Swedish Mental Health Care Research Articles

A qualitative analysis of the documentation of DSM-5 Cultural Formulation Interviews with non-native speaking patients in a Swedish mental health care setting.

Cultural variety in expressed symptom presentations of mental health problems creates difficulties in transcultural diagnostic assessments. This emphasizes the need of culturally sensitive diagnostic tools like the Cultural Formulation Interview (CFI). Although the CFI is being implemented worldwide there is a lack of studies analyzing what kind of information it provides when used with new patients in routine psychiatric assessments, and how CFI information contributes to diagnostic evaluations. This study aimed to find out what information the CFI questions revealed when used with non-native Swedish speaking patients. We also wanted to understand how the CFI may facilitate identification of psychiatric diagnoses among these patients. The CFI was used as part of a routine clinical psychiatric assessment in an outpatient clinic in Sweden. Interpreters were used in the consultations when needed. A qualitative thematic analysis was used to analyze the documented CFI answers from non-native speaking patients. We found that the CFI information contained contextualized descriptions of dysfunction and current life conditions, as well as expressions of emotions, often described along with somatic terms. Our results indicate that the narrative approach of the CFI, giving contextualized information about distress and functioning, can facilitate clinicians' identification of psychiatric symptoms when language, psychiatric terms and understandings are not shared between patient and clinician.

“It’s about Living Like Everyone Else”: Dichotomies of Housing Support in Swedish Mental Health Care

The deinstitutionalization of psychiatric care has not only altered the living conditions for people with severe mental illness but has also greatly affected social services staff. In the Mental Health Act launched by the Swedish government in 1995, a new kind of service called ‘housing support’ and a new occupational group, ‘housing support workers,’ was introduced. However, housing support does not currently operate under any specific guidelines regarding the content of the service. This study explores housing support at local level in various municipalities of one Swedish county. The data is based on discussion with three focus groups: care managers, managers for home and community‐based support, and housing supporter workers. The perspective of institutional logics as a specific set of frames that creates a standard for what should or could be done, or alternately what cannot be questioned, is applied to analyze the constructed meaning of housing support. The meaning of housing support is constructed through three dichotomies: process and product, independence and dependence, and flexibility and structure. These dichotomies can be understood as dilemmas inherent in the work and organizing of housing support. With no clear guidelines, the levels of organizational and professional discretion create a space for local flexibility but may also contribute to tremendous differences in defining and implementing housing support. We discuss the potential consequences for housing support users implied by the identified discrepancies.

Generational Differences in Support and Care of Individuals Diagnosed With Severe Mental Illness

As part of the process of de-institutionalizing the Swedish mental health care system, a reform was implemented in 1995 moving responsibility for social support for people with severe mental illness (SMI) from the county to social services in the municipalities. In many ways, older people with SMI were neglected in this changing landscape of psychiatric care. To investigate possible generational differences in support experiences, two nonoverlapping cohorts were created from surveys conducted every fifth year between 1996 and 2011 in one middle-sized municipality in the south of Sweden, aiming to detect the needs for social support. Cohort 1 includes everyone detected at the 1996 survey aged 65 and 79 years (N = 92). Cohort 2 includes individuals first detected at the 2011 survey who were aged 65 to 79 (N = 104). Results indicates significant differences between the two cohorts in diagnosis, reflecting changes over time in diagnostic tendencies. Cohort 1 was on average 10 years older than Cohort 2, even within the restricted age range. After correcting for age, there were no differences between the two cohorts in education, functioning (CAN and GAF), or marital status. Although Cohort 1 experienced more days of institutionalization than Cohort 2 (median = 424.5 days vs. 382 days), the difference was not statistically significant. Cohort 2 had significantly higher additional subsidies and disposable income, as well as significantly higher income from other sources after retirement. Results indicate the changing demands that older adults with SMI will place on care systems.

