Challenges of Combining Perspectives

Subjects

Of 88 asylum-seeking patients identified from the medical records of patients registered for suicide attempts from 2005 to 2009 at the Stockholm County mental health central emergency services, all 18 women who had received compulsory care were selected. The studied patients were 19–43 years old, 11 were younger than 30. Seven patients were born in Bangladesh, two in Jordan, two in Azerbaijan, and one in each of Uzbekistan, Iran, Afghanistan, Iraq, Pakistan, and Congo. They had resided in Sweden between a few months and more than 5 years, but in the majority of cases for less than 2.5 years. One of the women was sent directly to a hospital in another county after initial assessment. The others were hospitalized for between 5 and 197 days, the majority for less than 2 months. Of the 18 patients, four were followed up in primary care and 12 in specialized mental health services; in two cases follow-up was not documented.

Information on the use of interpreters was fragmentary in the records. However, at the time, interpreters were available at the emergency services, even though their qualifications varied. Culture brokers were not available. Cross-cultural consultation and supervision were not well-known to the staff and rarely used in the studied cases.

Material

We studied the digitalized medical records from the initial assessment in the emergency services and from the hospital ward if the patient was hospitalized in the same hospital. Similarly, outpatient care records were available for our review when the care was provided within the same mental health services as the emergency care unit, and from the emergency services and hospital wards if the patient was re-admitted over time.

Medical records are written by all professions (physicians, nurses, social workers, psychologists, mental health workers, occupational therapists, physiotherapists) in the services, and updated after each assessment, treatment intervention, conversation with the patient, communication with other services, network etc. Normally there are several items added every day, of varying length. Formal suicide assessments are made by psychiatrists. Specific categories of suicidality or suicidal behavior are recommended, but at the time of the study, using them was not mandatory. Information on suicidality could thus be found in all types of records.

Data Analysis

The medical records were analyzed with content analysis (Krippendorff, 2004), using the software NVivo9 (Bazeley & Jackson, 2013). The following procedure was applied: (a) codes were assigned to meaning units gleaned from the texts; (b) codes were grouped into preliminary categories; (c) broader themes were identified with the help of written memos synthesizing the findings of each record; (d) potentially relevant codes for each theme were further explored and the themes were refined.

One author (MS) coded all records after which the codes were discussed and consensually adjusted in discussions with another author (SB). All authors read successive drafts of themes. In the end, again by consensus, six themes were formulated.

Ethical approval was given by the Regional Ethical Review Board of Stockholm (number 2010/3:6 and 2012/982-32).

Unbearable Realities

The first theme focuses on the documentation of the communication about external realities that both patients and staff experienced as extremely difficult to handle. Two categories within this theme were salient: the asylum process, and the situation as a woman.

Decoding Languages of Distress

This theme covers the documentation of how clinicians struggled to decode a variety of languages of distress. The theme can be divided into four categories: difficulties of contact and verbal communication; unfamiliar behavior and symptoms; unfamiliar forms of expression; unfamiliar life circumstances.

Elusive Trauma

This theme refers to the documentation of how trauma was communicated and taken into account in the assessment and treatment processes.

Even when trauma was noted in the medical records it was rarely explored further. Trauma narratives were developed almost exclusively in contacts at outpatient units, especially if the patient had a long-term continuous contact with one clinician. The three patients whose traumatic experiences were extensively addressed in the medical records all had higher education, a political background, and some understanding of the cultural context of their experiences.

One of them gave repeated descriptions of the effects of trauma: not sleeping at all, having constant flashbacks of the rapes, difficulties breathing, popping of the ears, hearing problems, strong heat sensation in the body, constant fear and death thoughts. Another woman was reported to say that, "it feels as if the person who raped her is with her all the time,"

When women who had disclosed traumatic experiences in outpatient contacts were admitted to hospital, the traumatic experiences disappeared from view, overshadowed by their dramatic symptoms and social circumstances, or because the woman did not want to talk about them. There were few examples of the hospital inviting the outpatient clinician to clinical conferences.

Even when the patient received a diagnosis of PTSD, the criteria of this diagnosis seemed not to have been systematically evaluated. The assessment of suicide risk tended to focus on suicide intent, degree of depression, hopelessness, and the attitude to care. The patients themselves, however, often described trauma-related, impulsive suicidal behavior.

