Saturday, 1 August 2009

Lost in Translation

Over the last few years our comparatively quiet rural town has experienced an influx of workers from the European Community. They have come in distinct waves. First it was the Portuguese, who found that they could earn enough in a few years in this country from seasonal work on the land and factory work processing food and vegetables to return to Portugal and buy their own farm. Then there was an influx of Eastern Europeans with similar ideas – in particular, Poles, Latvians and Lithuanians (often, it seems, graduates prepared to do menial work for more money than they could earn in their own countries following their professions, or young people wanting to make enough money to return to their home country and go to university). Best estimates put the current population of non English speaking EU nationals in the town as 10-15%.

This understandably creates problems when assessing people under the Mental Health Act: not only do you have to find an interpreter as well as two doctors, but you then have to make judgments as to the mental state of someone at another remove, trusting the interpreter to give an accurate translation of the patient’s answers, and then trying to assess whether these responses constitute evidence of mental disorder. An interpreter shaking their head and telling you that the patient is “speaking nonsense” is not good enough: you need to know what kind of nonsense they are speaking. It’s like trying read a book while wearing boxing gloves.

On this particular occasion I actually encountered the problem before I received the referral. Looking out of the window of the CMHT, I saw a teenage girl sitting on the pavement while a much older man and woman whom I took to be her parents attempted to persuade her to get into a car. She resisted entreaties and threats, lashing out at them with her fists if they got too close. Eventually she was persuaded to get into the car, which then sped off.

Not long after, the girl’s GP rang up. Benedita was Portuguese. Her parents had brought her to the surgery. The GP had seen her with an interpreter, and was concerned by her agitated, aggressive and irrational behaviour. Back in Portugal she had been under a psychiatrist and had been prescribed antipsychotic medication. The parents had a letter (in Portuguese, of course) from the psychiatric services there giving a diagnosis of “polymorphic psychotic disorder”. Could I assess her under the MHA?

I decided to make at least a preliminary assessment while the interpreter was available (the surgery had so many Portuguese patients that they even had an interpreter on their staff). Within a few minutes I was at the GP surgery, accompanied by one of the Community Psychiatric Nurses from my team.

The interview was even more complicated than I was expecting. Benedita was not only Portuguese, she was also born without hearing. She communicated with her mother through a combination of idiosyncratic Portuguese and her own form of sign language which only her mother understood. We therefore had to give questions to her mother, who would then communicate with Benedita with a bewildering combination of speech and signing. Benedita would then use speech and signing to answer, her mother would tell the interpreter what she had said, and the interpreter would then translate it into English for my benefit.

Ideally, we would have involved an interpreter with a knowledge of sign language (but that would have added yet another layer of potential confusion) and a psychiatrist with knowledge of the effects of hearing impairment on mental health (but the nearest was 100 miles away). So we decided this was the best assessment we were going to manage in the circumstances.

Through this convoluted means we managed to obtain some idea of her mental state. We gathered that Benedita knew she was going to die. The reason for this was that her cousin had taken some pictures of her, but was not allowed to. And this was all because the Chemistry teacher in her home town in Portugal had told her to go to the toilet, when everyone knows she has to hold on or else. From time to time, without provocation, she would suddenly attack her father, striking him over the head, which judging by his resigned acquiescence he was probably accustomed to.

We thought she probably was psychotic. The GP had already prescribed appropriate medication, but she had not yet taken it. We thought that would be a good idea. We also thought a tranquilliser would be a good idea in the short term, in order to reduce her agitation. We watched as her mother persuaded Benedita to take the medication. She gradually calmed down.

I was unhappy about admitting her to hospital. They wouldn’t be equipped to properly assess her, Benedita would be unable to communicate her needs and would become even more distressed, and she would probably end up being heavily sedated. She needed to stay with her mother if possible. But how were we to keep Benedita and her family safe and ensure she had the care and treatment she needed?

Her parents told the interpreter that they had been thinking about a trip back to Portugal. This seemed like a very good idea. She could be seen by her Portuguese psychiatrist who could then decide what to do next. Although a little ragged around the edges, I felt that this was an acceptable alternative means of providing the care and treatment Benedita required (Para 4.4 Code of Practice of course).

So her mother booked a flight for herself and Benedita, and they returned to Portugal a few days later. Sometimes the expedient option is also the best (or at any rate the least worst).

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