Longitudinal Changes in Functioning and Support After Initial Survey for Individuals With Severe Mental Illness

After the Swedish Mental Health Care reform was enacted in 1995, many individuals with severe mental illness were released from long-term care institutions. As a result, they had new living and support situations. Following 236 individuals over time supported investigation of the effectiveness of social support services in caring for these individuals. Surveys were conducted in 1996, 2001, 2006, and 2011 and annual data were available from national registries. Primary diagnosis was psychosis (over 60%); depression was the second highest diagnosis (20%). Mean age in 1996 was 60.8 (range = 45 to 86) and 47% of the sample were women. Only 36% of the group had more than nine-year compulsory education. Compared with other groups in the larger study, this group was more likely to have never married (66%) and 18% had accumulated more than 10 years in an institution over their lifetime (mean = 6 years). Even after correcting for age, functioning as measured by the Global Assessment of Functioning and a 9-item measure assessing hygiene, economy, food preparation, etc. declined over time. As a result, although 49% were living independently (with or without support) at the first wave, only 34% were doing so at the last wave; by 2011 66% were living in a special home or institution. Examination of longitudinal trends in income indicated that disposable income and total income from all sources was constant between 1990 and 1995 but increased significantly over time after reform was enacted. Overall, results suggest mixed success of social support services.

“Living poets society” – a qualitative study of how Swedish psychologists incorporate reading and writing in clinical work

ABSTRACT Different forms of reading and writing can have therapeutic effects and therefore beneficially are incorporated into mental health care. In Swedish mental health care such incorporation is not established but the field is gaining increased interest. In this study, five psychologists in Swedish mental health care who incorporate reading and writing in their clinical work were interviewed about how they incorporate such activities and how they perceive reading and writing in terms of patient recovery. An Interpretative Phenomenological analysis resulted in the following themes: New perspectives, The psychologists’ perceptions, Shared symbols, Freedom to express oneself, and Safety through structure. The results show a need for flexibility in clinical work; since unique individuals express themselves in different ways, practitioners should be encouraged to offer patients opportunities for creative expression. It is suggested that reading and writing need to be established as valid and easily identifiable interventions in Swedish mental health care.

Facing the Challenges of Cultural Competency in Swedish Mental Healthcare

Facing the Challenges of Cultural Competency in Swedish Mental Healthcare

Service Users Experience of Peer Support in Swedish Mental Health Care: A \u201cTipping Point\u201d in the Care-Giving Culture?

Peer support workers are increasingly considered an essential ingredient in recovery-oriented mental health services. While research continues to point to promising results concerning the ability of these workers to positively impact service users’ experience of hope, quality of life and even health, peer support workers have only recently been introduced in Sweden and the aim of this study was to investigate service users’ experience of receiving peer support in Swedish mental health services. The results were described with three main themes corresponding to three levels of focus from the service user perspective; experience-based knowledge, competence and non-judgmental awareness (individual level), peer support as impacting the relationship with the caring environment (organizational level), and awakening hope for a life beyond the illness (community level). The results suggest the addition of peer support workers as contributing not just to individual outcomes, but to a more trusting relationship to Swedish psychiatric services, which are often considered to work primarily from a medically oriented treatment paradigm.

‘It used to be here but moved somewhere else’: post-asylum spatialisations – a new urban frontier?

This paper presents a number of spatialisations of mental health care in Sweden, exemplifying these spatialities in three vignettes drawn from the Swedish post-asylum landscape. Working with the notion of a ‘new urban frontier’, I examine: (1) how these landscapes have been transformed by processes of decentralisation and austerity measures; (2) how this transformation plays out within and through physical space; and (3) the new spatial relations that are produced through such transformations. The idea of ‘landscapes of care’ and the concept of ‘multiscalarity’ are used to understand the changing spatialisations evident in mental health care, and the shift we are presently witnessing which replaces the tangible spaces of ‘bricks and mortar’ of the past with, rather, a diversity of settings, localisations and administrations. The empirical material that forms the basis of the analysis derives from a larger study of spatial discourses in Swedish mental health care, which I carried out between 2008 and 2011. The paper concludes with some thoughts on the kinds of spatial relations evident within the post-asylum landscape of formal mental health care in times of austerity and decentralisation, wherein I consider whether these spatialisations can be regarded as a ‘new urban frontier of care’.

