2009). More exploration of issues related to roles and neutrality is given in the following sections. Within studies of community interpreting, medical interpreting and legal interpreting are the two major domains (Pöchhacker, 2004). Features of community interpreting mentioned in the previous section are consequently applicable to both. Issues of neutrality and detachment are also the center of debate. Although there is much in common between medical and legal interpreting, such as principles of impartiality, fidelity and confidentiality are emphasized and the consequences of communication in these settings affect clients’ lives, there are also 15.

(26) significant differences in the practice of medical and legal interpreters (Hale, 2007). According to Hale (2007), medical interpreting takes place in “private practice, hospital settings and consultations with other health care professionals” (p.36) and is participated by healthcare provides, patients and an interpreter. On the other hand, compiled by Gamal (2009), legal interpreting takes place mainly in courtrooms, sometimes in police sections, attorneys’ chambers, customs and immigration offices with legal professionals, clients and interpreter(s) as participants. Hale (2007) also mentioned that although the expressions used in these settings are important to both medical and legal interpreting because they may impact the result, the intentions behind the expressions in both settings are different. Medical consultations are not adversarial so physicians ask questions to gain information that facilitates them to help the patient. However, the courtroom is adversarial and lawyers tend to ask questions to draw forth the answers they want to support the case. In addition, patients are allowed to ask questions at any time in medical encounters while only lawyers can initiate questions in the courtroom. Finally, since medical consultation is a private and informal setting, rather than a public setting that is governed by strict rules of evidence as in the courtroom, the demand for neutrality is less apparent. However, there is yet consensus on this point. The private and informal setting of medical encounters where the healthcare provider’s goal of communication is to express clearly and be understood by the patient makes it possible for medical interpreters to assume tasks taken by non-conduit roles (Hale, 2007). Kaufert & Putsch (1997) argued that unlike legal interpreting, major disparities in cultural background often occur in medical interpreting. In order to enhance mutual understanding between primary parties, medical interpreters are required to “engage in explanations, culture brokerage and mediation when these actions are necessary” (P.75). Hsieh (2006) also observed that 16.

(27) medical interpreters take actions intending to manage interactions between healthcare provider and patient. Roles of interpreters are therefore important issues in studies of medical interpreting. In addition, empathy has been found to be relevant to successful medical encounters. Hale (2007) said that successful communication in medical setting is relevant to attentive and empathetic listening to the patient, not only to his/her verbal expressions but also to the non-verbal responses (Vasquez & Javier, 1991). Harres (1998) also observed that providers use tag questions to express empathy with the patient. Reynolds and Scott (1999) found that research evidence supports empathy being crucial to a helping relationship and thus argued for applying empathy to clinical nursing. They offer operational definition of empathy in the setting which is to accurately perceive patient’s world and communicate this understanding to the patient. Moreover, since the outcome of the medical consultation depends highly on the rapport between physician and patient (Tebble, 1999) while empathy produces supportive communication and develop relationship (Redmond, 1989), it can be argued that empathy is vital to successful medical communication. However, there have been no in depth discussions about how to demonstrate empathy in medical interpreting yet. One of the goals of this study is therefore about the ways of incorporating the concept and skills of empathy into medical interpreting.. 2.2 Roles of Medical Interpreters Role of community interpreters has been one of the most prominent topics in interpreting studies (Pöchhacker, 2004), particularly on the expanding roles other than conduit (Avery, 2001). Diverse names are given to describe medical interpreter’s roles, such as “clarifier, explainer, cultural mediator, helpmate or agent” compiled in Pöchhacker’s study (2000, p.65), communication facilitator, linguistic intermediary, 17.

