Code-switching – building bridges and breaking down barriers

Code-switching is defined as 'The act of changing between two or more languages, dialects (forms of a language), or accents (ways of pronouncing words) when you are speaking.' Growing up, I would always code-switch with my family and friends. I would speak a mixture of slang and Mirpuri, a language which is spoken in many parts of Pakistan, including Kashmir, Azad Jammu, and Rawalpindi (where my family history traces back to). 'Proper' English seemed foreign to me.

When I moved to college and then subsequently university, I felt pressure to speak 'correct' English. I would still code-switch whilst I was at home, but then I would change again when I left the house. This left me feeling as though I was not being my authentic self when in professional working environments, even with my colleagues. I felt like I was wearing a mask sometimes, covering who I really was.

It was only when I left university and began working with patients at a mental health trust that I realised how important code-switching really is. I now firmly believe that being yourself when working with patients or clients, and being mindful of the language you use, can have a great impact on building rapport and breaking down barriers.

Why is code-switching so important?

When I first started working on mental health wards, I'd notice that patients would sometimes feel uncomfortable when speaking to me. Some would give me one-word responses when I would attempt to engage with them; others, for who English was not their first language, would feel pressured to try and speak 'proper' English with me. These same patients also tended not to engage in the psychological interventions I'd facilitate on the ward.

However, I noticed that some staff who could code-switch with patients had very good rapport with them. When I first witnessed a staff member speak in complete slang with a patient who was previously not engaging with me, and I saw they were responding very well to that staff member, I was shocked. This challenged everything I believed about making sure to speak professionally when engaging with patients and clients. It highlighted the importance of how language can be used to connect with other people, even if it is not 'proper', and how important it is when trying to build rapport with patients. 

After reflecting on this, I began to code-switch on the ward – lo and behold, I started to get more psychological engagement from patients. It was as if a wall between them and I broke down when I started to code-switch, further highlighting its importance in clinical settings.

Where's the research?

Of course, anecdotal experience only goes so far – in psychology, we need to make sure our practice is somewhat evidence-based. Sadly, however, there seems to be a scarcity of literature regarding code-switching within clinical settings, specifically in a psychological context.

In the Journal of General Internal Medicine, Wood (2019), a physician working within the medical field, reflects upon his experience with code-switching and mentions that he has found "Folks appreciate feeling a sense of kinship with their primary care providers, and code-switching to highlight a common bond in the patient-provider relationship is one means of achieving this." There's also a book published by the Pasalo Project called Tuning in: An anthology of unheard experiences of multilingualism in psychological therapy which, as the name suggests, is a collection of stories, dialogues, poems, and letters documenting experiences and perspectives.

I'd love to see further research on code-switching carried out formally to explore and measure its effects on rapport building. One example of how this could be done is clinicians being taught how to code-switch and then undergoing sessions with clients in a controlled setting. The clinicians and clients should then undertake semi-structured interviews to find out how comfortable they felt code-switching with one another, and if the experience was positive or negative overall. It's just one idea, but perhaps it could open the door for future research and interest. 

How I code-switch

Below are a couple of examples of how I used code-switching to build rapport and engage psychologically with patients on my wards. Pseudonyms have been used to maintain anonymity of the patients.

The first patient I had code-switched with was Tariq, a Pakistani gentleman who was going through a manic/psychotic episode. Initially, when I would say hello to him or attempt to speak to him, either for a psychology drop-in or as an invitation to one of the other psychology interventions, he would just nod at me and not say anything. I later found out that his English was not the best and that he had responded very well to one of the staff members who would speak Mirpuri with him. I also found out he was a Muslim too. As I knew how to (somewhat) speak Mirpuri, I decided to switch up my language when I would next engage with him. 

The next time I saw Tariq, I said "Asalamualykum" (Peace be upon you) to him, which is the Muslim greeting and asked him how he was in Mirpuri. His face lit up. I then had a 20-minute conversation with him regarding his mental wellbeing, any previous psychological input he has received, any concerns he had on the ward, etc. After this fruitful conversation, he began to engage in the various psychology groups which would take place on the ward, such as the emotional coping skills group, or the five ways to wellbeing group. I would attempt to translate some of the content for him, such as the instructions on how to do mindfulness, which he was able to understand and engage meaningfully in. 

