Learning from the other
Dialogues with unaccompanied refugee children about barriers
and possibilities for health and participation
Maria Tornée Bergström
Department of Education Master thesis 30 HE credits Pedagogy and health
Master Programme in education with a specialization in health Autumn 2019
Handledare/Supervisor: Ulf Olsson Examinator: Gunnar Karlsson Learning from the other:
Learning from the other
Dialogues with unaccompanied refugee children about barriers and possibilities for health and participation
Maria Tornée Bergström
As a departure for the study, statistics regarding the increased experiences of illness, especially psychic, among children and youth, were presented. With inspiration from Maxwell´s (2013) interactive design, and guided from the perspectives of phenomenology, hermeneutics, and
pragmatism, the study was placed into the lived everyday world of the participants. Phenomenological, narrative interviews with six youths were conducted through the interview technique direct scribing (Martin, 1998). Moreover, as the title of the thesis indicates, the general aim was to reach knowledge regarding the increased illness among children and youth by learning from the other, a group of youth with experiences arriving in Sweden as unaccompanied refugee children, helpfully to share their views and experiences. The study’s specific aim was to gain knowledge from the unaccompanied refugee children’s experiences and thoughts regarding health/illness and obstacles and possibilities for experience health in their group home (HVB) in Sweden and their country of origin. The plot in the narratives of the youth was built up by five sequences; orientation, relief, dislocation, restitution, and participation, recognition, and agency. The results showed barriers to health, such as impersonal relations, loneliness, and dislocation caused by language and cultural change. Possibilities for health were described by a healthy lifestyle, family, dialogue, and positive relations. The reciprocity from the relationships was also described of the youth as the main source to help the youth manage the process from the vulnerability and chaos they felt when arriving in Sweden to an agency and a feeling of ability in order to participate in their new society. The following interpretation and discussion tried to make the result transferable by pointing at changing historical and cultural views regarding health and illness. The feelings of lack of belonging and potential stigmatizing individuals could experience due to different categorizations such as ethnicity and medical diagnoses, are discussed with the concepts of the other. Finally, drawing on Levinas, the possibilities of breaking the categorical monological thinking through dialogues in face-to-face encounters were discussed together with Ricoeur`s ethics pointing at changing views regarding society and the Other. Further research and practice were also discussed.
Acknowledgements ... 0
Introduction ... 1
The study's connection to the discipline of pedagogy ... 2
Structure of the thesis ... 2
Limitation ... 3
Background ... 4
Unaccompanied refugee children ... 4
Risks with categorizing unaccompanied children ... 5
Group-home for unaccompanied refugee children, the institution HVB ... 6
Networks of agents surrounding the unaccompanied children ... 6
Summary ... 7
Literature review ... 8
Medicalization of problems in life ... 9
The diagnostic expansion ... 9
The importance of support and care ...11
Privatization and professionalization of HVB ...11
The lack of feeling at home ...12
The importance of close relationships ...12
“Mental illness” and migration ...13
Cultural differences regarding diagnoses, Depression, PTSD and Trauma ...13
The colonization of western psychiatry ...14
Learning from the Other ...15
Summary literature research ...16
Aims and objectives ...16
The specific aim ...17
Research questions ...17
The general aim ...18
Theoretical and conceptual framework ... 18
Epistemology and ontology ...18
Everyday life ...20
Concepts of health, dialogue, learning, and the other ...24
Pathological concepts of health...25
Public health ...27
Health promotion ...27
Learning about the Other ...29
Learning from the Other ...30
Design and method ... 33
The goal of the study ...33
Conceptual framework ...33 Research questions ...34 Method ...34 Interview ...35 Direct scribing ...36 Recruitment ...36 Participants ...37 Analysis ...38
Result and analysis ... 39
Narratives regarding everyday life at HVB, obstacles, and possibilities for health ...39
Participation, recognition, and agency ...45
Blended health concepts ...46
Societal and cultural changing views of health ...50
The research questions in the specific aim ...54
The research questions in the general aim ...56
Discussion ... 58
Learning from the Other ...58
Perspectives to guide the inquiry ...58
Health and illness; the views of the unaccompanied refugee children ...59
Health promotion as a social transformation ...62
Taking the results further ...63
Method discussion ... 66
Direct scribing as a way to reduce the risk of collecting sensitive data ...67
Extra protection by full anonymity ...68
Obstacles and possibilities in the co-produced text influenced by direct scribing ...68
Quality of the research ...70
The issue of validity and reliability ...70
Validity through generalization ...72
Postmodern criteria regarding quality in research ...72
References ... 74
Appendeces ... 82
Appendix 1. Letter of confirmation ...82
Appendix 2. Information- and consent-form (Swedish) ...83
Appendix 2. Information- and consent form (English) ...85
There are different kinds of spiritual gifts, but the same Spirit is the source of them all. There are different kinds of service, but we serve the same Lord. God works in different ways, but it is the same God who does the work in all of us. A spiritual gift is given to each of us so we can help each other. To one person the Spirit gives the ability to give wise advice; to another the same Spirit gives a message of special knowledge. The same Spirit gives great faith to another, and to someone else the one Spirit gives the gift of healing. He gives one person the power to perform miracles, and another the ability to prophesy. He gives someone else the ability to discern whether a message is from the Spirit of God or from another spirit. Still another person is given the ability to speak in unknown languages, while another is given the ability to interpret what is being said. It is the one and only Spirit who distributes all these gifts. He alone decides which gift each person should have. 1 Corinthians 12:4-11, NLT
Differences are initially problematized in the thesis, describing how certain categories are developed and maintained, often leading to stigmatization and suffering. However, the biblical text above also describes differences as the variety of gifts given to each of us, celebrating differences as a human condition, which could lead to learning and healing.
Writing this thesis has been hard work for a little more than a year. The dialogical theme, “learning from the Other,” has not only been connected to the actual writing of the thesis. During the writing-process, several gifts have been given to me through the diversity of dialogues. Apart from the most important contributions, the conversations with the unaccompanied refugee children, I also have to thank several people and settings for the learning I received. First, I would like to give a huge thank you to my supervisor, Ulf, for good conversations during tutorials. Surprisingly, I also found out that the limited comments you sometimes respond to my texts and e-mail, which sometimes made me a bit annoyed and insecure, also helped me into a more in-depth dialogue with myself to reflect. I also want to thank you for your advice on taking a couple of month’s break from the writing. Your advice did not only give me recovery from the stress I experienced, but it also gave me the possibility to learn more from the refugee families I worked with during the thesis writing. They have together with colleagues also been excellent teachers, helping me validate my results, as well as all the fantastic people I have met in my voluntary work in the language café in church. Also, many thanks to the staff and members in the church, you have been a valuable source of learning. When it comes to my own language struggle with writing the thesis in English, acknowledgments to Daniel, and all the writing groups I participated in during the year. I cannot imagine how this project had developed without your support. Acknowledgments are also aimed to Åsa for all the learning during the first tutorials with you. Moreover, I also want to thank all the teachers and students on the program, which has been a significant source of learning, especially I want to thank the participants at the “Hälsopedagogiska seminariet” and “Subjektivitetsseminariet.”I am very thankful for the valuable comments I have received from my opponent Karin and examinator Gunnar. Finally, a huge thank you to my family and friends for all your love and support. Jonas, your support and patience during this time has been invaluable.