(28) bilingual and bicultural communicator in Roy’s study (1993/2002), leading to confusion in their definitions, duties and consequences of conducting a certain role (Hale, 2007). Based on the approximation between source and target utterance (Roy, 1993/2002), Avery (2001) proposed an incremental intervention model to compare roles, “ranging from the least intrusive role of conduit, to clarifier, to culture broker…and finally, to the most intrusive role of advocate” (p.9). Since this study will touch upon the issue of interpreter’s involvement in the communication in section 2.3 and Avery has provided a preliminary model that distinguishes interpreter’s level of involvement of each role, this study therefore adopts his way of classification and compiles descriptions related to those four different roles in this section to give a clearer shape of each role. In addition, medical interpreting service users’ expectations and medical interpreter’s codes of ethics are reviewed to understand better their perspectives on the acceptability and appropriateness of the behaviors performed by each role. In sociology, role refers to a social position performing certain behavior patterns that are subject to expectations held by participants within the context (Borgatta & Montgomery, 2000). Many studies have demonstrated that interpreter is an active co-participant of medical encounters (Roy, 1993/2002; Wadensjö, 1998; Angelelli, 2004; Hsieh, 2007). Therefore, the appropriateness of medical interpreter’s behaviors is shaped by expectations of healthcare provider (or “provider” in short), patient and interpreter. Surveys on primary parties’ expectations are cited in this section, so are community interpreter’s codes of ethics, which is the embodiment of working interpreters’ collective expectations and regulations of proper behaviors (NCIHC, 2004).. 18.

(29) 2.2.1 Conduit Adopting a conduit role implies that the medical interpreter bridges healthcare provider and patient who speak different languages (Hale, 2007), that facilitates them to communicate in a way that is similar to interaction in monolingual settings (Avery, 2001). Interpreters are required to reproduce the source utterance faithfully, accurately and completely in the rendition (Dysart-Gale, 2005). No addition, omission or editing is allowed (Avery, 2001). These requirements originate from the key assumptions behind conduit model of communication: “there is underlying objective knowledge in the world that has universal applicability; language can be a medium for representing objective knowledge and words have fixed meaning; human beings can achieve universality of understanding since fixed meanings of words can be communicated objectively from one person to another” (Boland & Tenkasi, 1995, p.354). The conduit role restrains the medical interpreters’ duties from going beyond language transformation (Avery, 2001). Interpreter’s codes of ethics and surveys on users’ expectations both reflect the emphasis on accurate rendition. In National Code of Ethics for Interpreters in Health Care developed by the National Council on Interpreting in Health Care (NCIHC) in the US, accurate rendition is highlighted as the second principle after confidentiality. On the other hand, Hale’s (2007) survey conducted in Sydney, Australia found that accurate rendition is considered the medical interpreters’ most important duty (50% of the responding doctors). To interpret accurately refers to convey both verbal and non-verbal information of speaker’s expression faithfully. To be able to deliver speaker’s verbal information, interpreter’s language proficiency in source and target languages is the primary expectation (96%) of provider and patient toward interpreter (Mesa, 2000). Background knowledge of health issues, such as formality of service and professional jargon, is also considered vital to interpreting by provider (Hale, 19.

(30) 2007) and patient (Alexander et al., 2004). On the other hand, “the manner of speech is just as important as the content of the speech” (Hale, 2007, p.152). The NCIHC National Code of Ethics (2004) suggested that “gestures, body language, and tone of voice… add significantly to the content of message” (p.13). Other non-verbal information, such as patient’s talking speed, change in emotion and illogical expressions, is expected to be expressed in the rendition particularly by psychiatrists as critical clues of diagnosis and treatment (Roat, 2011). There are consequences when accuracy is compromised. Mesa (2000), conducting survey on healthcare workers in Quebec, said that they attribute the difficulties of making accurate assessment and diagnosis with medical interpreter’s addition, omission and alteration in meaning of the source language. From clinician’s perspective, Vasquez and Javier (1991) also mentioned that these behaviors are mistakes which may detain clinicians’ crucial interventions and put patients’ life in danger. Proponents of faithful interpreting, which is different from verbatim rendition, argue that this approach yields many advantages to both primary parties. First, it empowers patients by facilitating them to access all information and make decisions on their own (Hale, 2007). Patients’ participation of deciding their treatment plans ensures their compliance with the treatment (Mesa, 2000). Second, language and ways of expression used by the provider to build relationship with the patient could be delivered, which affects outcomes of the encounter significantly (NCIHC, 2004). Third, provider can control the effectiveness of communication (Hale, 2007). Finally, it keeps the focus of communication on patient-provider interaction (Roat, 2011). However, the conduit model is seriously challenged on its assumption of passively conveying meanings and limitation to language transformation. Rather than drawing out meanings that are already embedded in the sentences, Wilcox and Shaffer 20.

