Frame of Reference

Frame of Reference

Can diagnoses depend on your doctor’s mother tongue?

My  passion for the nuances of language has deep roots in who I am as a  person. I study intercultural communication: it’s about how people from  different cultures interact with each other. About how compatible their  communications are, and what happens when they aren’t.

The real moment things fell in place for me, however, can be traced to a single story a lecturer told in my second year.

It was about bilingual people. Being diagnosed by a doctor. The results were different depending on which language they used.


When  I started university, I took a course called General Linguistics. The  course is cold, clinical and objective; I always thought about it as the  maths of languages. Grammar calculus, if you will. I hated it.

But  the next year, I was able to take a class called Applied English  Language Studies, and that class illuminated my path in life. Applied  linguistics is all about how people use language.  About teaching and assessing and translating, and how people learn a  second language, or even many at once; about speech therapy, language  policy, and more.

If  General Linguistics was languages caged and categorised in a zoo, then  Applied Linguistics was actually seeing those languages in the wild. I  was fascinated.


My  lecturer had been to a local mental-health hospital. She was doing  studies in schizophrenia, the condition including things like false  beliefs, confused thinking, and seeing things that aren’t really there.

But  this time, the focus was a bit different from what you might expect.  Since this was Applied Linguistics, my lecturer was looking at  “schizophrenia presentation in first and second languages”. That means  seeing how people with schizophrenia display their symptoms, and how it  shows up differently when using the mother tongue versus a language that  was learned later.

She  went on to tell us about an interview where the patient showed very few  symptoms in their first language, while presenting far more in their  second language. The patient even seemed unaware of their diagnosis in  their second language but discussed how the medication was helping in  their first!

Now,  I have a feeling that this lecturer may have been excited to tell us  something so interesting and embellished slightly. But there are  definite, proven connections between schizophrenia diagnoses and the  language of the doctor, patient and interview.


For  those of you who are unaware of how psychiatrists diagnose, they use  the Diagnostic and Statistical Manual of Mental Disorders, or DSM for  short.
The most recent version is the DSM-5, published in 2013, lists  five categories of symptoms for schizophrenia. Don’t try hard to  remember them all, but here they are:

  1. delusions: believing something that’s obviously false
  2. hallucinations: seeing, hearing, or otherwise sensing something that’s obviously not there
  3. disorganized speech: jumping across topics, spewing a “word salad” of random words, or otherwise “messy” speech
  4. grossly disorganized or catatonic behavior: being too physically rigid, or too flexible, or too sluggish, or too something else that shouldn’t be happening
  5. negative symptoms:  behaviours that are conspicuous in their absence, like not showing  feelings, not enjoying things, or not doing something else that most  people normally would

To  be diagnosed with schizophrenia, the patients should have at least one  symptom from the first three categories, and one more from anywhere in  the list.


There  have been thousands of studies on schizophrenia over the years, with  many of them focusing on language and language use. However, very few  have focused on non-native speakers of a language: people using a  language that they didn’t grow up speaking.

The  study that really stood out to me was published in 1973. I won’t bore  you with the technical details, but the basic idea is that patients  answered recorded questions. They did this twice: once in Spanish, their  home language, and then once in English, which they had learnt later.

Multiple  psychiatrists — both English and Spanish — listened to the answers. And  then, they rated these patients using the tools at their disposal.

The results of this study blew me away.


On  the most basic level, the doctors totaled up the pathology (think  indicative symptoms) for each language. Look at the graph below: the  black lines are how much each patient was graded for the English  interview, and the white for the Spanish.

As  you can see in the figure, all of the patients were scored considerably  higher in English. In other words, when interviewed in English the  patients were judged to be demonstrating more pathology: they were  either showing more symptoms, or those symptoms were deemed to be more  severe.


Why  did the patients’ symptoms seem more prominent when interviewed in  their second language? There are several possible reasons.

To start with: although they did their best to control it, perhaps there was some sort of prejudice from the raters.

Or  maybe the patients themselves are the cause: people suffering from  schizophrenia often find it difficult to describe their experiences  anyway, and they may have reached a point in this experiment where they  just tensed up further and gave up.

And, there’s a third option. Maybe the interviewers’ frame of reference for the world was not the same as the patients.


One  of the (many) linguistic indicators for depression in a native-English  speaker is taking longer pauses. If they keep pausing for too long, it’s  possibly because they’re depressed.

But  some languages use longer pauses than English and this could very well  carry over to their second language. People also naturally use longer  pauses when they’re not confident in a language, because they are  planning their speech or trying to think of the right words.

Speakers  of different languages could have different frames of reference:  different ideas of what’s normal, or, in this case, of how long a  “normal” pause should be.

But  here’s the thing: interviewers and doctors have frames of reference  too. And their frame of reference will influence how the pauses are  interpreted. Are these people really depressed? Or are they just used to  a language where pauses are longer?


I  want you to take a moment and think about the patients throughout  history who have been interviewed and diagnosed in their second  language. How many were misdiagnosed? How many would never find the  correct medication dosage? How many were lobotomized?

And that’s just for schizophrenia.

How  many sick people have not been able to get the treatment they need  because of a language barrier and the assumptions that come with it?


If  you have one, think about your second language. Sure, you might be able  to get by day-to-day: order a meal, get directions, chat with a friend.  But now imagine you are ill, you are anxious and you are sitting in a  room with a doctor, a doctor who wants detailed descriptions of what  you’re going through, a doctor who uses technical language and expects  some of the same from you, a doctor who does all of this in your second  language.

And  that’s all it takes. To put yourself in someone else’s shoes. Take a  moment and think about a person you have met that you thought was dumb,  uneducated, rude, untrustworthy.

Sometimes,  those gut reactions from you have to do with intercultural  communication. Norwegians have longer pauses in their native tongue that  carry to their English, English speakers believe Norwegians to be  ‘stupid’ or not fluent.

A  young Zulu boy is taught that not looking his elders in the eye is  respectful, his English teacher thinks he’s lying when he says he did  his homework but won’t look at her.

A  Chinese business man follows his cultural norms of saying no to second  helpings several times before he accepts, his German business partner  thinks he doesn’t like the food.


Intercultural communication is vital to us living peacefully, and it doesn’t just have to be between different languages.

Think  about how you speak and act in your country, your area, your town, even  your own family! Being aware of how you communicate, and that it might  be different from other people, could make your interactions smoother  and more enjoyable.

But  importantly, carry that awareness over to people you meet. The next  time you meet someone who won’t make eye contact, or laughs too loud or  is brusque, don’t jump into assuming negative things about them.

Instead, start by asking yourself if perhaps they’re just different.


Want to write with us? To diversify our content, we’re looking out for new authors to write at Snipette. That means you! Aspiring writers: we’ll help you shape your piece. Established writers: Click here to get started.

Curious for more? Sources and references for this article can be found here.