Meaning in work and emerging work identities of housing support workers: A quest for a comprehensible plot

Work and employees are often marginalized in studies on community-based psychiatric care and support systems. This paper highlights the role of the worker at congregated supported housing for people with severe mental illness (SMI). Housing support workers (HSW) are a fairly new professional role and have developed as a result of major changes in Swedish mental health care and services. The development of new roles is not unproblematic and raises intriguing questions. The purpose of this article is to describe housing support workers' experiences of meaning in their work, and in addition illuminate how the work identity of HSWs can be negotiated and constructed. Four focus group interviews were conducted with a total of 25 participants. Additionally, three follow up sessions were conducted with the same participants. The material consists of employees from four different sites. The intepretation of the material was inspired by a constructionist approach. The analysis generated three themes: to do a good job, everyday needs and the formal role. The work identity for HSWs is complex and not easily interpreted. The experience of an unclear assignment affects the description of what is meaningful and important-the work identity and significant affiliations for HSWs. In the long run, this fragmented world can have negative implications for the HSW.

Gender Differences in Needs and Care of Severely Mentally Ill Persons: Findings From a Swedish Cross-Sectional and Longitudinal Study

A great amount of research has been done in the area of gender and severe mental illness. However, there is an apparent lack of studies on gender differences concerning needs and care. To analyze differences in needs and care between men and women considered to be severely mentally ill (SMI) after the 1995 Swedish mental health care reform. In one area of Sweden, surveys were made in 1995/96 and 2006 of persons considered to be SMI. These persons were interviewed and their needs assessed. In a cross-sectional study in 2006, the needs and care of men and women were compared. In a longitudinal study, men and women interviewed in both 1995/96 and 2006 were compared concerning the development of needs and care. The structure of needs differed between men and women. Men had more needs concerning functional disability and those needs seemed possible to meet in the existing service structure. Women's needs concerning physical health, information about health and own security, seemed to be more difficult to meet. Only a few gender differences were found in satisfaction with services and service utilization. It seems urgent to have a gender perspective in a needs-led mental healthcare service.

Needs and care of migrants considered as severely mentally ill – cross-sectional and longitudinal studies of a Swedish sample

Purpose Higher incidence of mental illnesses and less access to care is previously reported concerning migrants but few studies focus on the needs and care of migrant groups in psychiatry. The aim of this study was to compare differences in needs and care between migrant and nonmigrant groups of severely and persistently mentally ill (SMI) after the 1995 Swedish mental health care reform. Methods In a Swedish area, inventories were made in 2001 and 2006 of persons considered as SMI. These persons were interviewed and their needs were assessed. In a cross-sectional study in 2006, needs and care were compared between migrants and nonmigrants. In a longitudinal study, migrants and nonmigrants interviewed in both 2001 and 2006 were compared concerning the development of needs and care. Results The needs of the migrant group were less taken care of. In 2006, there were more unmet needs in this group concerning accommodation, physical health, psychological distress, basic education and economy. Conclusion The improvement of groups considered as SMI concerning functional disability and efforts of care found in the actual area did not seem to include the migrant group, at least not to the same degree.

Severely and persistently mentally ill—A changing group. Ten years after the 1995 Swedish mental health care reform

Aim: A mental health care reform was implemented in Sweden in 1995. The target group of the reform was persons considered severely and persistently mentally ill (SMI). The aim of this article was to study changes in the target group 10 years after the reform, i.e. changes in the group of persons defined as SMI. Methods: Inventories of persons considered SMI were made in a municipality of Sweden in 1995/96, 2000/2001 and 2006 based on the same definition. The invented persons were interviewed. The same interview procedures, questionnaires and need assessments were used on all three occasions. The results were based on comparing the new groups considered SMI in 2000/2001 and 2006. Results: In 2006, the group of persons considered SMI was younger. Fewer persons with a diagnosis of schizophrenia and more persons with a diagnosis of mood disorders or addictive problems were included. Problems concerning relations and physical health were more evident. A greater part had all their income from social security in 2006, and fewer persons were occupied in some kind of salaried employment, full-time or half-time, regular or sheltered. Conclusion: The target group of the reform had changed and other groups of persons were considered SMI in 2006. These new groups require other strategies of care.