(31) (2005) argued that interpreters actively form the speakers’ meaning according to their verbal and non-verbal expressions. Many prominent scholars also challenge the idea of interpreter being “invisible” (Angelelli, 2004). Interpreters’ visibility refers to that they ”influence the process and content of the provider-patient interactions” (Hsieh, 2007, p.925) and they, at the same time, are influenced by the interaction of social elements within the context. These scholars argue that interpreters conduct tasks more than rendering the speaker’s explicit expressions and thus are visible (Angelelli, 2004). In addition, Avery (2001), Kaufert and Putsch (1997) argued that accurate rendition requires more than linguistic transformation, cultural and institutional contexts are also critical. Furthermore, an alienated attitude adopted by conduit in apparently ineffectual or offensive interactions is criticized “as unacceptable and as morally and legally irresponsible” (Avery, 2001, p.9). These arguments lead to expanding roles other than conduit in the medical setting.. 2.2.2 Clarifier Avery (2001) gave no clear description of the role of a clarifier when the term was first coined. Dysart-Gale (2005) based on Avery’s study and depicted a clarifier as a role “in which the interpreter departs from the conduit model in cases of linguistic incommensurability” (p.94). Niska (2000), on the other hand, said that a clarifier illustrates technical or cultural related concepts for the receptor of target language to have a better understanding. Since there is no unified definition of a clarifier, this study refers the definition of “clarification” to the American Heritage Dictionary of the English Language (2000) as: “To make clear or easier to understand…To clear of confusion or uncertainty…” (p.342) and argues that a clarifier is the interpreter’s role of facilitating primary parties’ mutual understanding of non-cultural related factors and alerts primary parties if there is misunderstanding. 21.

(32) According to Angelelli (2004), interpreter’s adoption of these tasks is influential to the communication and the interpreter is thus visible. Clarifier is different from a culture broker who makes clarification by explaining cultural facts. The role of a culture broker will be discussed later in the next section. The importance of a clarifier’s tasks is recognized by provider, patient and interpreter. In Pöchhacker’s (2000) study, 88% of the responding providers and 100% of the responding interpreters surveyed said that “clarifying indeterminate statements by immediate follow-up questions to the client” (p.58) is part of the interpreter’s tasks. In addition, 97% of the responding patients in Mesa’s (2000) survey expected interpreters to facilitate them comprehending the situation. Hale (2007) who reviewed seven community interpreting codes of ethics also concluded that codes speak for interpreters to ask for clarification when it is necessary. In terms of alerting misunderstanding, 92% of the responding providers in Mesa’s (2000) survey, 96% in Pöchhacker’s (2000) and 65% in Hale’s (2007) found that providers would like interpreters to tell them when interpreters think the patient does not understand or there is misunderstanding in the conversation. Pöchhacker’s (2000) survey also shows that 94% of the responding spoken-language interpreters consider this task as part of their responsibilities. Therefore, interpreter adopting role of clarifier conforms to users’ expectations and interpreter’s perception of his/her profession.. 2.2.3 Culture Broker Since the end of the 1970s, cultural sensitivity has been highlighted as an important factor affecting cross-cultural communication (Roy, 1993/2002). In medical interpreting, “culture influences the meaning given to symptoms, the diagnosis of those symptoms, the expectations regarding the course of the related disease or illness, the desirability and efficacy of treatments or remedies, and the prognosis” (NCIHC, 22.

(33) 2004, p.9). In addition, to interpret accurately, knowledge of culture is critical to understand the hidden or unstated meaning as part of the total experience of speaker (Avery, 2001). Before healthcare providers are fully aware of cultural differences, they rely on interpreters to provide such assistance. In fact, it has been observed that many inter-cultural healthcare services in the US, Canada and Europe have allowed interpreter’s role of culture broker (Kaufert & Putsch, 1997). Assuming role of culture broker demonstrates that interpreters influence and are influenced by social factors; interpreters are therefore visible (Angelelli, 2004). The concept “culture” used here is referred to social science as “all that in human society which is socially rather than biological transmitted…Culture is thus a general term for the symbolic and learned aspects of human society” (Scott & Marshall, 2009, p.152). As a result, social class, sex, schooling (Avery, 2001), language, ways of verbal and non-verbal expression (Roy, 1993/2002) and so forth are all included under the umbrella term of culture. Cultural differences are considered obstructions of communication in medical encounters (Avery, 2001). Primary parties and medical interpreters all recognize the importance of supplementing cultural information in the encounter. Surveys on healthcare workers found that 78% of the respondents in Quebec (Mesa, 2000) think respecting for patient’s values and beliefs is very important while 62% of respondents in Vienna (Pöchhacker, 2000) expect that interpreters illustrate foreign culture for them. In terms of addressing difficult communication resulting mainly from class and education differences, Pöchhacker (2000) found that 87% of providers expect interpreters to explain professional jargon and make their inner meanings more explicit to the patients. Mesa (2000) also discovered that 98% of the patients expect the interpreter to speak in terms and expressions that they can easily comprehend. When asking interpreters, they attached a significant level of importance to simplification and 23.