In general, the treatment for trauma-related symptoms was medication with antidepressants, hypnotics, and sometimes neuroleptics. Structured activities and physiotherapy were also sometimes recommended. Psychotherapy was generally not regarded as an option owing to the limited access to care in general for asylum seekers.

Meanings of Suicide and Communication of Meaning

This theme refers to the documentation of the meanings patients attached to suicide and suicide attempts.

The records often included an evaluation of a suicidal act based on a suicide risk assessment scale, but more rarely documented the patient's own thoughts about not wanting to live. We noted the following typical comments on the meaning of having attempted suicide: "There is no future," "there is no other way out" were expressions about suicide as a way out of an unsolvable dilemma that was usually linked to the asylum situation. One clinician reported: "She says that she has come to Sweden to start living, and if that is not allowed, she just wants to die." The task of protecting one's children from a dismal future was another unsolvable dilemma for many of the women.

The patients who were parents usually regarded their children as a reason to stay alive. Later in the process, however, some said that the child would be better off without them, sometimes with the addition that the child's chances of asylum might be strengthened if it lost its mother. Three women were reported to consider extended suicide.

Another meaning of suicide was to relieve the woman of immediate pain, to "get rid of the poison inside," as one woman expressed it. This pain tended to be linked to intrusive memories of trauma.

Several women described suicide as a way of being reunited with dead relatives. "We [referring to herself and her daughter] will go to granny, we are not returning to… [home country, omitted]," one woman was reported to say. Staff rarely engaged in dialogue on these or other existential – or religious – issues with the patients, even though practical support for religious activities was given.

Challenges of Combining Perspectives

This theme refers to the documented challenges for the clinicians to embrace multiple perspectives on the patients' experiences and clinical conditions.

When the patients talked about the causes of their mental ill-health, they most often gave social and existential explanations. The clinicians generally assumed biomedical explanations. Social stressors, including the asylum process, were not seen as causal factors. The clinicians repeatedly asked themselves: Is this merely a crisis reaction or a diagnosis proper? In the majority of cases they assessed it as either–or. "The patient's ill-health is assessed to reflect on her life situation at large, and impossible to treat medically," one clinician concluded. Only in very few cases were both explanatory aspects recorded.

Diagnoses, even of the same individual, were frequently changed in the medical records. These changes often seemed related to the patient's social realities. For example, when the asylum situation became more pressing, the diagnosis was sometimes changed from depression or PTSD to adjustment disorder or crisis reaction. The most common diagnoses were depression, PTSD, adjustment disorder, psychosis, and crisis reaction.

Even when social and existential background factors to the patient's condition were prominent, the typical treatment offered was medication and other medical interventions. In some cases, when the clinician was uncertain about crisis reaction or depression, suicide risk seemed to be downplayed, which indicates that suicide was seen as linked to mental illness rather than to social factors.

Shared Powerlessness

This theme refers to repeatedly documented experiences of powerlessness in patients and staff members alike.

One woman was reported to express that, "the more time that passes, the less able she is to control her life." When patients experienced setbacks in the asylum process, their powerlessness was frequently expressed in self-destructive behavior. Confronted with the prolonged asylum process, the clinicians too seemed to feel powerless. When the patient asked for support with her asylum case, the clinician sometimes told her that, "psychiatry has no responsibility." In some cases, the patient was discharged from the hospital when the pressure of the unresolved asylum situation was rising, even shortly after a deterioration of her mental state. "All has been done," was the comment in one record.

Another record stated:

Other situations that seemed to provoke feelings of powerlessness in the staff were when mothers rejected their children or considered extended suicide, and when patients starved themselves or refused medication.

Powerlessness appeared to be reflected in the clinicians distancing themselves from the patients by the use of value judgments to describe their behavior. Thus, the patient could be described as "demonstrative," "regressive," "unwilling to collaborate" or as not assuming "adult responsibility." A very common expression, which sometimes also came across as a value judgment rather than an aspect of a diagnostic assessment, was that the patient "acted out."

The treatment measures, too, seemed to testify to the clinicians' powerlessness. Electroconvulsive therapy was sometimes described as a last resort, even though the patients did not, according to the records, meet the diagnostic criteria for this intervention. Analogously, "activation," sometimes involving occupational therapy, was repeatedly invoked as a measure against self-starvation.