The Public Health Agency of Sweden (Folkhälsomyndigheten) reports that children's experiences of mental and somatic illnesses are duplicated over a 30-year period. In the report
(Folkhälsomyndigheten, 2016), it is described that the number of 15-year-old boys which in their surveys have reported experiences of physical or mental illness at least two times a week, has increased during the period from 15% to 31%. Experienced illness among 15-year-old girls has increased from 29% to 57%. Folkhälsomyndigheten (2020a) also reports that the number of 13- and 15-year old girls and boys, with psychosomatic problems have doubled from the year 1980 The National Board of Health and Welfare (Socialstyrelsen 2017a) and BRIS (2017a) point out the age-group, 16-24, as especially troubled and problems as worry and anxiety have been tripled from 9 to 28 percent during the period 1980-2015. Experiences of worry and anxiety are the year 2018 reported from 52% in the age-group 16-29 (Folkhälsomyndigheten, 2020b). Socialstyrelsen (2017a) reports that diagnoses as depression and different kinds of anxiety syndromes are significantly contributing to the increased diagnostic and subscription of psychiatric drugs. Folkhälsomyndigheten (2020a) specifies that during the year 2017, almost 48500 children received psychiatric diagnoses, and Attention Deficit Hyperactivity Disorder (ADHD), autism, depression, and anxiety syndrome were the most common. Even though the increased mental illness among children and youths has caught much attention in recent years, similar statistics are found in the whole population, and Folkhälsomyndigheten (2020b) reports that 39% of the population year 2018, reported experiences of worry or anxiety and a fifth of the population declared that they at some point in life been diagnosed with depression. A group that seems to be overrepresented regarding mental ill-health, are immigrants, and Socialstyrelsen (2015b) argue that 20-30 percent of the asylum-seeking refugees arriving in Sweden is estimated to suffer from mental illness.
The statistics raise questions about the sustainability of our society. What barriers in society hinder good health and what circumstances in society have the ability to promote health? The statistics also raise questions regarding standpoints in our society when it comes to ideas about health/illness and normality/deviation. Biesta and Säfström (2011) describe how the tension between the taken for granted and the desirable may emerge when the taken for granted is disturbed by new elements, and this tension leads to possibilities for learning. The different views of people with different cultural backgrounds may interrupt common sense, and through openness to difference, create new meanings through dialogue (Lock and Strong, 2010, p.70). Arlebrink (2012, p. 34) explains that while the pathological, biomedical model is focused on the human’s physical condition, the holistic, hermeneutic model, focuses on the human beings’ thoughts, feelings, and experiences.
By taking the research out from technical, laboratory research such as screening and survey studies, which produced the statistics above, into the lived world of the participants, a better understanding might be reached. This study will try to get a better understanding of health and illness, and possible health promotion, finding salutary factors contributing to health (Antonovsky,1987). However, not through an aim to reach objective knowledge, but instead through dialogue in a face-to-face encounter, aiming to reach an understanding of the youths experiences in their everyday life. Moreover, as the title of the thesis indicates, the knowledge is hopefully gained by learning from the other, a
The study's connection to the discipline of
Dahlöf (1992) illustrates the Swedish research in pedagogics through a picture of a house containing rooms of dimensions spanning from psychophysiology, psychic functions, individual- and group psychology, groups, institutions, nations, and culture, studied with the help from disciplines such as physiology, psychology, social psychology, sociology, and social anthropology. Dahlöf also describes pedagogy as a discipline that moves between these dimensions from micro- to a macro level, also using a historical dimension. Even though it is a quite narrow but very diversified group, which is the object of the study, the phenomenological and hermeneutic interpretations are spread in most of the pedagogical rooms, moving from micro- to the macro level and back and forth in time.
The discipline of pedagogy is also described by Biesta and Säfström (2011), containing ethics of a responsible subject, and esthetic of freedom illuminating contexts when equality emerge in a situation tinged with inequality, leading to a change of our common-sense knowledge. Finally, Biesta and Säfström (2011) describe the discipline of pedagogics containing an emancipating politics with the aim to shape a new and better future.
The study's aim learning from the Other, the unaccompanied refugee children, instead of about the Other, with the help of phenomenology and hermeneutics, aims to an esthetic of freedom where equality emerge in a situation of inequality with the possibility to change our common sense knowledge regarding suffering and healing. The ethics of Levinas and Ricoeur show a path for the subject's responsible encounters and relations with the Other. Finally, with the help of the
interpretations of the unaccompanied refugee children's narratives, emancipating suggestions for politics regarding health and a charitable and sustainable society is explored.
Structure of the thesis
In the first chapter, background, a definition, and background regarding the unaccompanied refugee children are provided together with information regarding one of the main contexts in the current study, the institution HVB. After that, a description follows regarding the network of actors surrounding the unaccompanied refugee children and the institution HVB. The different categorizations of the unaccompanied refugee children, for example, the labeling of them as
3 emphasize the importance of conversations between the East and the West, and the thesis aims and objectives, learning from the Other, is introduced.
The second chapter, theoretical and conceptual framework, starts with a description of central concepts such as experience, thought, lifeworld, everyday life, and understanding named in the aims and objectives. A suggestion of perspectives to gain knowledge is following, consisting of the perspectives of phenomenology, hermeneutics, and pragmatism. Moreover, a selection of health concepts, dialogue, learning, and the other, are described. Finally, the section tries to picture how the thesis attempts to break the monologue of totality-knowledge of the other through dialogue provided by phenomenological, narrative interviews with the unaccompanied refugee children. The section also describes how a better understanding of their situation and the increased illness among all children and youth could be reached through hermeneutics. The chapter ends with a description of how the
perspective of pragmatism is used in the design of the study, described in the next section.
The design and method are described in the third chapter. The design is, to a large extent, inspired by Maxwell´s (2013) interactive approach. Maxwell problematizes using a prefix strategy in a qualitative design. Instead, the design of the study is constructed and reconstructed during the research.
Interviews with six youths by the method of direct scribing (Martin, 1998) are used to collect data. In the fourth chapter, result, and analysis, bricolage, a mix of analysis from both coding categories and analyzing the narrative structure (Kvale & Brinkmann, 2009), is used, commented with a hermeneutic interpretation. The chapter is finally followed by a result- and method discussion. The discussion mainly focuses on health-promotion and sustainable society. A way to promote health is to change the lens of health/illness away from the person and avoid thinking in the biomedical model. If the focus instead is shifted to society, the health-promotion could be aimed at us all instead of at a separate person or group. However, suggestions for suitable care focusing on the ability and narrative of the person are described. By learning from the other, equality may increase by shifting the lens from the other as “Les Miserables” to a source of teachers. By learning from the other, (the title inspired by Todd, 2015) instead of about the other, may also by dialogue create possibilities to a mutual integration leading to participation and equality.