(34) explanation of technical expressions (75%) and illustration of foreign culture (81%) (Pöchhacker, 2000). These results support that medical interpreters are expected to adopt strategies of explicitation and domestication as a culture broker during interpreting service, which will be given more elaboration in Chapter Four. Studies have indicated that taking the role of culture broker by medical interpreter is beneficiary to both of the primary parties as well as medical institutions. With the facilitation of cross cultural communication by interpreters, the explicit meanings of both primary parties can be shared and thus increase the possibility of faithful interpreting (Avery, 2001; Kelly, 2008). Primary parties’ mutual understanding creates a good layer of foundation that enable providers to make a treatment plan that conforms to patient’s cultural background (Mesa, 2000); patient’s compliance to and the effectiveness of the plan are therefore enhanced (Kaufert & Putsch, 1997). Furthermore, Kaufert and Putsch (1997) argued that clear illustrations of the healthcare system and patients’ rights in ways that conform to health service users’ cultural background would improve health education. However, medical interpreters should constantly remind themselves to respect for individual differences and to be aware of possible consequence of stereotyping. According to Kelly (2008), role of culture broker should only be adopted when it is indispensable. When in situations that interpreters have to temporarily stop the flow of communication and alert both parties the cultural facts, they should bear in mind that even they seem to share the same language and culture with one of the parties, their differences may still exist because of other social factors. Therefore, interpreters should avoid inference that their perceptive cultural knowledge is applicable to all people of a certain cultural community, such as people in the same race, gender or citizenship. Cautious checkups of an individual’s culture norms are necessary (NCIHC, 2004). 24.

(35) 2.2.4 Advocate Definitions and descriptions of an advocate have been significantly confusing. Niska (2000) defined that an advocate’s service extends to settings other than mediated medical encounters and takes actions on behalf of patients to help them deal with cases such as healthcare institutions’ bureaucracy or discrimination. Roat (2011) further clarified that the role of an advocate, who is no longer a mediator, is adopted only when one of the primary parties is incapable of communicating his/her needs. On the other hand, Avery (2001) argued for a conditioned advocate who gives information about medical or other services, but acts directly on behalf of either primary party is forbidden. However, Hsieh (2008) observed that some interpreters as an advocate “have sought information, provided answers and requested services for a patient without consulting the patient” (p.1373). These behaviors overlap with Roy’s (1993/2002) description of a helper, who “offer advice… and make decisions for one or both sides” (p.349). Though these definitions vary widely, the common point of view is that interpreter acts more than linguistic transformation as a conduit and is therefore visible. Another similarity between these descriptions is interpreters’ argument that they act on behalf of users, either provider or patient, for their benefits and rights, such as quality of care or patient’s well-being. While acting on behalf of users’ benefits seems to “justify” a wide range of an advocate’s behaviors, not all the actions taken by an advocate are considered appropriate by service users. Pöchhacker (2000) discovered that providers oppose interpreter’s omission to primary parities expressions with the intention of saving time. Although an advocate may be well-intentioned to enhance the efficiency of communication, making decision on what to interpret or leave out on behalf of the primary parties erodes provider’s trust on interpreter (Hale, 2007). Interpreters have conversations with one of the parties and exclude the other is also unappreciated 25.

