Lost in Translation: Reporting on PTSD among Refugees

Having people open up about atrocities that would make a normal person blanch can be difficult under any circumstance. Hearing the stories in translation underscores the complexities of understanding the effects of trauma on people who not only speak a different language, but are from utterly different cultures.

I came across this challenge while reporting on my National Health Fellowship project and trying to detail the effects of post-traumatic stress disorder on survivors of the Cambodian genocide. Through the course of the project, I met with many survivors who would tell me their stories. And I was repeatedly struck by how different our world views were and how inadequate and incompatible English and Khmer were in conversation and translation. This also brought me to the realization that treatment for Cambodians suffering with PTSD is a huge challenge. And the reporting often seemed similarly hindered.

Currently within psychiatric circles there is considerable debate about cross-cultural applicability of treatment of PTSD. In fact, there is a belief among many that PTSD itself is a Western culture-bound diagnosis that in some cultures might have no validity.

This may help explain why Cambodians have been so difficult to treat and why their PTSD symptoms have been so resiliant. Studies show refugee survivors of the Cambodian genocide, which left about 2 million dead, still have high rates of PTSD, sleep paralysis, intergenerational conflict, and anger and are more sensitive to negative stimuli.

Clearly, it seems our Western therapy is not working.

One person describing the difficulties of cross-cultural treatment made an analogy of treating New Yorkers traumatized by the 9-11 tragedy by bringing shamans from Borneo to lead treatment.

That's the kind of disconnect Cambodians face. 

One of the Cambodian immigrants I interviewed, Dr. Sam Keo, is a Western-educated licensed psychotherapist. Even with those advantages, he suffered from PTSD for more than a decade and needed intense psychotherapy, along with medications, to finally conquer (or at least subdue) his demons.

When he first sought treatment, he said two therapists told him he was fine.

"I said thank you and left," Keo recalled. Later he was given Prozac. 

By contrast, he says, most of the refugee victims from Cambodia in the United States are uneducated farmers. They are economically challenged, have families to take care of, and face a variety of issues more pressing to them than seeking treatment for the nightmares, or "thinking too much," or any of the other PTSD effects that are the norm in the community.

One wonders what kind of chance these victims have to get meaningful help. 

In addition, Khmer is not a language that translate well into English. The Cambodian language is much simpler, with a smaller vocabulary. Many Cambodians use French when there is no Cambodian equivalent.

And then there is the skill of the translator. Many are not trained, and even those who are often often try to tailor their translation to what they perceive a person wants to hear. 

Stanford Psychiatrist Daryn Reicherter said his Cambodian translators would often describe patient responses to questions in such a way that they knew they would fit a PTSD or similar Western diagnosis.

Similarly, there are concepts in the culture that simply do not translate. For example, Cambodians believe that many mental diseases are family, rather than personal, afflictions.

This stew of confounding variables has made treatment of Cambodians difficult at best. It also makes one wonder if the findings of the countless studies are indeed accurate and can be trusted.

Now, overlay and cast this on the reporting process. If licensed therapists had trouble understanding the minds of their patients, what chance was there for me? At times, I wondered if I really understood ANYTHING. Approaching this job with my own Western-constructed and constrained mindset made me at times feel like "The Ugly American," trying to divine truths. And then wondering if what I had found was a Western truth or an Asian truth and whether I was smothering the Asian truth with my own beliefs.

I had previously done a story about a Cambodian woman bringing her daughter to the United States for surgery unavailable in her country. I was struck by the woman's seeming lack of emotion and asked whether she was grateful. This ended up leading into a protracted discussion between the translator and me about the nature and concepts of gratitude in Western and Buddhist cultures and then how that is displayed.

Westerners are always charmed at the Cambodian greeting with hands steepled and a slight bow. To Westerners, this might signal graciousness and respect, but to a Cambodian it may be more of a handshake.

Most of my colleagues in this fellowship have described ways to use data sets and provided suggestions for research and future stories. They have provided helpful links and other helpful guides. We try to aid those who follow. I am not sure I have any good answers about how to better handle cross-cultural journalism. All I can suggest is that you try the best you can to check your assumptions at the door and keep your thinking as open as possible.

Try to understand or learn a little about the culture and history of your subjects. Buddhist or Hindu or animist or even Christian religions can greatly shape and frame how everybody views the world. Think about how the notions of faith and Christ dying on the cross to wash away sin  play a role in one's world view.

Trying to "walk a mile in their shoes" may sound frightfully inadequate and prosaic, but it's a start.

Also, be sure to question the translator. Multitudes of meaning are lost in translation, and sometimes you need to sit down and learn how your translator thinks and expresses himself or herself before you embark on the interview. You may not have a choice of translator, but you should try to somewhat understand where they're coming from.

At the end of the day, you can only try to get a glimmer of truth.

I don't know to what extent I was successful in these area. I am presenting the weekend series I wrote to a Cambodian publication, which will be translating it into Khmer. I can only imagine how that will come across.

Hemingway wrote "All you have to do is write one true sentence. Write the truest sentence you know." If I did that, well, it's something.

Editor's Note:

Greg Mellen's series,a project for our National Health Journalism Fellowship, can be found here.

For other ReportingonHealth resources on cross-cultural health issues, see Interpreting Health: Medical Translation in a Sea of Immigrants, No Longer Lost in Translation,  Misplaced Metaphors and Other Things that Can Wreck Health Translations, and Professional Interpreting Services Are the Key to Good Health Care for Non-English Speakers.