Effective Communication for Displaced Persons

Original Editor - Donald John Auson & Jordan Awale as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson, Admin, Vidya Acharya and Stacy Schiurring  

Introduction

Effective and respectful communication is central to working with displaced persons. Communication is the process of exchanging information, ideas and thoughts between two or more individuals. It can be verbal and non-verbal. Effective communication is important as it can provide the basis for building good interpersonal relationship.

In health care settings, effective communication can create a more effective therapeutic setting, thus leading to improved outcomes and the attainment of goals. It can be achieved with various communication skills and techniques. The ability to communicate is a key to providing effective rehabilitation services. A treatment session is a joint project between the therapist and the client, and it is essential to have something in common to do something together. Establishing common ground is therefore essential. Rehabilitation services are typically completed over a period of time, which provides a unique opportunity to establish this common ground. Although communication can be one-directional, like listening to the radio, or the rehabilitation professional telling the patient what “to do”, we understand communication as an active process where messages are exchanged between two or more individuals. The concept of “effective communication” covers the ability to listen, as well as interact with clients based on a mutual understanding, which is essential for culturally sensitive care. Communication in rehabilitation is an ongoing process between the rehabilitation professional and clients who have experience of displacement.

Many displaced persons may end up in an area where they speak a different language or a different dialect. This can make establishing communication a challenge. Communication and the difficulties that arise due to language barriers are prominent and recurring themes in research. Language barriers can lead to negative health outcomes, decreased adherence to treatment plans or a patient’s unwillingness to participate in rehabilitation treatment. A recent study by BBC Media Action examined the needs of displaced persons in relation to communication and access to information, as well as the challenges humanitarian agencies face when it comes to providing for the needs of displaced persons. The study highlighted that communication should not only provide information, but that displaced persons must be listened to, and able to tell their stories and participate in dialogue that provides them with physical, social and psychosocial support and trauma counselling. Rehabilitation professionals need strong, culturally competent communication skills to ensure that appropriate care is provided to their patients. Communication efforts should also take into account diversity. Diverse methods of formal and informal communication can help overcome barriers to effective communication with displaced persons.

Key Considerations

At the Beginning of an Interaction

Trust is a key factor when it comes to communicating with displaced persons and can be both a catalyst or a barrier to establishing communication. Trust is defined by the Merriam-Webster Dictionary as “assured reliance on the character, ability, strength, or truth of someone or something”. Having trust in health care workers involves reliance on the capabilities and competence of the staff, even with the existence of uncertainties and without assurance. At the beginning of all interactions, it is key that rehabilitation professionals try to make the individual or group feel comfortable in order to build this trust and create an environment where they feel safe to communicate and share information.

Creating a Therapeutic Space and Alliance

Creating a therapeutic space when working with displaced persons can be challenging because of communication barriers, cultural differences and other factors. However, these challenges can be overcome within the health care setting through the use of a wide range of strategies, including the use of interpretation and translation services, cultural mediation with appropriate adaptation of health information and materials, and guidance and training for health staff.

First create an environment that fosters trust, safety and respect. The environment should also encourage participation of the patient in creating goals as this has been shown to lead to better outcomes. Adjust the physical space to create a positive environment that ensures privacy. The encounter between rehabilitation professionals and displaced persons typically starts in a therapy room. Although the therapeutic room varies based on circumstances, the situation and setting becomes a sociocultural space. In essence, it is the therapist’s home ground. The environment has the potential to create disparity, as the professional is “at home” while the care seeker is “visiting". Further, the therapist represents authority, and challenging authority might be uncommon and scary for the patient. It is important to be aware that tacit and unwritten rules such as these and others represent barriers for culturally sensitive communication and could influence the rehabilitation process. These barriers need to be overcome to balance the relationship between the therapist and patient. Simple strategies such as the removal of physical barriers between you and the displaced person, such as desks or computers, may be beneficial in order to demonstrate that you are equal.

Secondly, actively create a relaxed atmosphere to foster a relationship of trust and respect. Something as simple as greeting them in their language can provide a positive start to the interaction, while still maintaining a high level of professionalism:

• Clarify your role when you first contact the client.
• Introduce any other participants, such as interpreters at the beginning and explain why they are present.
• Ensure the patient knows that they are free to take a break at any point if they need to.
• Be realistic and specific when discussing what help you can offer.
• Focus on establishing rapport. It may take a number of sessions to identify the real issue.
• Don’t assume you understand the client’s problem - clarify it with them.

Ensure Confidentiality

Consent and confidentiality are vital aspects to consider when working with vulnerable populations, including displaced persons. Vulnerability refers to the fact that an individual's condition or life circumstances may disadvantage them compared to others. Some displaced persons are unfamiliar with the concept of confidentiality, and reluctant to trust interpreters and service providers, particularly those from their own community. Due to the sensitive and private nature of many interactions, both formal and informal, displaced persons might be reluctant to talk about complex issues that may impact their health. Take precautions to ensure and maintain the confidentiality of information for everyone involved. Clearly stating who will or will not have access to the information can help create a safe environment in which the person feels able to communicate openly. Where confidential information needs to be shared with others, discuss this with the individual and ask for consent.