The development of needs in a group of severely mentally ill

The objective of this study was to follow the development of met and unmet needs in a sample of severely mentally ill after the 1995 Swedish mental health care reform and to analyse whether the efforts made by social services and mental health care have been more adequate since the reform. Inventories were made in 1995/1996, 2000/2001 and 2006 in an area of Sweden. A total of 171 persons who were considered to be severely mentally ill both in 1995/1996 and 2006, using the same criteria of definition, were interviewed using the same form of interview and their needs were assessed according to Camberwell Assessment of Need on all three occasions. The number of met needs had increased between 2006 and 1995/1996 and unmet needs in important need-domains had decreased. The changes in needs mostly referred to needs in the factor 'functional disability'. The degree of effort by psychiatric care and social services had increased. The number of wage-earners in the group had decreased to almost zero and the degree of social isolation had increased in 2006. The target group had made some progress referring to their functional disability and the efforts from services had increased. However, the integration in society had decreased in fundamental aspects.

RESPONSE

We would like to thank Chan (2007) for her detailed and positive commentary on our paper (Schröder et al. 2007) and would like to respond regarding four points that she raises. Firstly, we agree that earlier literature shows that care staff (Hugo 2001) and also students (Chung et al. 2001) have a stigmatizing and unfavourable attitude to patients with mental illness. This can have serious consequences for the patient, which is an important issue to be taken up in the education of staff. Research needs to focus more on the influence of programmes of education and on the responsibility of those in a leadership position with regard to the attitudes of health-care staff. However, this was outside the aim of our study. Secondly, what patients perceived as the characteristics of ‘poor’ quality of care is very important for nurses to know. In accordance with the aim of the study, the participants described how they perceived the concept of quality of care in the psychiatric setting. The results show that the concept was perceived in a positive light and loaded with subjective judgements. In an ongoing study we have developed (on the basis of the results of the study with which we are concerned here) an instrument for measuring quality of inpatient care from the patients’ point of view. The instrument is at present undergoing a pilot test and we hope that it will help to elucidate patients’ experiences of ‘poor’ quality of care in the case of inpatient psychiatric care. Thirdly, we agree that it must be interesting for the journal's readers to have information about the Swedish mental health care delivery system. Therefore, we would like to draw attention to an article which illuminates the said system in past, present and future (Silferhielm & Kamis-Gould 2000). For further information we would refer readers to the Swedish Compulsory Mental Care Act (1993), Forensic Mental Care Act (1993) and Health and Medical Service Act (1984) (which contains the legislation on voluntary care). Fourthly, we would like to clarify the issue of the sample size. It is a question of 20 (not 21) patients and most of them have experience of both inpatient (17/20) and outpatient care (20/20). The selection of both inpatients and outpatients is in accordance with a phenomenographic approach. This approach has its focus on the exploration of qualitative variations in data.

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.

Recovery from Severe Mental Illness: a 5-Year Follow-Up Study After the 1995 Swedish Mental Health Care Reform

The aim of this study was to follow up the target group of the 1995 Swedish Mental Health Care Reform, focusing on recovery. In 1995–96, in one area of Sweden, 602 people were surveyed and judged to be severely mentally ill. Five years later the number of people who had recovered was estimated and compared with the group still judged to be severely mentally ill. A sample of recovered people was interviewed in order to gain an understanding of the recovery process. Of those surveyed, 14% were estimated to have recovered to the degree that they were no longer considered to be severely mentally ill. Support from others, medication and healthcare contributed to recovery, sometimes in a complex and contradictory way. It was also found to be important that the person took an active role in his/her own process of recovery. The recovered person's locus of control could be internal as well as external.