(36) (Roat, 2011); for example, suggest the patient to raise question if he/she has trouble understanding the provider without informing the provider about this suggestion (Hale, 2007). To use what interpreter wants to ask to substitute for primary parties’ questions is even regarded as a mistake of interpreters by clinicians (Vasquez & Javier, 1991). On the other hand, there are cases when primary parties expect interpreter to act on behalf of them, such as making a diagnosis on behalf of the provider (Hsieh, 2007) or when the patient asking the interpreter to teach him/her the right ways to ask for the service and information they want (Hsieh, 2008). There is no congruent point of view toward the appropriateness of advocate in code of ethics as well. After reviewing seven community interpreting codes of ethics, Hale (2007) concluded that the codes support interpreters to make clarifications, to supplement cross-cultural references or to sight interpret documents and forms given by the healthcare institutions, but do not approve of interpreters being an advocate. On the other hand, the code of ethics proposed by NCIHC (2004) argued for conditioned advocate. If it is very likely that one or both of the primary parties may face significant negative consequences and actions taken by other less intrusive roles cannot solve the problem, it is the interpreter’s duty to advocate on behalf of them. Consulting with a supervisor is suggested before taking any action to advocate. Roat (2011) also supported the idea of conditioned advocate, but she added other criteria including service users’ will for the interpreter to advocate on their behalf and approval of advocating by the agency and the institution that employ the interpreter. From the literature reviewed above, it is shown that current controversy is not about total rejection or acceptance of advocate, but the incoherence of views between provider, patient and interpreter on appropriate behaviors of advocate. Not every action taken by the advocate is considered appropriate by primary parties and not everything primary parties expect an advocate to do is regarded appropriate by 26.

(37) interpreters. A unitary criterion that can integrate both sides of perceptions and distinguish the appropriateness of advocate’s behaviors is required.. 2.2.5 Summary The involvement of interpreter in the medical encounter extends from least involved role of a conduit, to a clarifier, then a culture broker and lastly an advocate (Avery, 2001). The descriptions of each role are compiled as follows: . Conduit: converts verbal and non-verbal information into another language faithfully, accurately, without omission, addition and edition.. . Clarifier: facilitates primary parties’ mutual understanding of non-cultural related factors and alerts primary parties of possible misunderstanding.. . Culture broker: bridges the culture gap between primary parties to facilitate level of understanding.. . Advocate: acts on behalf of a user, provider or patient, for his/her benefits and rights either within or outside of medical encounters. Surveys on users’ expectation and interpreters’ codes of ethics show that roles of. conduit, clarifier and culture broker are considered appropriate while an advocate is controversial. However, the criterion that can distinguish interpreter’s proper involvement from improper intervention is still missing (Roy, 1993/2002). This study therefore aims to propose a criterion that can explain the inconsistent views on medical interpreters’ roles.. 2.3 Medical Interpreter’s Roles and Neutrality Conduit, the role that involves in the mediated communication the least in Avery’s (2001) incremental intervention model, “requires the interpreter to perform in a neutral, faithful, and machine-like manner” (Hsieh, 2006, p.721). Roy 27.

(38) (1993/2002) listed interpreter’s non-neutral behaviors, including “to introduce topics, change topics, ask questions of their own, interject their opinion or give advice” (p.347), which covers the tasks of all non-conduit roles. In addition, Kaufert & Putsch (1997) argued that interpreters should adopt non-neutral roles such as culture broker or advocate. These arguments show that a conduit is the only role being described neutral. Non-conduit roles that take purposeful actions other than faithfully interpreting the primary parties’ explicitly expressed utterances are not neutral. In other words, these studies consider making judgments on what actions to take and supplementing information other than primary parties’ explicit message are non-neutral behaviors. However, other studies accept non-neutral non-conduit roles such as clarifier and culture broker based upon user expectations and interpreter’s codes of ethics while an advocate is considered controversial. Why non-neutral roles are viewed differently? What does neutrality mean? In Oxford Advanced Lerner’s Dictionary of Current English (2010), the word “neutral” means “not supporting or helping either side in a disagreement, competitions, etc…deliberately not expressing any strong feeling…” (p.1027). In APA Dictionary of Psychology (2007), neutrality refers to a manner of behavior adopted by the therapist who “does not express judgments of right and wrong or suggest what is proper behavior on the part of the client” (p.629). These definitions show that neutrality includes three attitudes: user-centered, preference free and non-judgmental. User-centered attitude refers to that no suggestions are given by the neutral person and thus the client’s autonomy is respected. Preference free attitude means that the neutral person does not side with any of the participating parties in a communicative activity while non-judgmental attitude indicates that the person expresses no judgments. Deliberately not to express any strong feeling or emotional detachment is also mentioned in the definition of neutrality at the beginning of this paragraph. This 28.

