Beyond Boundaries column, The Psychologist, March 2009

Cultural sensitivity may not be enough because madness does not speak a universal language. We assume that words are but tools to express the inner turbulence of mental illness but a growing literature documents the fact that hallucinations and delusions can be language specific. In a landmark study, psychiatrist R.E. Hempill reported on 30 multilingual South African patients, all diagnosed with schizophrenia, who heard auditory hallucinations in only one or some of their languages. More surprising was a case where the patient had extensive delusions when speaking one language but was insightful and non-psychotic when speaking another. Although pioneering, the 1971 study now makes for uncomfortable reading. As a self-described study of “White and Coloured schizophrenic patients”, it is dusted with the language of apartheid South Africa and clearly demonstrates that cultural and linguistic sensitivity are not nearly the same.

In more enlightened times, a 2004 case series by De Zulueta and colleagues reported on three bilingual patients who were formally assessed in both languages by the same researcher. All three were found to report language-specific psychotic symptoms, two seemed emotionally more insightful in one language rather than the other, and one patient was a higher suicide risk – but only when speaking Portuguese rather than English. Contrary to what we might expect, the native language was not always the tongue in which powerful experiences were more readily apparent. In a wide ranging review published in 2008, psychologist Michel Paradis quotes studies suggesting that there may be a linguistic effect across the range of neuropsychiatric disorders, although curiously, psychosis seems the most likely to be differentially expressed.

The implications of these studies are clearly spelt out by the authors. Cultural sensitivity is necessary but not sufficient to address the mental health needs of people who regularly speak more than one language and who make up the majority of the world’s population. In multi-cultural Britain, these studies also question our reliance on interpreters as ‘universal translators’ through which we assume we can do our work adequately, even if it is not as well as we would like. It is clear that translators are still an essential service, but for bilingual clients we really need bilingual psychologists, because we may be missing and misunderstanding the experiences of the people we meet if we rely on only one channel of communication. We assume psychologists will be gifted communicators but it may be time to include the appreciation of another language as part of our development.