Unfortunately, I have had many a patient disclose to me that healthcare professionals, including interpreters have made disparaging remarks or not interpreted in an impartial fashion. Most recently I recall an LGBT patient admitting that an interpreter called their lifestyle sinful and treated them with disdain for the remainder of the encounter. It goes without saying, instances like this should not happen, but the fact remains that they do. Furthermore, such instances are not limited to the LGBT community. Any patient can experience such judgment as the result of the personal biases of any member of their healthcare team, and it can have especially serious consequences for the LEP (limited English proficient) patient.
The Effect of Bias is Compounded with LEPs
It’s no secret that it can be extremely isolating being unable to speak the primary language of the country you live in, and many patients of mine self-report that they feel like they are (more often than not) treated as “lesser” because of this and/or their racial background. It would be rare to find an LEP patient who hasn’t experienced a sense of “otherness” or not belonging, for a variety of reasons beyond their inability to express themselves proficiently in English. While the patients I work with are no strangers to judgment, they are not immune to it, and this can deepen the trauma they have experienced or are currently experiencing. Any show of bias could prevent the patient from opening up during an encounter, cause them to lose trust in interpreters, or exacerbate any issues they already have.
Someone once shared with me a story about an interpreter assisting them in filling out paperwork. The interpreter performed a sight translation of the form, and when it came to race and ethnic background, the interpreter asked if the patient was an “indio” or “Indian” although the patient did not understand this to be one of the options on the form. In English, Indian is generally considered to be varying levels of offensive and incorrect way to refer to indigenous peoples. In Mexico, “indio” is a far more derogatory term, typically used as a classist insult, and the patient corrected the interpreter, insisting that their background was not “indio” but rather “indígena” or indigenous. According to the patient, the interpreter chuckled and told them they both meant the same thing, then proceeded to make an insensitive joke towards indigenous folks. This was certainly an overt and egregious display of bias, and the patient took it very personally. As a result, the patient disclosed that they limited their communication during the encounter with the interpreter because they felt terribly uncomfortable. What sort of health consequences could this lack of disclosure during a healthcare encounter have for this patient?
Bias: Implicit and Explicit
Not all expressions of bias are quite as overt or explicit as the example given above; however, the smallest grimace, hesitation, or lack of kindness can still have a lasting effect on members of the LEP patient population. It’s not uncommon for a patient to say they “felt like” an interpreter was being biased or judgmental, their proof being something as simple as a sidelong glance. Regardless of whether or not the patient accurately read the interpreter’s intentions or the presence of bias, the fact is that our job as an interpreter is to facilitate communication, and that ability can be impeded by even the bias our patients only perceive.
I’m going to share an embarrassing story. I grew up in a very rural area in Virginia and I developed a lot of questionable opinions regarding race. While I have worked long and hard to unlearn many of the racist things that were normal to me growing up, it’s important to keep in mind that unlearning racism is an ongoing process and we all operate on racial assumptions, whether we want to or not. About 7 years ago, I began working at a pharmacy in a predominantly African-American neighborhood and I felt that I was a finished product– that I had unlearned all the ugly things that were instilled into me during my youth growing up in the country. Yet, I could not for the life of me understand why our white customers treated me fairly well, but our black customers really didn’t like me. I assumed it was because I was the only white person working there during night shift because they treated the rest of my coworkers well.
One day I brought up this (what was to me) apparent disparity in customer interactions with a coworker of mine who was African American. She suggested that maybe, just maybe, the customers really didn’t have an issue with me, but rather I had an issue with them. I was floored and my face turned bright red. My knee-jerk reaction was to respond that I was the victim in this situation. For Pete’s sake, I was working as a cashier, night shift, at barely above minimum wage in a pharmacy in the big city and it was anything but a cake walk! The old me would have stopped there, completely discounting my coworker and insisting that I was the one falling victim to prejudice. But I trusted her opinion and understood the importance of listening to others when I haven’t walked a mile in their shoes.
I decided to make a conscious effort to be more mindful of and purposeful in my interactions with our black customers. In no time at all my coworker’s suspicions were confirmed, much to my surprise. In being hyper-conscious of my facial expressions and interactions, I discovered that I would unconsciously smile more often with non-black customers. This was combined with the fact that my normal, supposedly expressionless face is anything but relaxed and resembles a more serious or even slightly annoyed expression (colloquially referred to as RBF). It wasn’t that I was actually angry or displeased with black customers, but it certainly came off that way and our interactions were affected by it, setting off a negative feedback loop that made me smile even less and made our black customers dislike me even more. It never occurred to me that I was still carrying the weight of some of those biases from my upbringing.
I decided from that point forward to make some changes. I listened more, I read more, I learned more, and I had to be brutally and uncomfortably honest with myself. I continued working at the pharmacy, surrounded by my black coworkers who were patient enough to carry out the labor of teaching me about the realities of their lives that I was once blind to every day. I was fortunate enough to have classes in college taught by African American and Afro-Latino professors who really opened my eyes to a lot of things I had no clue about. I read books, blogs, articles, and op-eds by black authors who shed light on points of view that I had never entertained. Most importantly, I did and continue doing all this not to be a performative ally, but rather to grow out of empathy and understanding and move forward.
