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Experiences and Explanations of Mental Ill Health in a Group of Devout Christians from the Ethnic Majority Population in Secular Sweden: a Qualitative Study

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Experiences and Explanations of Mental Ill Health in a Group of Devout Christians from the Ethnic Majority Population in Secular Sweden: a Qualitative Study http://www.diva-portal.org This is the published version of a paper published in BMJ Open. Citation for the original published paper (version of record): Lilja, A., DeMarinis, V., Lehti, A., Forssén, A. (2016) Experiences and explanations of mental ill health in a group of devout Christians from the ethnic majority population in secular Sweden: a qualitative study. BMJ Open, 6(10): e011647 https://doi.org/10.1136/bmjopen-2016-011647 Access to the published version may require subscription. N.B. When citing this work, cite the original published paper. Permanent link to this version: http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-129024 Open Access Research Experiences and explanations of mental ill health in a group of devout Christians from the ethnic majority population in secular Sweden: a qualitative study Aina Lilja,1 Valerie DeMarinis,1,2,3 Arja Lehti,4 Annika Forssén1 To cite: Lilja A, DeMarinis V, ABSTRACT Strengths and limitations of this study Lehti A, et al. Experiences Objective: To explore existential meaning-making in and explanations of mental ill an ethnic-majority subgroup with mental ill health and ▪ health in a group of devout This study on experiences of mental ill health is to increase knowledge about the importance of gaining Christians from the ethnic qualitative and contributes original empirical data majority population in secular access to such information in mental healthcare. on an understudied minority within an ethnic Sweden: a qualitative study. Design: Qualitative study using in-depth interviews majority, that of devout Christians in a highly BMJ Open 2016;6:e011647. and systematic text condensation analysis. secular context. doi:10.1136/bmjopen-2016- Participants: 17 devote Christians with an ethnic- ▪ The participants represent a broad variation 011647 Swedish background, 12 women and 5 men, regarding symptomology, diagnosis, gender, 30–73 years old, from different congregations across age, class, sexual identity and denominational ▸ Prepublication history for Sweden, having sought medical care for mental ill affiliation, while also reflecting the cultural dom- this paper is available online. health of any kind. inance of Lutheranism in the Swedish society. To view these files please Setting: The secular Swedish society. ▪ The project was performed by a multidisciplinary visit the journal online Results: A living, although asymmetric, relationship team, with long clinical experience of treating (http://dx.doi.org/10.1136/ with God often was seen as the most important mental ill health. bmjopen-2016-011647). relationship, giving hope and support when ill, but ▪ An interviewer well aquatinted with the partici- ’ Received 23 February 2016 creating feelings of abandonment and fear if perceived pants religious belief system proved important, Revised 19 September 2016 as threatened. Symptoms were interpreted through an increasing trust for participants and providing a Accepted 30 September 2016 existential framework influenced by their view of God. rich material, but also increasing the risk of A perceived judging God increased feelings of guilt, shared blindness to certain aspects. sinfulness and shame. A perceived merciful God ▪ For ethical reasons, we chose to include only soothed symptoms and promoted recovery. Existential participants relatively stable in their illness consequences, such as being unable to pray or experiences, implying that some experiences participate in congregational rituals, caused feelings of may have been forgotten or too difficult to raise ‘spiritual homelessness’. Participants gave in the interviews, a fact that might have had an biopsychosocial explanations of their mental ill health, impact on the results. consonant with and sometimes painfully conflicting with existential explanations, such as being attacked by demons. Three different patterns of interaction among INTRODUCTION biopsychosocial and existential dimensions in their Mental ill health is designated as one of the explanatory systems of illness causation were largest future health problems in the Western identified: (a) comprehensive thinking and consensus; 12 (b) division and parallel functions and (c) division and world. In the summary report of the competitive functions. European-wide ROAMER study, a roadmap for 3 fi Conclusions: Prevailing medical models for public mental health research, the rst priority understanding mental ill health do not include the area focuses on positive mental health, protect- individual’s existential experiences, which are important ive factors and well-being. The second area for