Use of Interpreters and Translators

Sometimes an interpreter is required in the therapy room. The presence of a third person can influence communication in many ways. Interpreters do not replace the interviewer, but play a vital role in facilitating communication with displaced persons. Their presence can help or harm communication. An interpreter is a skilled and trained person who converts oral information into another language; a translator is a skilled and trained person who converts written information into another language. Their role is to ensure clear communication between health care providers and clients / patients / persons who are speaking different languages. Their goal is to convert oral or written information “meaning for meaning” and not “word for word”. This implies that interpretation and translation must consider the context of the message being conveyed, as well as the emotions and expressions included in the delivery.

Key Points for Communicating with Interpreters

• Whenever possible, use certified interpreters and ensure they have adequate language and interpreting skills and the necessary training.
• Consider the age, gender and diversity characteristics of the interpreter that may make the displaced person more open to communicating (e.g. selecting a female interpreter when speaking with a female).
• Address and make eye contact directly with the displaced person, not with the interpreter. Avoid talking to the displaced person “through” the interpreter.
• Shorten the sequence of your sentences. Select your words carefully in order for the interpreter to clearly understand. Adjust the kind of language that you normally use e.g. less medical or formal words and avoid use of acronyms.
• Ensure that the information and correct meaning is not lost in translation. To avoid misinterpretation and loss of information, if you have sufficient time, apply triangulation techniques (i.e. rephrasing responses, reformatting questions). This helps to minimise the loss of information from interpretation.
• Interpreters should not have to feel the need to filter what they are translating. No matter how crude, harsh, or offensive, the interpreters should still translate exactly what the patient said. The purpose of this is to enable medical professionals to gain a full understanding of how the patient is feeling. It is the medical professional’s job to work out what is going on if the conversation is going off topic. The health care professional should encourage the interpreter to translate EXACTLY what the patient has said at all times. Remain alert to any signs of potential problems with the quality of the interpretation (for instance if the response does not answer your question; the interpretation is significantly longer or shorter than appears appropriate; words you recognise without interpretation are not interpreted; exchanges between the interpreter and displaced persons are not interpreted)
• It is CRUCIAL to ensure that the interpreters you work with have breaks and adequate rests. Breaks are VERY important for interpreters and mental fatigue can massively affect the quality of translation. Also consider the potential psychological effects of either past experiences or interpreting the trauma of patients, it is so important to make sure that they do not burn out

Be aware that a displaced persons may also feel more reluctant to participate in meaningful communication if the interpreter present is not trusted. You can read further details about use of interpreters here: Use of an Interpreter for Displaced Persons.

During an Interaction

Pay Attention to Cultural Considerations

Culture, education, and experience influence both the therapist's and the patient's communication style and skills. Communication can take on different forms. It can be verbal or non-verbal, and includes facial expressions, body language, and even silence. Dialogue is central. Language is used in some form to exchange ideas and thoughts. A dialogue implies that the involved parties listen to each other. They aim to create something together that is meaningful in the situation. It also implies an ability to take on the other person’s perspective. By asking questions, listening to the answers and acknowledging the stories told, it is possible to establish a therapeutic alliance built on trust. This is particularly important in the treatment of vulnerable groups, such as displaced persons. It can also create new knowledge and insight for all involved parties.

Communication is central and important in all types of clinical work. Communicating is something we do every day. We are used to it. But while it may appear simple, many barriers and factors can disrupt and complicate communication. Therapists working with displaced persons need to utilise a client-centred approach when providing rehabilitation services. This includes providing culturally sensitive care. We must also be able to communicate appropriately with the person seeking help. For many displaced persons, their cultural background is often very different from that of the country where they seek rehabilitation services. These differences can create certain challenges. As rehabilitation workers, we should consider our client's culture, as well as our own. And we must be aware of other factors (e.g. health conditions, distress and emotions) that may influence communication. We also need to understand we may have certain cultural biases. It is important to acknowledge these biases and recognise the influence they may have on our way of communicating.

Health care professionals do not have to be cultural experts, but we do need to try to understand our clients and communicate effectively with them. The following will help you negotiate many cultural differences:

• Ask the client what their expectations are and how things were done in their country.
• Acknowledge and respect differences that may exist between your beliefs, values, and ways of thinking and that of your client. Talking about the differences may help give your client a framework for understanding your culture.
• Make an effort: even showing a basic knowledge and an interest in their culture can be invaluable to clients trying to adjust to their new healthcare system.
• Avoid generalisations about cultural groups: there is variety within each culture that’s influenced by urban or rural background, education, ethnicity, age, gender, social group, family and personality.

Active Listening

In the clinic, the patient’s needs guide communication. However, it is most likely the physiotherapist who controls the communication by initiating the dialogue and by selecting the follow-up questions and topics. However, the therapist must facilitate the dialogue so that the client has an opportunity to present their story. It is also the therapist’s obligation to make clear that they have heard what has been said, and to use the story as a starting point for further communication.