Everyone is Biased
If you are reading this article and you think it doesn’t apply to you, I would like to point out that not a single person in this world is exempt from being biased. I thought I had progressed enough, that I was a finished product, and could not fathom that I was succumbing to, for lack of a better word, microaggressions towards African Americans. I was.
So what does this mean for the biases we know we have? If biases we don’t know or acknowledge we have can still manifest in such a way, how might biases we are fully aware we have manifest unintentionally in an interpreting encounter? I posit that if we have biases, it is not only important to be aware of them, but also to actively work towards eradicating them in order to strive towards impartiality as an interpreter. Otherwise, I firmly believe we are doing a great disservice to the population we serve.
The Interpreter Bias Self-Assessment
I highly encourage interpreters to go through what would simply be a self-assessment of personal biases. I’ve organized it into a succinct list with explanations for each step, as well as an example assessment I’ve done myself. I encourage you to go through each and every bias you identify and repeat the steps. If this seems like a lot of work, you’re correct. Self-improvement is difficult, but it’s necessary not only for the people we serve but for ourselves as well. Oftentimes the root causes of bias can be as a result of trauma and it can be therapeutic to work through them. If you have a therapist or even just a friendly ear, it may be helpful to share after some thoughtful self-reflection.
1. What Are Your Biases?
It’s helpful when examining your own biases to think of the patient population you serve as an interpreter. What are the sorts of cases you deal with? Examining biases can be far more difficult if you are an independent contractor as you likely interpret in a variety of environments. Common cases that awaken bias can touch on: substance use, sex work, abuse, gang affiliation, ethnic/racial background, gender expression and identity, immigration status, sexual orientation, or mental/behavioral health disorders. These are only a sampling of some of the subjects that can touch a nerve and expose our biases. In addition, nothing is neat and tidy and cases can often touch upon more than one of these areas.
This is really a two-part question because often when answering you begin to explain the sources of your biases. Was it a traumatic event that caused you to feel this way? Could it be your upbringing? Is there a religious motivation behind why you feel this way? In my earlier example, I had to stop and ask myself, “Why was I smiling less with black customers?” It’s an ugly question, but one I had to ask myself, nonetheless.
My father is a recovering alcoholic and his alcoholism has had a profound effect on my family. I am fully cognizant that this is a huge source of bias for me.
2. What are some possible consequences of holding these biases?
Consequences of biases are not always the result of a conscious decision; however, sometimes we can be so moved by our own strong opinions to act in an unprofessional manner. Is there a particular emotion that your bias makes you feel? How might that emotion manifest in an interpreting encounter? How might it prevent you from interpreting accurately and completely?
I could see my father in a patient and I could possibly get angry or impatient with them. Instead of being impartial, I may feel like I have an emotional involvement in an interpreting encounter with an alcoholic patient. I may be dismissive of an alcoholic patient’s needs or downplay them unintentionally because of a lack of empathy towards them.
3. What can you do or are you currently doing to overcome these biases?
Now that you see that your biases can have consequences, how can you overcome them? Sometimes, biases come from a lack of understanding or empathy. Can you put yourself in someone else’s shoes? Would you be able to meet with an individual or a group that may be able to heighten your understanding? Maybe it has nothing to do with anyone else, but the understanding needs to be channeled towards the self. Would therapy be helpful? The possibilities are endless and you may need to come back to this later, or think about it over multiple sessions.
If I haven’t convinced you to be open to this step by this point, I can’t really do much more. Even if you think your biases aren’t something that need to be resolved or worked on, at least try.
I tried Al-Anon once but it really wasn’t for me because most of the attendees were elderly. Perhaps I could try attending Al-Anon again at a different location where there are people more my age. I have been very supportive of one of my best friends who is in recovery from their drinking and this has been very cathartic and eye-opening for me.
4. If you cannot overcome your biases, what strategies can you use to reduce their potential consequences?
You may not be ready to deal with your biases. Perhaps the source of your opinion or how you feel is still there and it seems impossible to feel or think any other way. Maybe you’ve tried many times before to see things from a different perspective and haven’t made any progress. I’m not here to tell you that that’s okay, but I am here to tell you that it is your responsibility as an interpreter to make sure your biases are not allowed to affect your impartiality and professionalism as an interpreter.
Is there a way to avoid interpreting for people who you will be biased against? Are you a staff interpreter who can call or switch out with another interpreter, or are you an independent contractor? Do you have a colleague who is willing to sub in for you at a moment’s notice if a situation arises where your biases would impact your ability to do your job? All of these things are your responsibility to your patients so they can get the care that they need.
It’s difficult for me to avoid patients with alcohol dependence because I rarely have a diagnosis when I walk into an appointment. If I do end up on an assignment with an alcoholic patient and believe I will not be able to be impartial, I have many contacts who I could reach out to who would be able to take my place. Furthermore, I can always contact the interpreting agency and report a conflict of interest.
Our job as interpreters is not to open up old wounds or to create new ones. Needing an interpreter, LEP patients have one more wild card in the room while being seen at healthcare facilities. We may be able to step into a patient advocate role when necessary, but we are limited in our capacity to mitigate biases coming from other sources in the room. All we can do is focus on making ourselves the best we can be. This has become far more of a personal post than I had originally intended, but our own biases often are very raw and personal. Ultimately we must be able to effectively put our biases on mute (which is an incredibly difficult, if not wholly impossible skill to possess) or overcome our biases to the best of our ability.