Media has, during recent years, reported several articles about the unaccompanied refugee children. The pieces are often questioning the unaccompanied children’s rights in different ways. Much of the materials in media are written in a way that denigrates them as a group. Other articles disparage the groups, which is problematizing their rights. Even though a more open and less infected dialogue about their situation probably would gain them, the current study will not address such perspectives in the thesis. Since the literature review addressed a lack of research regarding the unaccompanied not only as a group but as an individual, a normal youth with both everyday and unique experiences, this will be the departure for the research. Also, the thesis has an interest in breaking our common categorical thinking, in this case, for example, articles problematizing perspectives that only address the vulnerable of these youth, but also their strength.Therefore, I have chosen to let the youth help me to understand the general increased mental ill-health in Sweden and explore a possible health
4 questions concern, they are in the study named as unaccompanied refugee children or youths. The problems the participants with an experience of arriving in Sweden as unaccompanied refugee children might have experienced after leaving their accommodations for children are not either notably
attended in the study. The study mainly focuses on their narratives from their country of origin and their first time in Sweden. The result and discussion derive from a small sample of interviews, and the study does not aim to describe any representative group or reach any objective knowledge. Instead, the research by letting the participants shine in their own light strives to reach an understanding of their particular experience, which also could be something generalizable to reach a better understanding regarding health and the increased ill-health among other groups in Sweden.
Unaccompanied refugee children
During 2014 (7 049) and 2015 (35 369), a large number of unaccompanied refugee children seeking asylum in Sweden (SCB, 2018). According to Wimelius, Eriksson, Isaksson, & Ghazinour (2017), which refer to UNHCR (2012: 28), in recent years Sweden, has become one of the largest European recipients of unaccompanied, asylum-seeking refugee children. A majority of these children were boys 13-17-year-old from Afghanistan, Eritrea, and Somalia, and about 75 % - 88% during the years 2014-2016, received permanent residence permits (Migrationsverket, 2019).
The Swedish law LMA, Lagen om mottagande av asylsökande m.fl.(1994:137), (Swedish Reception of Asylum Seekers' Act) often shortened to LMA, which are regulating the placement of the
unaccompanied refugee children, defines them as:" children under age 18 which during arrival to Sweden are separated from both their parents or from any other adult person substitute for the parents" (Law 1994:137 1b§, my translation).
Malmsten (2014) emphasizes that unaccompanied refugee children arriving in Sweden are not something unique to the late twentieth and the twenty-first century. During the Second World War, approximately 70 000 Finnish children fled to Sweden during the years 1939-1945. After the war ended, 15 000 stayed in Sweden (Malmsten, 2014). Other examples of an influx of refugee children to Sweden and other parts of Europe mentioned by Malmsten (2014) are the 23 000 unaccompanied children from Greece during the civil war (1946-1949) and the 6 000 children who fled from Hungary during the revolution year 1956.
According to Kamali (2015, p. 62), the increasing migration to Sweden during the twenty-first century has origins in globalization, leading to wars and conflicts which destroy local, traditional, and
5 When it comes to borders, wars, and conflicts, Kamali (2015, p. 1) argues that an uneven
modernization, often derived from colonial and imperialist motives, have created many disintegrated countries. With consequences such as disputed colonial borders and distorted national belongings, the modernization and "Westernalisation" has laid the ground for many ethnic and political conflicts. Kamali (2015) means that "Westernalisation refers to the uneven changes accompanying the transformations of non-Western countries into a capitalist world system, following the interests of Western colonial structures" (Kamali, 2015, p.1). Kamali (2015, p.8) means that the capitalist market and the neoliberal agenda for the development of non-western countries, have in many cases, led to increasing poverty, wars, and conflicts, resulting in millions of displaced people, in addition to many deaths and injuries. Many prejudices portray the West as developed and peaceful, and the East as undeveloped and violent (Hedin, 2006; Kamali, 2015; Munk, 2008). Munk (2008, p. 1231) describes how those ideas have led to fear in the West against people migrating from countries with violence and conflicts.
Risks with categorizing unaccompanied children
In the research overview by Wernesjö (2012), the focus on mental health in studies regarding
unaccompanied children is problematized since many studies are conducted within individual-oriented disciplines focusing on psychopathology based on questionnaires and quantitative methods. Wernesjö (2011), who refers to a range of studies focusing on the high prevalence of psychiatric diagnoses such as depression, anxiety, and PTSD, emphasizes the risk of pathologizing unaccompanied children by categorizing at risk for developing mental illness. Wernesjö (2012) means that by placing these children in a deviant category, there is through prejudices a risk of othering them, which could affect their feelings of belonging in their new country.
Even though it is easy to understand that migration often is connected with suffering, it may be constructive to reflect on the effects, diagnosing the distress as a mental illness. The fear and prejudices in the West against migrants from countries with violence and conflict may increase if migrants also carry the stigma of mental illness. Ohlsson (2017) describes that the representations of mental illness in the newspaper often include a public discourse of individuals with mental ill-health as deviant and dangerous. Goffman (1963), the most prominent user of the concept stigma, defines it as "Stigma is a 'mark' that signals to others that an individual possesses an attribute which reduces them from 'whole and usual' to 'tainted and discounted" (Goffman 1963, p 3). Due to the sociology of health, stigma occurs when an individual is considered deviant from what at the time is considered normal. Stigma is connecting with negative stereotypes leading to prejudices and discrimination. Pescosolido (2015) describes how Goffman's work became central in the 1960s, with the social and political movement of deinstitutionalizing the treatment of mental illness. Pescosolido (2015) also explains that Goffman did not consider the nature and effects of stigma as static but more as a
continuum depending on other aspects as the individual's 'moral career' or the broader societal context. One aspect of reducing the stigma connected to mental illness is that the acceptance to call several problems in life for mental illnesses could have contributed in some way to the increased
medicalization. Medicalization is a concept often used to describe processes when nonmedical problems are defined and treated as medical problems, often labeled in the form of illness and
disorders. An introduction to the concept of medicalization will be found in the literature review in the next section.
Group-home for unaccompanied refugee children, the institution HVB
When unaccompanied refugee children are arriving in Sweden, the arrival municipality has the responsibility for the initial reception, and the children are usually offered accommodation in transitional-houses. In connection with the asylum application being registered, the children are sent by the Migration Board (Migrationsverket) to more permanent accommodation in the instruction municipalities. The instruction municipality is responsible due to the Social Service Act
(Socialtjänstlagen, SFS 2001:453) for ensuring that there are available family homes, HVB, or support residences. The most common accommodation for the unaccompanied refugee children, and which constitutes the context for the current study, is the institution HVB, short for hem för vård eller boende (home for care or accommodation). Health and Social Care Inspectorate (IVO), describes the purpose of the group-home (HVB) as giving the children support, care, and nurture (IVO, 2019).