The second time I had used code-switching was with Fred, an Eritrean man who was experiencing a drug-induced first episode psychosis. I remember the first time I tried to engage with him. He completely ignored me and was acting standoffish with me. When I approached Fred for a psychology drop-in session, remembering my experience with Tariq, I took a curious approach with him and asked him what language (besides English) that he spoke. He told me that he could speak Arabic as he had grown up in Saudi Arabia. At the time I knew a little bit of Arabic, so I attempted to engage in conversation with him using the language. I asked him "Kayfa haal lak? Kayfa al-Mustashfa?" (How are you? How is the hospital?). He smiled and replied saying he was fine, and that the hospital was fine too. We then had a 10-minute conversation with a mix of Arabic and English regarding his personal background, previous experiences with a psychologist, etc. Like Tariq, Fred started to actively attend the psychological interventions which were happening on the ward, as well as staff reporting that he would meaningfully engage with other activities which were taking place on the ward.

Code-switching isn't just about completely changing languages; we can also code-switch in relation to changing dialects too. Dwayne, a British born Afro-Caribbean client with a diagnosis of paranoid schizophrenia, was initially quite positive with me. He would kindly decline any interventions that I would offer him, including the psychology drop-in session offered on the ward. I would notice that Dwayne was comfortable enough to code-switch with various other staff members, of different backgrounds, with them code-switching back with him.

One day, however, there was some issues between Dwayne and another patient. This patient had tried threatening Dwayne, leading to a verbal altercation between the two. Dwayne walked away from the situation, but then mentioned to the nurses that he was very angry about how staff handled the situation, he felt it involved racial prejudice as the other patient was from a white middle-class background. When I came on the ward that day, Dwayne was pacing in the corridor. Because of my observations with how he would code-switch with staff members, I approached him asking him "Wag1 Dwayne?" He was very surprised by this and asked if he could speak to me in private. He then opened to me about how he was feeling and his frustrations surrounding that incident. Dwayne also began to open up to me regarding his upbringing and, to my surprise, we shared very similar upbringings when it came to the type of schools we had attended and areas we had lived in. I felt like he had begun to become more comfortable with me as he had started to code-switch mid conversation, so I continued to code-switch with him too. That whole conversation I was using words such as "Innit" (isn't it), "Long ting" (Usually used when describing something as difficult), etc. At the end of the conversation, Dwayne mentioned that he felt much more confident in the staff and reassured.

What can clinicians do?

Based on my experiences with code-switching, I believe it to be a very valuable tool in a clinician's arsenal, especially when trying to engage psychologically with a patient. I believe staff who can, should code-switch with patients (when it feels appropriate to do so), in order to effectively build rapport with them. This also promotes staff members to bring their authentic selves to work and make them more comfortable whilst at work. 

With staff members who do not know how to code-switch or if they do not know another language, I believe they could be trained and open to it. For example, they could have a 'cheat sheet' of different words and phrases in different languages and dialects to help them with their clinical practice and build further rapport with their patients. 

One thing to note is that code-switching may not always be appropriate in some circumstances, so it would be up to staff to discern when it would and would not be appropriate to use. For example, I would not have used code-switching with Dwayne if we didn't have shared experiences in terms of our backgrounds and if he was not already code-switching with staff members already. Staff could be trained on what contexts it would and wouldn't be appropriate to use it.

What can psychologists do?

At undergraduate or postgraduate level, I feel some training around code-switching should be offered. This would encourage future psychologists to bring their authentic selves to therapy, allowing them to learn how to build rapport more easily with patients. 

For working psychologists, why not speak to colleagues who have experience with code-switching and explore any avenues that may be available to do this with future clients? Code-switching is not a necessity: but for psychologists who are finding it difficult to connect with some patients, perhaps it could be a very useful skill to have.