Sofie Bäärnhielm

The cultural formulation: A model to combine nosology and patients' life context in psychiatric diagnostic practice.

This article discusses the experience of adapting and applying the Outline for a Cultural Formulation in DSM-IV to the Swedish context. Findings from a research project on the Cultural Formulation highlight the value of combining psychiatric nosological categorization with an understanding of patients’ cultural life context in order to increase the validity of categorization and to formulate individualized treatment plans. In clinical care practitioners need models and tools that help them take into account patients’ cultural backgrounds, needs, and resources in psychiatric diagnostic practice. We present a summary of a Swedish manual for conducting a Cultural Formulation interview. The need for further development of the Cultural Formulation is also discussed.

Cognitive-behavioral treatment of tortured asylum seekers: a case study

The present study examined results of cognitive-behavioral treatment (CBT) in a 22-year-old, male, tortured asylum-seeker living in Sweden. The patient received 16 sessions of CBT involving mainly self-exposure to trauma-related cues. Clinical measures (assessor- and self-rated) were completed at pre-treatment, weeks 6, 8, 12, and 16, post-treatment and at follow-up (1-, 3-, and 6-month). Treatment led to significant improvement across all measures of post-traumatic stress disorder, anxiety, and depression. The improvement was maintained at 6-month follow-up. The results suggest that CBT could be useful in treating tortured asylum-seekers and refugees despite the additional stressors experienced by asylum-seekers and refugees.

Historical reflections on mental health care in Sweden: the welfare state and cultural diversity.

This article discusses historical reflections on the response of Swedish mental health care to cultural diversity and immigration and our views regarding future directions for clinical care, research and training. Sweden has become increasingly multicultural through immigration. Mental health care in Sweden faces the challenges of encountering cultural diversity and the mental health consequences of forced immigration, acculturation, and refugee trauma. In our view, Swedish mental health care is at a crossroads: either it takes up the challenge raised by immigration of an increasing cultural diversity or it satisfies itself with rhetoric, thus leaving reality at the margins. Equity regarding access to mental health care in Sweden today must include an acceptance of, and interest for, the diversity of the population.

Use of the Cultural Formulation in Stockholm: A qualitative study of mental illness experience among migrants

This paper explores the contributions of the Cultural Formulation (CF) interview to an overall understanding of patients, and focuses on the narratives of 23 newly referred patients with migrant backgrounds seeking help at a psychiatric outpatient clinic in Stockholm. Through text content analysis methods we identified five themes: displacement in space and time; mental illness as a physical disability; life events as etiological factors; concealing as a coping strategy; and being lost in a fragmented health care system. Findings indicate the need to contextualize symptoms for an in-depth comprehension of patients’ phenomenology. Both clinical and policy implications are discussed. The findings suggest that a section on migration and acculturation should be added to the cultural formulation in the next edition of DSM.

The Use of International Videoconferencing as a Strategy for Teaching Medical Students about Transcultural Psychiatry

Videoconferencing is an innovative method that potentially allows medical students exposure to international teachers in refugee mental health who would otherwise be inaccessible. This article reports a pilot study using videoconferencing with international teachers from Australia, Sweden and the USA participating in the training of ten senior Swedish medical students. Interviews with an actual and a simulated patient were conducted at the U.S. and Australian sites respectively, followed by discussions involving those two sites with students and their supervisors in Sweden. Students evaluated the method favourably, as did the teachers, although the brevity of the program was seen as a limitation. Teachers noted the importance of preparing students and patients and ensuring that the technology operates smoothly to ensure success. Although cost-effective in teaching medical students in developed countries, videoconferencing may still be out of the reach of training programs in many developing countries where it is most needed.

Revising psychiatric diagnostic categorisation of immigrant patients after using the Cultural Formulation in DSM-IV

This study evaluated the use of the Outline for Cultural Formulation (OCF) from the DSM-IV in the diagnosis of immigrants and refugee patients at an outpatient psychiatric clinic in Sweden. Using the OCF in conjunction with standard diagnostic procedures led to major revisions of diagnoses for 56.5% of patients. Anxiety disorders, especially PTSD, constitute the disorder group in which the most changes were made. In order to understand how information from the OCF interview led clinicians to revise diagnoses, data from clinical discussions were analysed through qualitative content analysis. This revealed four major themes related to the reevaluation, and at times confirmation, of given clinical psychiatric diagnoses: new information; expression of distress in emotional language; expression of distress in relation to life experiences; and improved understanding of the patient’s suffering. The findings suggest that the OCF may be useful for: (a) formulating culture in relation to illness experiences, (b) contextualising diagnostic categorisation, and (c) improving overall understanding of the patient that may facilitate individualised planning of treatment and therapy.