The institution HVB was during the initial stream of refugee 2014 and the beginning of 2015, regulated through the governing document, Socialstyrelsens föreskrifter och allmänna råd (SOSFS 2003:20) om hem för vård eller boende (The National Board of Health and Welfare's regulations and general advice (SOSFS 2003: 20) regarding home for care or accommodation). The institution HVB was not created especially for the unaccompanied children, and the regulations from the year 2003 were not specially created for care and accommodation for unaccompanied refugee-children but have initially regulated a health care institution for individuals, usually children and youths, with social or psychological problems. This fact can be mirrored in the regulatory document, which consistently uses concepts like treatment and treatment-plan when describing the institution´s goal. Depending on a large number of unaccompanied refugee children arriving in Sweden during 2014-2016 and the difficulties meeting the requirements (mainly requirements regarding education and experience for staff and management) in the regulatory document, an exception to specific regulations and general advice was created through the regulatory document HSLF-FS 2015:34. In this document, the
concepts treatment and treatment-plan are replaced by concepts such as methods and work procedures. However, in 2016, the exceptions were removed, and the original regulatory document was replaced by HSLF-FS 2016:55. In this regulatory document staff and management experience and education reintroduced, concepts like treatment and treatment-plan still replaced by methods and work-procedures but with an emphasis that they should be executed based on available knowledge, also often described as evidence-based (Socialstyrelsen, 2016).
Networks of agents surrounding the unaccompanied children
When the unaccompanied refugee children arrive in Sweden, they are from the Social service act, allocated a social welfare officer who is responsible for investigating the child's needs. They will also be allocated a legal attorney who will assist the child in the asylum case and a legal guardian who is a layperson who voluntarily works with unaccompanied refugee children and is paid a monthly fee for taking responsibility of the child's personal and economic needs until he or she becomes 18 years old. However, the legal guardian has no responsibility for the child's provision, the daily care, and
supervision of the child. The Migration Board (Migrationsverket) provides the child's provision through direct payments to the child and by redistributing funds to the municipality the child lives in or to the child's instructional municipality and the child's accommodation. The staff at the HVB should meet the children's needs for a safe environment, daily care, and support, and one of them, a contact
person, is specially appointed to help the child with the surrounding network of actors (Socialstyrelsen
2016). Migrationsverket (2019) informs that those asylum-seeking children have no school plight but have the same right attending school like other children in the community. The agent responsible for follow up the quality in school, drawing up control documents for the school's activities, and
7 The surrounding network also affects the refugee children's everyday life at the HVB, since the
network is dependent on the relations between actors on different levels, and the beliefs and politics among them. Apart from the children's micro-network, described above, the surrounding macro-network in addition to the Social Service act and the Migration Board, and the Swedish National Agency for Education mentioned above, Socialstyrelsen (2016) describe agents such as the
Inspectorate for Health and Care Services (IVO), which is responsible for supervision of health care and social services. Socialstyrelsen (2017b) also describes the unaccompanied refugee children network, including the County Council (Landstinget), which regulates the asylum-seeking children's equal right to dental, health, and medical care compared to other citizens. The County Administrative
Board (Länsstyrelsen) has the responsibility for the legal guardians and acts as coordinator of the
municipalities' reception of unaccompanied children. The National Board of Health and
Welfare (Socialstyrelsen) is, among other things, responsible for developing a knowledge base, advice,
and regulations regarding unaccompanied refugee children. They are also monitoring and evaluating the activities of the different healthcare and care providers.
This section gave a background and a definition to the unaccompanied refugee children arriving in Sweden during the influx of refugees year 2014-2016. After a short history regarding the earlier influx of unaccompanied refugee children in Sweden, different causes for their escape were discussed. The most common accommodation for the unaccompanied refugee children, which also constitutes one of the contexts for the current study, the institution HVB, short for hem för vård eller boende (home for care or accommodation), was also described and discussed on ideas and regulation documents regarding similar institutions for children and youth. A description regarding the network of actors surrounding the unaccompanied refugee children and the institution HVB was also provided. The tendency in earlier studies to solely focus on emotional problems arising from past traumatic
In the previous section, a risk of othering and stigmatizing the unaccompanied refugee children, which could affect their feelings of belonging in their new country, was described and the focus on the individual-centered psychological research, in the risk of pathologizing the unaccompanied refugee children were problematized by Wernesjö (2012). Wernesjö (2012) is referring to several studies describing the unaccompanied refugee children's emotional problems, trauma, and psychiatric diagnoses. Wernesjö is, for example, referring to a Belgian study (Derluyn & Broekaert 2007) that investigates the prevalence of emotional and behavioral problems experienced by unaccompanied refugee children living in Belgium. The study was conducted through self-report questionnaires (HSCL-37A, SDQ-self, RATS, and SLE), filled in by the refugee children and questionnaires (CBCL/6-18 and SDQ-parent) filled by social workers surrounding the children. The result showed that between 37% and 47% of the unaccompanied refugee children had severe symptoms of anxiety, depression, and Post Traumatic Stress (PTSD). Wernesjö (2012) which call for research focused on the refugee children´s own perspectives of wellbeing and the obstacles and possibilities in the host country contributing to their experiences of health, argues that the existing research runs the risk of constructing the unaccompanied refugee children as solely passive and vulnerable instead of seeing them as able, actors in their own right even though being in a vulnerable position. However, currently, a couple of years after Wernesjö:s (2012) call for an evolved research in the field, the selection, and variation of articles regarding unaccompanied refugee children and health are increased, but still not very extensive. A search during spring 2019 in Stockholm's University's library, using the words unaccompanied and health, focused on articles written after the year 2014, approximately 600 peer-reviewed articles in total worldwide and 60 when it comes to articles concerning a Swedish context were found after exact duplicates were removed.
A similar view to Wernesjö (2012) problematizing the focus on unaccompanied refugee children's vulnerability is also held by Celikaksoy& Wadensjo (2017) which are analyzing the labor-market outcome of the group since they also lack research not only focusing on the unaccompanied refugee children's vulnerability but also on their strength, resilience despite their traumatic experiences and challenges. However, much literature and reports, for example (Al-Sudany, 2017; BRIS, 2017b; Socialstyrelsen, 2015) which has in common pointing at the high risk for unaccompanied refugee children developing mental illness, often referring to trauma gained through traumatic experiences in the refugee's country of origin or during the escape. The distress experienced of unaccompanied refugee children is often described in terms of mental illnesses as Posttraumatic Stress Disorder (PTSD), depression, and Generalized Anxiety Disorder (GAD). When it comes to the refugee in total, Socialstyrelsen (2015) argue that 20-30 percent of the asylum-seeking refugees arriving in Sweden is estimated to suffer from mental illness. In their knowledgebase, Socialstyrelsen (2015) argues that many of the refugees have contact with the primary care, but fewer of them have visited the specialist care. Socialstyrelsen (2015) argues that many of the migrants with psychiatric problems come from cultures that often stigmatize persons with psychiatric illnesses. They mean that this may be a reason why they avoid the specialist care, and they hope that their knowledge base could act as a support for the staff at the primary care to notice, diagnose and treat refugees and migrants with experience of war, violence, and assault.