Lack of Knowledge

Some difficulties seemed to reflect a lack of knowledge in psychiatry at the time of the study period. The medical records indicated a lack of knowledge about trauma-related disturbances such as memory problems and dissociation. Cultural perspectives were also underdeveloped in the diagnostic manuals of the time (American Psychiatric Association, 2000). Currently the use of a Cultural Formulation Interview, exploring the patient's definition of the problem, the patient's perceptions of cause, context, and support, of self-coping and past help-seeking, and of cultural factors affecting current help seeking, is recommended for the assessment of all patients in the DSM-5 (American Psychiatric Association, 2013).

One Bengali woman's state of mind was invariably described as "fear" (a word the interpreter used), but what was meant by fear was never clarified. There are different words in Bengali for fear, related to the intensity as well as the cause or object of the fear reaction. For instance, there is a special word that refers to the fear of losing one's honor and another word for the fear of emptiness, which can mean death but also meaninglessness. There are also fears of bodily phenomena and fears related to spiritual beliefs (H. Bose Hakansson, personal communication, September 19, 2016).

Need of Patient-Centered Focus

The clinicians in this study struggled to understand their patients, but often assessed the patients' reactions against measures of normality that seemed to fit the clinician's earlier experiences. Our findings attest to those of Kirmayer (2003), who wrote that differences in experiential worlds and in knowledge of social contexts may lead to failures of imagination and to refugees facing misunderstanding and incredulity in the psychiatric system.

The subjective meanings of the concerns presented by the patients were rarely explored in the records and not seen as central to the treatment. However, in cases in which the records did convey experienced meanings of suicide, trauma-related impulsive symptoms often came to the fore as a risk factor for suicidal acts. When some clinicians assessed impulse-driven suicide attempts as less serious, this appeared to follow the logic of instruments measuring suicidal intent, for instance, the Suicide Intent Scale (Freedenthal, 2008). A more open exploration of the meaning of suicide for the patients might have enriched the assessment.

The records illustrated the difficulty for patients to disclose and clinicians to explore trauma. Continuity and a therapeutic alliance were necessary for trauma to be genuinely taken into account.

Combining Perspectives

The difficulty of combining contextual and existential perspectives with medical, psychiatric ones was evident in diagnostic processes as well as in treatment plans.

The theory of social causation of mental ill-health and, indeed, of suicide is not new (Durkheim & Simpson, 1897/1952). Concerning the increased risk of suicide in some female migrant groups, cultural conflicts, autonomy issues, and domestic violence have been advanced as explanations (Bhugra et al., 2011; van Bergen, van Balkom, Smit, & Saharso, 2011). However, biomedical models predominate in clinical thinking on suicidality, supported by findings that 90% of all suicides are linked to mental disorder (Mann, 2002). Studies have shown that these figures vary between different countries (Phillips et al., 2002; Radhakrishnan & Andrade, 2012). In our material, the patients often presented a narrative about a desperate life situation, whereas the clinicians' perspective remained dominated by an illness model, which seemed not to support viewing the patient narrative as meaningful. The wish to die expressed by some women was treated as a symptom and not as a personal disclosure.

Traditionally the prospect of being granted asylum in Sweden on grounds of mental ill-health was slim, and in 2006 it was further restricted when the relevant legal statute was revised from offering "asylum on humanitarian grounds" to doing so in "exceptionally distressing circumstances" (Utlänningslagen [Aliens Act], 2005). Underscoring that the mental state of the patient had no importance whatsoever for the asylum decision, some clinicians seemed to exaggerate their own powerlessness, and statements like "psychiatry has no responsibility" sometimes appeared to reflect frustration and a wish to maintain distance to the patient's suffering. When descriptions of the patient's reactions were presented out of context in the records, this also seemed to reflect a distancing and sometimes moralizing attitude on the part of the staff.

Consequences for Treatment

Only rarely did the recorded dialogues address what might help the asylum-seeking women handle their unbearable realities. Few systematic psychological interventions were offered to the patients, even during long periods of hospitalization. The fact that so few of the patients were offered psychotherapy can be explained by the general lack of such resources or by a too-restrictive interpretation of asylum seekers' legal access to care. Further, a disinclination on the part of clinicians to initiate therapy in an unstable situation may be misguided. Recent studies have shown that asylum seekers can profit from psychotherapy in spite of their unstable life situation (Başoğlu, Ekblad, Bäärnhielm & Livanou, 2004; Ter Heide, Mooren & Kleber, 2016).

Efforts were made to counteract powerlessness through psychosocial work involving the patients' social networks, including public agencies. The social worker of the ward established collaboration with the social services in all cases of women with children.