Refugees’ mental health—a call for a public health approach with focus on resilience and cultural sensitivity

Sweden, as the rest of Europe, faces the humanitarian responsibility of welcoming and providing a safe space for refugees from war zones and conflict areas. This is an urgent task with the current humanitarian catastrophe in Syria, which has caused the largest refugee crisis since World War II. It is estimated that around 470 000 persons in Syria has been killed since the start of the war, 11.2% of the Syrian population is killed or badly injured, and 50% of the population on flight. Lindert and colleagues point out that the current situation requires a timely and effective response in particularly within the mental health domain. They emphasize that many refugees, asylum seekers and internally displaced are vulnerable and at risk of mental health problems. They discuss possible individual and social interventions, and argue for an expansive intervention approach that includes both contextual factors and, whenever needed, trauma-focused interventions. I agree with Lindert and colleagues that we need to overcome the dichotomy between individual and social interventions and the importance of better knowledge on how …

Approaching the vulnerability of refugees: evaluation of cross-cultural psychiatric training of staff in mental health care and refugee reception in Sweden

BackgroundThis study evaluates the outcomes of cross-cultural mental health training given to professionals in health care and refugee reception in Stockholm, Sweden.MethodsA mixed method approach, with quantitative data from questionnaires (n = 232) and ten qualitative focus group interviews, was used.ResultsAfter training, the participants reported that the hindering effect of lack of knowledge on their work decreased significantly from 2.81 (SD1.22) before, to 2.29 (SD1.00) (p < 0.001). Focus group interviews contributed to an understanding of this. According to findings from focus group interviews, after training, the participants shifted from emphasising communication barriers towards empathy with refugees with mental ill-health.ConclusionTraining resulted in an increased experienced capacity among participants to understand the social vulnerability of newly-arrived refugees with mental distress. However, the lack of collaboration and the structural barriers between the different organisations were not affected.

The meaning of pain: A cultural formulation of a Syrian woman in Sweden:

Ethnography provides a method for psychiatric assessment to obtain an insight into the patient’s culture, context, and life situation. The Outline for a Cultural Formulation (CF) is an ethnography-based, idiographic formulation intended to complement the multiaxial assessment in DSM-IV. Its contribution to routine clinical praxis will be discussed with reference to a case of a Syrian-born woman in Sweden. Using the CF in the clinical diagnostic process shifted understanding of the patient’s suffering from a mainly somatic frame of reference to an emphasis on emotional and social aspects. The usefulness of ethnography in clinical psychiatric diagnostic practice is discussed.

Mental health for refugees, asylum seekers and displaced persons: A call for a humanitarian agenda:

Every day, nearly 34,000 people are forcibly displaced as a result of war, conflict or persecution. Globally, more than 65 million people have been forced from their homes and about 21 million of these are refugees, over half of whom are under the age of 18. About 80% of these refugees, over 16 million, are under UNHCR (the UN Refugee Agency) mandate, and fully 5.2 million Palestinians are refugees registered by UNRWA (United Nations Relief and Works Agency for Palestine Refugees in the Near East). Approximately 10 million persons are stateless and denied access to basic rights such as education, healthcare, employment and freedom of movement. Currently, more than half of the world’s refugees are from three countries: Syria, Afghanistan, and Somalia (UNHCR, 2017). The major receiving countries are Turkey, Pakistan, Lebanon, Iran, Ethiopia, and Jordan. Despite all of the popular media attention to waves of refugees, only 17% of those displaced reach Europe; 56% remain in Africa and the Middle East. Behind every number in the UNHCR statistics there is an individual story of someone forced to uproot and move due to war, conflict, persecution, and hardship—and, for many, this situation has led to persistent displacement and uncertainty in ‘‘temporary’’ situations that now span generations. We know that being an asylum seeker, refugee, or forcibly displaced has a profound impact on mental health, with an increased risk of developing common psychiatric disorders, such as, depression, anxiety, post-traumatic stress disorder (PTSD), psychotic disorders as well as disabling symptoms of psychosocial stress (Hassan, et al., 2015; 2016). In addition, there is often poor access to mental health care and a lack of funding for Editorial