9 Taljemark, Lindgren & Johansson (2015), and Johansson, Täljemark & Ramel (2012). In a
comparison of inpatient psychiatric care between unaccompanied refugee children and other patients, 3.40% of the population of unaccompanied refugee children received inpatient care and 0.67% inpatient involuntary care, compared to 0.26% and 0.02% respectively of an age similar population, both comparisons p < 0.001. Their findings show that 86% of the unaccompanied refugee children stress was related to the asylum process, and no differences were found in diagnoses except for neurotic disorders, which were more common in the group with unaccompanied refugee children.
Medicalization of problems in life
Even though it is easy to understand that migration often is connected with suffering, as described above, the distress of the unaccompanied refugee children is often described in terms of mental illnesses as Post-Traumatic Stress Disorder (PTSD), depression, and Generalized Anxiety Disorder (GAD). The medicalization of the unaccompanied refugee children’s problem with the labeling and treatment of the unaccompanied refugee children's problems as illnesses could, as earlier described by Wernesjö (2012), contribute to othering the unaccompanied children which could affect their feelings of belonging. Is their distress for sure a medical condition in need of medical or therapeutic aid, or is their distress created by forces (organizational, societal, political, etc.) outside themselves and therefore should be seen as the unit in need of aid? Even though the unaccompanied children as all other humans are vulnerable and sometimes in special need of support and care, the labeling, the learning about the unaccompanied refugee children, might lead to not seeing them as able with their own agency could also as later discussion will show, contribute to a lack of learning from them. Conrad (2007) defines medicalization as: "Medicalization describes a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness and disorders" (Conrad, 2007, p 4.). Sachs (2002, p. 85) explain medicalization as a process when human social life is transformed into something biological. This process means that the relationship between the individual and the social body is neglected. Sachs (2002) also believes that the prevailing health promotion and health surveillance, therefore, also through this approach is primarily rooted in the individual and biological
A search for literature in Stockholm's University's library regarding medicalization and migration gave very few hits, which indicate a need for further research. In the section below, an introduction of medicalization will be followed by some peer-reviewed articles regarding unaccompanied refugee children in Sweden during recent years and other literature, primarily focusing on medicalization and migration.
The diagnostic expansion
10 Diagnostic and Statistical Manual of Mental Disorders (DSM). In DSM-I, published in 1952, there were 106 diagnostic categories in a manual of 130 pages. In 1994, with DSM-IV, the expansion of diagnoses had increased to 297 in a manual of 886 pages. In DSM-5, published in 2013, there are 15 new diagnoses, even though some earlier diagnoses are eliminated (Brinkmann, 2016, p. 11). Swinton (2016, p.22) describes how the critics of the DSM-5 criteria for mental disorders, mean that its inclusion of phenomena such as shyness, grief, internet use, and mathematical disability, would instead of medicine and psychiatry, preferable belong to other fields such as religion, law, and education.
Summerfield (2004, p. 233) argue that contemporary mental health practice has its roots in the enlightenments worship of reason. The confidence in scientific accounts for mental disorders came from the Cartesian dualism, separating the body and mind. Besides an enduring faith in science, Conrad (2007, p 8.) points out social factors like a decrease in religious faith, the power of medical professions, technical and individual solutions to people's distress, beliefs in rationality and progress, and an overall humanitarian trend in the West.
Summerfield (2004, p 233) also describes the secularization in the West and the wane of tradition and religion as the primary cause for the transformation of human suffering into psychiatric medical knowledge. Naidoo and Wills (2000, p. 9) describe how the western scientific medical model arising during the Enlightenment was accompanied by the spread of different equipment and techniques to study the world. The belief that everything could be knowable through a proper scientific method aiming to measure and categorize shaped the thought that the science regarding the human body and mind could be seen as true knowledge in an objective and universal science (Naidoo & Wills, 2000, p.9).
Conrad (2007, p 148) argues that medicalization brings social consequences in the way we pathologize life problems. The medicalized view of different problems in life focus on the individual instead of the social context, which can lead to neglect of the social issues in our society, which creates the personal life problems which are medicalized. By label the problems as medical, we also define what is "normal, expected, and acceptable in life" (Conrad, 2007, p. 149). By the medicalization, he also claims that social control increase. The medical expectations set the boundaries for behavior and wellbeing. Rose (2006) refers to Foucault's work Madness and civilization (1967), which describes how the diagnostic classification began in the asylum, collecting the uncontrollably miserable such as the sexually promiscuous, criminals, gamblers, and alcoholics. However, today, the diagnostic manuals are no longer limited to those inside the borders of the asylum. Instead, the psychiatric diagnostics includes a range of moods and behaviors that once considered as a part of the normal ups and downs of life. Rose (2006) problematizes all this diagnosis, which also leads to treatments and prescriptions of psychiatric drugs advertised by the pharmaceutical companies to increase their market share and shareholder value. Rose (2006) also argues that the increased diagnosticating bring
substantial economic consequences for the society and barriers for the one with severe illness to get healthcare.
11 by the three-dimensional Hospital medicine where illness involved symptoms, sign, and pathology. In this kind of medicine, the sign and the symptoms did not in itself constitute the illness. Both pointed instead at a potential underlying lesion that was the disease. Armstrong (1995) continues describing how a four-dimensional medicine emerged early in the twentieth century, the surveillance medicine. This kind of medicine evolved from the problematization of the normal, and Armstrong (1995) gives as an example of the machinery of observations during the early twentieth century regarding children’s height and weight growth chart. From knowledge regarding children’s “normal” growth, the
possibilities of abnormal growth could be identified in reference to other children. In the same way, this new medical gaze also monitored psychological well-being, trying to identify abnormal forms. Another technical tool, screening for abnormalities, first introduced during World War II, was the socio-medical survey. Armstrong (1995) describes how the statistics from these surveys investigating the health status of the population, showed that people experience symptoms of illness most days of their lives and lead to a relief from the biomedical model’s binary separation between health and disease and classified instead health on a continuum. Everyone was normal, but no one was truly healthy (Armstrong, 1995, p. 397). This blurring between health and illness and the normal and pathological lead to the emerging surveillance services such as screening and observation. After World War II, this kind of health promotion grow and surveyed concerns such as diet, exercise, and stress. Armstrong (1995) writes that “The extension of a medical eye over all the population is the outward manifestation of the new framework of Surveillance Medicine” (Armstrong, 1995, p.400).
As an alternative to the biomedical explanation of the refugee children's "mental illness," there are also other voices examining the children's ill health through different interactions and contexts. Some of the pre-reviewed articles in a Swedish context are addressing the mental distress for the children and surrounding agents when it comes to the forced deportation of the youths (Hansson, 2017; Sundqvist, 2017; Sundqvist, Ögren, Padyab, & Ghazinour, 2016) and regarding medical age-control (Malmqvist, Furberg & Sandman, 2018). However, these issues are not further treated in the literature review since the present thesis primarily examines the unaccompanied refugee children´s everyday life experiences at their HVB.