identifying risk and protective factors as well as underscores the need for an interdisciplinary possible resources for recovery. The various perspective for understanding mental health expressions of existential meaning-making identified in complexities. The third area calls for strengthen- For numbered affiliations see this devout religious subgroup illustrate that existential end of article. ing the understanding of cultural factors (ie, eth- information cannot be generalised, even within a small, nicity, religion and value systems and nationality) seemingly homogenous group. The three identified Correspondence to relevant for public mental health. Attention to patterns of interactions formed a typology that may be fi Dr Annika Forssén; of use in clinical settings. this third area in dialogue with the rst and [email protected] second provides the overall framework here. Lilja A, et al. BMJ Open 2016;6:e011647. doi:10.1136/bmjopen-2016-011647 1 Open Access Mental ill health is classified as descriptive symptom connected to a fear of violating patient privacy.20 21 In diagnoses according to either of the two operative our own work within general practice and psychiatry, we systems ICD or DSM, implying that understanding have encountered patients wanting to talk about existen- symptom expression needs to be sensitive to differences tial concerns in relation to their suffering, but with the in culture, social groups and systems of meaning. experience of this wish not being recognised.14 2 23 Attention to existential information as part of cultural Since this study focuses on a group that is devoutly reli- information in the diagnostic process has been empha- gious and belonging to the majority secular culture, we sised in person-centred mental healthcare by the WHO4 will look particularly at the results of studies concerning and in the new DSM-5.5 religious worldviews. Addressing religious issues has since In Western countries, an attempt to explain the com- the beginning of the 1990s become an important and plexity of mental ill-health causation is the biopsychoso- growing component in mental health research in western – cial model.6 The model has become established not world contexts.24 27 This research has been conducted least in mental health contexts, though the definitions primarily in countries such as the USA where religion is and operationalisations of the concepts vary in different part of the dominant culture.27 Religious faith has often, cultural contexts. It has also been criticised as insuffi- but not exclusively, been identified as having a protective cient, since it does not account for the individual’s effect, or facilitating coping in relation to, for example, underlying meaning system which affects development depression, substance abuse, schizophrenia, psychosis – and interpretation of symptoms.78Though meant to and suicide.24 31 However, religious faith also, mainly in offer a more complete and integrated understanding, its European contexts, has been identified as a risk factor operationalisation into separate components might lead for mental ill health.32 33 It can create internal and exter- to the opposite, losing sight of the lived body marked by nal conflicts for patients with mental ill health,29 34 influ- all experiences.9 Inclusion of an existential component, encing motivation to seek treatment and compliance.35 as central for the integrating process, has begun to gain Religious beliefs and practices are considered important attention in mental health contexts.7 to public mental health promotion.36 37 Healthcare researchers in Scandinavia suggest inte- Very little research has been conducted in Sweden grating the biopsychosocial model with existential and Scandinavia regarding religious or other worldviews meaning-making, understood in cultural context.10 11 and mental health.10 12 13 Most studies are related to Existential meaning-making here includes all types and immigrant groups with different ethnicities. The few expressions of how meaning is made, such as traditional studies concerning ethnic-Swedes described a wide religious expressions, other worldview expressions variety of worldviews, including religious, as possible including atheism or more privately constructed expres- resources in relation to mental ill health,38 39 as well as sions of spirituality.10 12 13 The model is referred to as that Swedish patients wanted to talk about their world- – biopsychosocio-existential.14 There are two primary views in their contacts with healthcare.39 42 reasons for using this model. First, a wide variety of exist- Mental ill health is increasing in Sweden.43 44 Of ential meaning-making is encountered in mental health patients in primary care, 20–30% suffer from symptoms work in these countries. Second, access to such informa- of psychological distress and anxiety, and depressive tion provides important knowledge for interpreting the emotions are common in the population.45
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