(39) concept is included in non-judgmental attitude in this study because it facilitates the neutral person not to express judgments. More explorations of these three attitudes will be given in the sub-sections of this section. In addition, all of these attitudes have to be demonstrated in one interaction so that the communicator can be neutral. The reason is that he/she cannot abandon one of the attitudes without violating the other. For example, it is impossible for a communicator to be judgmental on the user while putting the user at the center. The communicator can neither side with the user without making judgments on the user and his/her experience. Moreover, in three-party communicative activities like medical interpreting, interpreters holding the three attitudes of neutrality toward one of the primary parties is not neutral. Instead, whether the interpreter is neutral or not is dependent on holding these attitudes toward both of the parties. All of the attitudes mentioned above are major conditions of empathy (Wispé ,1986), as will be illustrated in Table 3.1. It is therefore argued that empathizers are neutral. In Chapter Three, it will also be elaborated that deciding how to express empathy (Egan, 1975) or making the other person’s implicit message explicit is regarded as empathy (Carkhuff, 1969). These behaviors are thus argued to be neutral, which is different from the point of view in studies of medical interpreting as mentioned at the beginning of this section. The difference can be visualized as Table 2.2. While non-neutrality refers to making judgments on the other or his/her experience in studies of empathy (VandenBos, 2007), it is used to describe an interpreter who takes any action other than what the primary parties explicitly express in studies of medical interpreting. In other words, non-neutrality in medical interpreter studies indicates a broader scope of actions than the scope indicated in studies of empathy.. 29.

(40) Table 2.2 Neutrality in Medical Interpreting and Empathy Difference. Express Service User’s Explicit Message. Express Service User’s Implicit Message. Medical Interpreting. Neutral. Non-Neutral. Empathy. Neutral. Neutral. Topic. Source: compiled by this study. This study adopts the definition of neutrality in empathic theories and argues that neutrality, referring to the three attitudes mentioned above, can explain the inconsistent views on medical interpreters’ roles. In other words, it is argued that roles of conduit, clarifier and culture broker are neutral while an advocate is not. Since neutral attitudes are essential conditions of empathy (Wispé ,1986), empathy theories are adopted to examine each role’s neutrality. If the role expresses empathy with service user(s), it demonstrates neutral attitudes. More elaboration will be given in section 4.1.3. In the rest of the section, more studies of interpreting related to attitudes of user-centered, preference free and non-judgmental are elaborated. These attitudes will be used to compare with attitudes of empathizers in Chapter Four.. 2.3.1 User-Centered Avery (2001) argued that interpreters should be granted to interfere in the communication when misunderstandings may take place, but he also emphasized that interpreters should “stay in the background and to support communication and relationship building directly between patient and provider” (p.9). Choosing the least intrusive role that is already able to overcome communicative barriers is recognized as a major principle. Codes of ethics also affirm the centrality of primary parties 30.

(41) (NCIHC, 2004; Dysart-Gale, 2005). Since interpreters are secondary instead of primary party (Alexieva, 1997/2002), it is inappropriate for them to take over the interaction. Alexander et al. (2004) found that patients do not want their interpreter to his/her personal interests in front of theirs. Mesa’s (2000) survey also showed that providers expect interpreters not to take over their place. Vasquez and Javier (1991) even viewed interpreters assuming the role of primary parties as mistakes, such as replacing provider’s questions with their own and answering patient’s questions directly. According to Hale (2007), these actions exclude primary parties from making decision for themselves and hinder accurate diagnosis. The effectiveness of patient’s treatment plans is also decreased because these behaviors have been identified as the contributors that minimize patients’ compliance to the plans. Primary parties’ autonomy is respected when they are placed in the focus of communication. Though Avery (2001) supported interpreter’s involvement when necessary, he argued that primary parties are “the ultimate resolution of the encounter” (p.9). They have the right to speak for and make decisions for themselves (NCIHC, 2004). Mesa’s (2000) survey on patients also found that 95% of the respondents expect interpreters to respect their values and beliefs. As a result, interpreters are not in a position to make decisions, give advice, counsel or persuade either party.. 2.3.2 Preference Free Interpreters are expected to treat both primary parties equally instead of taking sides (Kelly, 2008). In Mesa’s (2000) survey, healthcare providers expressed their concerns that if patient’s family members or acquaintances assist interpreting, their interests may surpass the importance of faithful rendition. However, it is found that when provider and patient have conflicts, some interpreters take the side with 31.