The importance of support and care
The importance of a well-functioning reception with support and care is by several articles described as significant factors for unaccompanied refugee children's ability to remain healthy. Jahanmahan & Bunar (2018) investigate the significance of the refugee children's interaction with their social welfare officers and the legal guardian, especially during their asylum process. Their findings show that positive interaction is vital for refugee children's resilience. Wimelius, Eriksson, Isaksson &
Ghazinour (2016) problematize the lack of interaction between actors leading to difficulties regarding the refugee children's integration. Some articles point at the importance of social support and a functioning system of support and care in the country of arrival (Bjerneld, Ismail, & Puthoopparambil, 2018; Hessle, 2009; Thommessen, Corcoran & Todd, 2015). However, Kamali (2016) is concerned that too much support and caring passivate the unaccompanied refugee children. Moreover, he claims that the unaccompanied refugee children must learn to take responsibility, and the staff must act as good role-models.
Privatization and professionalization of HVB
12 Critics concerning the professionalization and privatization of HVB are also made by Meagher,
Lundström, Sallnäs & Wiklund (2016) which describes the processes of policy and actor's response to them during 1980 – 2000, turning more family-like public residential home for vulnerable and
troublesome children to professionalized large private companies. Meagher et al. describe, for example, how the professional logic during the 1990s, social work discourse gradually changed to evidence-based practice, which put pressure on the institutions to use scientifically-based
interventions. The earlier family-based care replaced by effective professional treatment. The unaccompanied children who started arriving in Sweden in the early 2000s, became a significant source of profit for the private companies since the demand for places for this new target group was more predictable than for children in the regular child welfare system. However, the consequences of the privatization of residential home by large companies have been discussed by media and society, witnessing of scandals and questioning profiting from vulnerable children.
Even though Kamali (2016) means there are many reliable private HVB, the privatization of HVB for unaccompanied refugee children would also appeal to unreliable actors to start up HVB with the result that the management and staff do not possess required background and qualifications.
The lack of feeling at home
Söderqvist, Sjöblom, and Bülow (2016) also criticize the professionalization of residential care and are using Goffmans (1961) understanding of total institutions as part of a conceptual framework, in their study analyzing the professionals understanding of the concept "home." Söderqvist et al. (2016) are referring to Saunders & Williams (1988), who highlights three criteria for a shared understanding of what could be called home; possibility of being in control, lack of surveillance, and a place to be you. Söderqvist et al. (2016) relate these aspects to the concept of ontological security. However, the findings showed that rules at residential care limited the youth's possibilities of control and being themselves. Since the professionals are supposed to observe the youth's wellbeing and behavior for later report to the social welfare office, a lack of surveillance is hard to achieve. Söderqvist et al. (2016) conclude that since unaccompanied refugee children have different backgrounds than children usually placed in care, the social work practice may decrease the wellbeing of the unaccompanied refugee children meeting their unique needs. The concept home is also discussed in an article by Wernesjö (2015) as the refugee children connect the concept of home with family and close social relationships. The article also problematizes the challenges of belonging the refugee-children can meet in more rural settings, which sometimes results in loneliness.
The importance of close relationships
“Mental illness” and migration
As earlier described in the introduction, it is not only the unaccompanied refugee children who are considering being at risk of developing mental illness. Socialstyrelsen (2015) reports that 20%-30% of asylum-seeking immigrants in total are considering the suffering of mental illness. A social
constructionist stance regarding the interface of migration and mental health, drawing on Ian Hacking, is done by Swinton (2016). Swinton (2016, p. 24-26) describes Hacking's interest in how certain 'kinds of people' enter into and exit from society at particular moments in time. When it comes to mental health and diagnoses, Hacking's point is not that the actions we now name with diagnoses have to be something new. Instead, he points out that before it might not be possible to describe a person as we do today, until the actions that form the special medical category were enshrined within the medical diagnosis, social policy and the laws of the land. First, when medicine and law decide to name a particular set of actions as a certain type of diagnosis, it is possible for someone or a group of people to include by the category. “Philosophically, Hacking describes this perspective as dynamic
nominalism, a form of nominalism that examines the mutual interactions over time between the phenomena of the human world and our conceptions and classifications of them” (Swinton, 2016, p.25). Swinton (2016, p. 26) explains that central to this idea is the historical process in which something comes into existence just by naming it. “Numerous kinds of people come into being (are 'made up') hand in hand. By new ways of the label and rename people; a social change creates new kinds/categories/ types of people” (Swinton, 2016 p. 26).
Swinton (2016) asks the question: “What exactly are we talking about when we try to unravel the entities that are classified as mental illness?” He argues that historically, the phenomenon "mental illness" has taken various forms, and diagnoses differ across cultures and contexts.
Mental illness is clearly socially constructed and, while that does not mean it is not 'real,' it is only relatively recently that illness has been the primary definitional language used to describe the
phenomenon. But if we try to impose a one-dimensional—and socially powerful—medical perspective on an entity that also has complex political, social, cultural and spiritual components, we are in danger of ignoring the nuances of our subject matter and generating misleading or unconvincing hypotheses. Such a constricted lens is also likely to mar our understanding of migration and undermine any attempt to evaluate the relationship between the two phenomena (Harper, 2016 p.9).
Cultural differences regarding diagnoses, Depression, PTSD and Trauma
Swinton (2016) argues that a study of migration and mental illness are depending on a reflection of what the mental illness stands for in its fullness and the different ways it could be manifested through, depending on culture and context. Swinton (2016, p. 24) refer to the work of anthropologist Arthur Kleinman and gives an example of how depression in Taiwanese culture is manifested differently from a western understanding. Since mental health problems are highly stigmatized in the Taiwanese culture, people's experiences of depression are often somaticized instead of manifested by Western perspective such as sadness, guilt, and shame.
14 anxiety. The experts recommend re-exposure to the original trauma, supervised by a counselor as the most effective treatment (Swinton, 2016, p.31).
Using the DSM-manual, researchers did find some signs of PTSD among the tsunami victims, but for Watters (2010), it was clear that the victim's cultural beliefs were different from the western
understanding of PTSD. The introduction of alien forms of treatment could instead be seen as a form of "mental health imperialism." Watters realized that the tsunami-victims suffering was not
manifestations of PTSD. Instead, their suffering was related to the fact that one's role in one's group was lost or deeply disturbed. The suffering was lived through a more communal rather than an individual way. Moreover, the expert's aid of PTSD treatment was not useful since talking about the trauma is central in the PTSD treatment. In that particular culture, many instead believed that the ability not to talk of distressing experiences is a sign of maturity. Also, treatment in the form of individual therapy may be counterproductive since it evokes fear of social isolation.