Communication can only be effective if everybody involved is attentive to what each other is saying. Instead of focusing only on conveying your messages, pay close attention to what the displaced person is saying. Active listening, also known as reflective or empathetic listening, is useful in this situation. It has been shown to improve interpretation of the sender's message, which is a critical skill when working with patients. Poor listening has been attributed to inaccurate diagnosis and incorrect treatment. Asking questions and responding effectively as part of this process ensure the displaced person is at the centre of the interaction and that they feel heard, valued, understood and respected. Guidelines for active listening include:

• Physically adjust your body to encourage two-way communication.
• Listen carefully without judgement, by giving your full attention and avoid interrupting.
• Pay attention and minimise distractions. Avoid looking at your phone, computer or anything else that could distract you from the interaction.
• Show interest and create a positive atmosphere.
• Use reflections.
• Don't get emotionally involved.
• Use non-verbal cues to show you are listening, such as nodding or say "I see."
• Invite further disclosure with phrases such as "tell me more."
• Clarify with open-ended questions, particularly when seeking a description or an elaboration on an answer.
• Paraphrase what they have said to demonstrate that you have listened, understood correctly and to show that it is important to you.
• Use non-judgmental phrasing in your responses and follow-up questions.

Consider Non-Verbal Communication

Non-verbal behaviour or body language such as gestures, facial expressions, movements and tone of voice can convey receptivity, interest, comprehension, hostility, disinterest, anxiety or discomfort. Interestingly, in cases where verbal and non-verbal messages contradict each other, non-verbal communication tends to outweigh the verbal message. Empathy and emotion are communicated more clearly via non-verbal communication than verbal communication. This means that non-verbal communication is an integral, but often overlooked part of the medical interview. Empathy is expressed by being warm, friendly and reassuring. It has been linked with better patient satisfaction and recovery rates, and subsequently better health outcomes. Take an inventory of your body language and consider what expressions or gestures of the person you are communicating with suggest. Do they fit the accompanying words or does the person’s body language convey a different message?

Talking to Persons who are Distressed

Individuals who have experienced traumatic events may be unable to speak of them or may be triggered easily by certain topics of communication. While a displaced persons may present with grief, trauma, depression, anxiety, emotional stress, the underlying problem may be their experiences of torture and/or trauma. There are different levels of distress, but some easily recognisable physical reactions include: tiredness, nervousness, and avoidance of eye contact. Clients with post-traumtic stress disorder may fall silent, lapsing into a dissociative state to avoid the memory.

Talking about certain events can potentially renew wounds or fears. Thus, it is important to be aware that even well-intentioned questioning may feel like an interrogation. Some topics like rape, abuse, harassment, trafficking and torture are sensitive and difficult to bring forward. Communication around these topics requires a sound therapeutic alliance based on trust and mutual recognition. Individuals with strong numbing symptoms may present as withdrawn, unresponsive and may be difficult to engage with. It is impossible to anticipate all the circumstances that could re-traumatise your client, but you can minimise the risk by avoiding settings or behaviour that could remind them of interrogation or torture experiences.

Provide Space for Managing Anger or Frustration

Experience of conflict, human rights abuses and displacement may increase feelings of insecurity, fear, anger or frustration. This can reduce people’s ability to clearly state how they feel or to express their point. It is important to create an environment in which displaced persons can fully express their anger, or frustration, particularly where it impacts on their health and well being. Be understanding: many displaced persons have survived traumatic events and struggle with daily challenges, and may have had to wait a significant period of time before accessing health care support. Remember that acceptance of their emotions creates trust and that any anger is likely aimed at the situation and not directly at you.

Resources

Migrants in Countries in Crisis (MICIC)

• Guideline 6: Communicate Effectively with Migrants. This guideline from Migrants in Countries in Crisis (MICIC) on communicating effectively with migrants, presents efforts by different stakeholders to adapt and effectively share awareness messages and early warnings with migrants. It also presents a tool for conducting awareness workshops on emergencies and recommended preparedness measures for migrant representatives.

Migrant and Refugee Women’s Health Partnership

• Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds - Competency Standards Framework for Clinicians January 2019. The Framework was developed by the Partnership, a national initiative bringing together health professionals—through their respective peak professional and standard setting bodies—community sector representatives and government to address systemic barriers to health access and outcomes when delivering care to people from migrant and displaced person backgrounds, while acknowledging and responding to the unique challenges faced by women within this cohort.

UNHCR

• Increasing two-way communication with refugees on the move in Europe. This report highlights and showcases some of the innovative approaches that have been taken to address complex communication challenges with displaced persons and discover new opportunities. 
• Effective and Respectful Communication in Forced Displacement. This resource provides detailed guidance on dealing with and managing stress and emotions, enabling individuals to treat persons of concern with dignity and empathy, and to further facilitate and strengthen effective communication.

WHO Europe

• What strategies to address communication barriers for refugees and migrants in health care settings have been implemented and evaluated across the WHO European Region? This scoping review examines strategies which have been implemented and evaluated to address communication barriers experienced by displaced persons and migrants in health care settings across the WHO European Region. Four main types of strategy were identified: cultural mediation, interpretation, translation of health information, and guidance and training for health care providers. These have been used to support access to health care, management of specific diseases and promotion of health across a wide variety of health care settings.