CHAPTER 2: LITERATURE REVIEW
2.13. Barriers in Accessing Psychological Services: South African Perspective
Language is a tool used in the social construction of reality which patients use to express themselves and relate their experiences (Deumert, 2010; Ross & Deverell, 2010).
According to Deumert (2010) during every interaction between the patient and the health care provider, language is always significant. The health care provider who is unable to speak the patient‟s language creates a communication barrier and access to services (Ross & Deverell, 2010). In Schlemmer and Mash (2006) it was stated that South Africa is a diverse country that has 11 official languages. Deumert (2010) stated that out of the 11 official languages English is perceived as the most common spoken language but not everyone is fluent in it, especially those who use it as second language. Moreover, elderly people often struggle with a second language or English as a medium of communication, particularly those who did not go through basic education. Furthermore, it may be challenging for those who speak indigenous languages to express their needs and feelings during consultations.
Deumert (2010) asserts that although language may be a barrier in accessing psychological services, it is the most important tool during therapy as it is used in building rapport.
Moreover, it is important for mental health care providers to understand patients in their context to avoid avoidance behaviour from patients. Furthermore, patients with avoidance behaviour are reluctant to access psychological services and only utilise them when their problem is severe. This may be due to the fear of being misunderstood or being alienated by the use of psychological or medical jargon during interventions. Service providers often use medical or psychological terminologies that patients may find difficult to understand (Levin, 2008). Inadequate communication may result in errors during diagnosis and management of
43 patients by mental health providers and patients may develop feelings of failure and despair (Deumert, 2010). Patients who have difficulties in understanding their mental health care providers may not understand the severity or seriousness of their condition and this may result in defaulting treatment or not complying with it (Duemert, 2010; Helman, 2007).
Deumert (2010) stated that sometimes patients‟ response may be based on what they can say in English and not what they have been asked because they fear being ridiculed or to humiliate themselves if they report that they do not understand. Consequently, this may result in a patient‟s presentation of the problem being misinterpreted. When patients feel that their indigenous language is not recognised they may feel invisible (Deumert, 2010) and believe the notion that mental health services is a profession that has unbalanced power dynamics as English is associated with power and high level of education (Drennan & Swartz, 2002).
Deumert (2010) gives a typical example of a service provider who avoids calling a patient with a native name because they cannot pronounce it properly. According to Drennan and Swartz (2002) in most cases language as a barrier results in conversations being dominated by professionals.
Some patients may prefer to be accompanied by family members to interpret or close the language gap between them (Deumert, 2010; Schlemmer & Mash, 2006). Additionally, if family members are not available to interpret indigenous languages, mental health providers usually uses black African nurses, potters or in patients as interpreters (Drennan & Swartz, 2002). Consequently, according to form 223 of the HPCSA this act is unethical because it may constitute a multiple relationship and there is potential for misinterpretation and confidentiality may be breached. Form 223 of HPCSA asserts that only competent interpreters fluent in two languages but with proficiency to the patient‟s language may be allowed to interpret. Searight and Armock (2013) stated that interpretation by an incompetent or unqualified interpreter may influence the outcome of psychotherapy, diagnosis, treatment and the relationship between a healthcare provider and a patient. Furthermore, they may be overwhelmed and experience emotional distress when discussing sensitive matters (Drennan
& Swartz, 2002). In conclusion, Deumert (2010) stated that it is vital for mental health care providers to learn the language used in the area they work in, in order to have a clear understanding of patients‟ presentation.
44 2.13.2. Stigma
Sorsdahl, Kakuma, Wilson and Stein (2012) reported that there is limited research in South Africa in relation to stigma and mental health. The fear of being stigmatised is strongest when individuals consider the reactions of those they interact with. Furthermore, stigma associated with seeking psychological services is associated with the view that seeking psychological help makes individuals less socially acceptable. Moreover, the individual who accesses psychological services may be perceived as deviating from the societal norms (Drapeau et al., 2009; Vogel et al., 2006).
In Vogel, Wade and Ascheman (2009) it is stated that some people may regard patients diagnosed with and using treatment for depression as emotionally unstable, less interesting and less confident than an individual seeking treatment for back pain and an individual having depression but not seeking treatment. As a result, according to Sorsdahl et al. (2012) individuals may experience anticipated, experienced or self-stigma. In addition, some individuals may expect or predict that they may experience discrimination from community members due to their mental illness while others may have experienced discrimination or prejudice as a result of their mental illness. Moreover, Sorsdahl et al. (2012) asserts that some individuals may experience internal negative thoughts or beliefs associated with mental illness and apply them. Consequently these negative internal beliefs may result in low self- esteem and may negatively influence help seeking behaviour.
In the study by Sorsdahl et al. (2012) members of the South African Depression and Anxiety Group (SADAG) were provided with questionnaires with the aim to explore the effect of internalised stigma towards accessing psychological services using the Perceived Devaluation and Discrimination scale (PDD) as a measure. The majority of the participants reported a high level of education and they were fully aware of their diagnosis (e.g. depression, bipolar mood disorder, anxiety etc.). Furthermore, the outcome of the study showed that individuals have socially withdrawn due to the experienced discrimination. In addition, although the results for self-stigmatisation were low, people still felt that community members stigmatise and reject people who are mentally ill (Sorsdahl et al., 2012).
Vogel, Wade and Ascheman (2009) assert that the public‟s stigmatisation of people utilising psychological services may influence help seeking behaviour and predict attitudes towards
45 psychological services. Consequently, an individual who is willing to seek psychological help may avoid treatment to reduce being stigmatised, discriminated or isolated.