The individual-centered, biomedical view is also problematized by Sousa and Marshall (2017) with the example of trauma as a medical experience instead of political violence. Political violence is by WHO defined as:
the attempt to achieve political goals through the methodical use of physical force, or manipulation, including the intentional deprivation of basic needs and rights, such as access to food, education, sanitation, healthcare, as well as freedom of speech and association" (WHO, 2002, referred by Sousa and Marshall, 2017 p. 787).
Sousa and Marshall (2017) problematize the biomedical model in the general humanitarian psychiatry and its response to mass civilian trauma events focusing on the individual clinical diagnosis and treatment, the biomedical model. By pathologizing individuals affected by political violence may lead people to view themselves as isolated victims suffering from mental illness that they must individually overcome, instead of collective experience as survivors of violence within a social and political context. Instead, it is suggested by Sousa and Marshall (2017) that healing from political violence is rather a communal process concerning the reestablishment of collective trust and social and political action, not an individual project. They also argue that medicalizing individuals suffering from political violence, correspond with neoliberalism. Such a movement center on privatization, deregulation and trade liberalization, primarily economic, and can deeply interweave into the social and political since it "prioritizes the individual over the collective and singular responsibilities over mutual obligations and rights" (Sousa and Marshall, 2017, p. 788). Instead, growing empirical research shows that collective-based forms of belonging, action, and meaning-making are of significant importance when it comes to recovering from the psychological effects of political violence. The case-study (Sousa & Marshall, 2017) of children from two Palestinian refugee camps in the West Bank shows that recovery from the effects of political violence is not a process in individual isolation. The recovery happens in the daily process, living in relationship with others. Such recovery creates both individual and collective identity, agency, and meaning.
The colonization of western psychiatry
15 thinking and the existing health promotion, using technical solutions trying to uncover the risk of illness and disease. Sachs explains the embeddedness of social and cultural factors when it comes to our beliefs regarding health and illness:
Beliefs about the body are never objective or neutral but always rooted in perspectives that relate to a society's morality, economy and political institutions, religion and views on, for example, male and female. When people talk about the body and changes in the body, they also talk about something else (Sachs, 2002, p.43).
Watters (2010, p 2.) also claims that over the last 30 years, American's have exported western
definitions and treatments about mental illness. Watters (2010, p 171) argues that western psychologist and psychiatrist has promoted the biomedical health concept around the world with the argument that it reduces stigma. By blaming genes or disturbed chemistry in the brain, the person of suffering avoids being blamed for lack of personal will or motivation. Historical, the forms of madness in different countries had a great diversity since the troubled mind has searched for meaning from the variety of religions, science, and social beliefs rooted in the culture. The increasing speed of globalization has changed the landscape of medical beliefs, and the diversity of conceptions of madness is disappearing. Instead, the psychiatric professions bible, DSM, has become a global standard (Watters, 2010, p 3). Watters claims that since the majority of researchers, organizations, research-conferences, universities, and drug companies, involved in the field of psychology and psychiatry, the western assumption of why the mind breaks and the best ways of healing it. Just like Swinton (2016), Watters (2010) argues that the experience of mental illness could never be separated from culture. Categories are shaped through a dialogical construction, and the collective beliefs are, therefore, also responsible in the process of shaping diagnoses as depression, GAD, and PTSD in a particular culture.
Swinton (2016) suggests that when we try to understand and heal the impact of migration by western psychological beliefs, we could get into all sorts of bother. Just examining individual psychological states could be a mistake since the real issues might instead concern the disconnection people feel in relation to their communities. Swinton argues that the feelings of disconnection may be somaticized or hidden, and maybe the language of dislocation is preferable to the language of depression.
Learning from the Other
The thesis title, learning from the Other, is trying to capture several ideas regarding learning and the other, and does not aim to categorize the unaccompanied refugee children as the Other. Still, even though the heterogeneity of the unaccompanied refugee children and their country of origin, they are probably bringing valuable knowledge regarding health and illness. The unaccompanied refugee children are often from an Islamic culture with different health concepts than the concepts in the West (Samuelsson, 2001; Samuelsson, 1999; Samuelsson & Brattlund, 1996). Sachs (2002) describes how cultural narratives regarding suffering and illness construct the relationship between medical beliefs and knowledge. Since the majority of the unaccompanied refugee children are staying at an institution that Jenkins (2014 p. 161) argues containing cultural shared ideal typifications (see Berger &
Luckman later in this text), maybe the unaccompanied refugee children could give some guidelines regarding cultural obstacles and possibilities for health. Bullington (2004) emphasize the importance of intersubjectivity and knowledge gained by conversations when it comes to healing from illness. Bullington (2004, p.65) also suggests that the West could learn from non-western cultures. Also, Timimi (2010), and Watters (2010), among others, claim that the diversity of cultural beliefs about suffering and healing could contain knowledge we cannot afford to lose. We might instead give more effort, learning from the other.
16 between them regarding God, humanity, ethics, creation, and life. In this background, several studies have been discussed. Wernesjö (2012) problematizes the tendency in earlier studies to solely focus on emotional problems arising from past traumatic experiences and the lack of research focusing on the perspectives and experiences of unaccompanied refugee children's opportunities and obstacles in the host country. When it comes to the high number of reported mental illnesses among migrants, Swinton (2016, p.33) asked following questions: Is the language of mental health and illness the most
appropriate way to express the experiences of migrants, or do we require a broader, less therapeutic approach to understand issues currently named as depression, anxiety, trauma and so forth?
Summary literature research
Much of previous research regarding unaccompanied refugee children pointing at their high risk for developing mental illness, often referring to possible trauma gained through traumatic experiences in the children’s country of origin or during the escape. However, several researchers in the field
problematize the risk of pathologizing the unaccompanied refugee children and lack research not only focusing on the unaccompanied refugee children's vulnerability but also on their strength, resilience despite their traumatic experiences and challenges. Researchers also call for research focused on the refugee children´s own perspectives of wellbeing and the obstacles and possibilities in the host country contributing to their experiences of health, argues that the existing research runs the risk of
constructing the unaccompanied refugee children as solely passive and vulnerable instead of seeing them as able, actors in their own right even though being in a vulnerable position. Therefore, a selection of articles emphasizing obstacles and possibilities such as the importance of support and care, collective based forms of belonging, the effects from privatization and professionalization, experiences from surveillance, is declared. Moreover, the literature review is bringing up some literature regarding the diagnostic expansion and the concept of medicalization, which problematizes the pathologization of different problems and challenges in life. The literature review also emphasizes cultural differences regarding common diagnoses among the unaccompanied refugee children, such as depression, PTSD, and trauma.
As a departure, the investigation will, therefore, turn to phenomenology by Husserl’s claim, “go to the things themselves.” A couple of voices from unaccompanied refugee-children, helpful to share their thoughts and concepts of health, will be heard and interpreted through hermeneutics. The knowledge gained from their opinions and their narratives regarding obstacles and possibilities for health might also be generalizable to other groups and contexts. The interviews in the thesis try to capture both the unaccompanied refugee children’s current views regarding health and their former views inhered from their country of origin. Despite a small sample of interviews, hopefully, the research with the help of phenomenology, hermeneutics, and pragmatism will lead to a better understanding of the
unaccompanied refugee children’s situation. Hopefully, this might also give a better understanding regarding the increasing reported illnesses among all children and youths living in Sweden by capturing obstacles and possibilities for health and a part of our cultural beliefs about suffering and healing.
Aims and objectives
17 We often speak of people from other cultures as "the Other," something foreign and deviant, which may lead to poor integration. We also often stigmatize people diagnosed with mental illnesses. We learn a lot from each other without thinking about it, for example, through media, which can create prejudice or create knowledge that we take for granted without reflecting on whether it is true
knowledge. Such knowledge may, for example, be about our beliefs about health / ill health and about different ways of curing experiences of ill health.
In the conceptual and theoretical framework, learning through dialogues will further be described through different thinkers. Gadamer uses the term fusing horizons and emphasizes how the different views of people with different cultural backgrounds may interrupt common sense and, through openness to difference, create new meanings and a possibility for transformation. Levinas describes that for reaching an openness in the encounter with the other, the face-to-face encounter is crucial. However, Ricoeur is emphasizing the response from the Other, a reciprocal encounter, for ethical learning.
The specific aim
The statistics described in the literature review show that the unaccompanied children, just like all children and youth in Sweden, described in the introduction, in a large amount, are diagnosed with different mental illnesses and are receiving a subscription of psychiatric drugs. However, the tendency to only focus on emotional problems among the unaccompanied refugee children arising from past traumatic experiences are problematized by several researchers since the labeling of the
unaccompanied refugee children could stigmatize them. Moreover, the researchers noticed a lack of research focusing on the perspectives and experiences of unaccompanied refugee children's
opportunities and obstacles in the host country.
During my working experience at HVBs of unaccompanied refugee children in 2016-2017, I also noticed that the unaccompanied refugee children had many good ways of dealing with the asylum-process, past experiences, and the concerns that a new country and language, and loss of family could bring. Therefore, the specific aim is to learn from the unaccompanied refugee children's thoughts and experiences regarding health and illness, investigated in their everyday life at their HVB in Sweden and their home in their country of origin.
• What do the unaccompanied refugee children think of as health and illness?
• How are changing thoughts regarding health and illness, since the unaccompanied refugee children arrived in Sweden, illuminated in their narratives?
The general aim
By pointing at the ethics and possibilities through different kinds of dialogues, the current thesis aims to better understand the increased ill health, in particular, mental ill-health among children and youth. Moreover, the thesis aims to explore a possible health promotion with the objective of reaching a more charitable and sustainable society. The aim is supposed to be reached through increased dialogue through learning from the other, in this case, the unaccompanied refugee-children instead of about the other, the diagnosed children and youth.
• How could the increased ill-health be understood as caused by changes in the overall situations around children and youth?
• How could an understanding of changing views regarding health/illness and normality/deviation also explain the experienced and reported ill-health?
• What kind of health promotion could be learned from the unaccompanied refugee children?
Theoretical and conceptual
As a specific aim, the study intends to learn from the unaccompanied refugee children's thoughts and experiences regarding health and illness and possible health promotion. The study has its department from the youth’s lifeworld here in Sweden and the one in their country of origin and aims to
investigate their experiences and thoughts from their everyday life.
The study’s general aim is to reach a better understanding of children’s and youth´s increasing illness and explore a possible health promotion.
Epistemology and ontology
Which theory would be most appropriate to meet the aims? Kvale and Brinkmann (2009) mean that researchers usually turn to the philosophy regarding the constitution of the world and how we can reach knowledge about it. What theory a researcher chooses to guide the research depends on the researcher’s epistemology, the assumption about what knowledge is, and how it is obtained (Kvale & Brinkmann, 2009). Brinkmann (2018, p.10) makes a distinction between the epistemological realist position and the anti-realist position. In the realist position, knowledge is something found or seen in the world, and knowledge could be reached by mirroring the world as accurately as possible. The anti-realist position, a constructionist viewpoint, claims instead that the mirrors are created by the
19 thoughts about epistemology, in turn, depends on the researcher’s ontology, the beliefs regarding how the social world is constructed, and the constituents of the reality (Brinkmann, 2018, p.33). The dialogues and co-produced texts with the unaccompanied refugee children are conducted with the inspiration of the openness of phenomenology. As later described, phenomenologist considers the human world build of intentional acts of consciousness and the objects are experienced immediately in a subjective, relative way, opposite to the constructed, objective, and not perceivable objects in natural science (Karlsson, 1993). Kristensson Uggla (1994) describe phenomenology as “the direct
investigation and description of phenomena as consciously experienced, without theories regarding causal explanations and as free as possible from unreflected prejudices and perquisites” (Kristensson Uggla, 1994, p. 103, my translation). Through the study’s hermeneutic interpretations, influenced from Ricoeur the epistemological thought is a movement from historicism focus on “the world behind the text” to the focus on “the world in front of the text” which Ricoeur (2011, p.14) means has the possibilities for the dialectics of multiple readings. The hermeneutic knowledge makes the absolute knowledge impossible (Ricoeur, 2011, p. 54). Kristensson Uggla (2002, p. 335) describes when the field of science is illustrated with different scientific methods, the choice of theory risks to be chosen without a thorough reflection and without any adaption to the context.
Since I do not believe a single theory could guide my understanding, I will adopt a more pragmatic stance, using different approaches to reach my aims. The pragmatist philosophers argue that knowing is more about doing (Brinkmann, 2012, p. 10), and ontology are seen as tools to think with
(Brinkmann, 2012, p. 33). In a pragmatic stance, Brinkmann (2012) also claims that “it would be just as foolish to demand that we stick to a single bounded ontology of the social, as it would be to demand of the carpenter that she should use only a saw in her work” (Brinkmann, 2012, p. 33-34). The
interviews with the youth are therefore interpreted with the help of different perspectives and theories which helps illuminating the meaning of their texts. The foundations of pragmatism are explained further at the end of this section. First, some perspectives connected to the concepts in italics in the description of the thesis aim above; experiences, thoughts, lifeworld, everyday life, and understanding will be introduced together with supporting perspectives.
The concepts experience, lifeworld, and everyday life, used in the study’s aims are central in phenomenology. The term phenomenology derives from the Greek world phainómenon “that which appears” and the word lógos “structure.” Phenomenology could, therefore, be described as “the study of the structure, and the variation of structure, of the consciousness to which a thing, event, or person appears (Giorgi, 1975, p.83, referred by Brinkmann, 2012, p. 66). In phenomenology, the study of the phenomena is made through the individuals everyday life experiences in the lifeworld, concepts which are further described below. Karlsson (1993) describes how Husserl, known as the founder of
phenomenology early during the 1900s, considered a crisis in natural science since it described a material world independent of human consciousness. Human experiences were treated as something physical instead of a meaningful experience of perception (Karlsson, 1993, p. 24-26). A key concept in Husserl’s philosophy regarding the process to shape a meaningful experience of perception is