What About Us? Experiences of Relatives Regarding Physician-Assisted Death for Patients Suffering from Mental Illness: A Qualitative Study

Physician-assisted death (PAD) for patients suffering from mental illness is legally permitted in the Netherlands. Although patients’ relatives are not entrusted with a legal role, former research revealed that physicians take into account the patient’s social context and their well-being, in deciding whether or not to grant the request. However, these studies focussed on relatives’ experiences in the context of PAD concerning patients with somatic illness. To date, nothing is known on their experiences in the context of PAD concerning the mentally ill. We studied the experiences of relatives with regard to a PAD request by patients suffering from mental illness. The data for this study were collected through 12 interviews with relatives of patients who have or had a PAD request because of a mental illness. We show that relatives are ambivalent regarding the patient’s request for PAD and the following trajectory. Their ambivalence is characterised by their understanding of the wish to die and at the same time hoping that the patient would make another choice. Respondents’ experiences regarding the process of the PAD request varied, from positive (‘intimate’) to negative (‘extremely hard’). Some indicated that they wished to be more involved as they believe the road towards PAD should be a joint trajectory. To leave them out during such an important event is not only painful, but also harmful to the relative as it could potentially complicate their grieving process. Professional support during or after the PAD process was wanted by some, but not by all.

‘No-One Can Tell a Story Better than the One Who Lived It’: Reworking Constructions of Childhood and Trauma Through the Arts in Rwanda

The intergenerational legacies of conflict and violence for children and young people are typically approached within research and interventions through the lens of trauma. Understandings of childhood and trauma are based on bio-psychological frameworks emanating from the Global North, often at odds with the historical, political, economic, social and cultural contexts in which interventions are enacted, and neglect the diversity of knowledge, experiences and practices. Within this paper we explore these concerns in the context of Rwanda and the aftermath of the 1994 Genocide Against the Tutsi. We reflect on two qualitative case studies: Connective Memories and Mobile Arts for Peace which both used arts-based approaches drawing on the richness of Rwandan cultural forms, such as proverbs and storytelling practices, to explore knowledge and processes of meaning-making about trauma, memory, and everyday forms of conflict from the perspectives of children and young people. We draw on these findings to argue that there is a need to refine and elaborate understandings of intergenerational transmission of trauma in Rwanda informed by: the historical and cultural context; intersections of structural and ‘everyday’ forms of conflict and social trauma embedded in intergenerational relations; and a reworking of notions of trauma ‘transmission’ to encompass the multiple connectivities between generations, temporalities and expressions of trauma.

Could the DSM-5 Cultural Formulation Interview Hold Therapeutic Potential? Suggestions for Further Exploration and Adaptation Within a Framework of Therapeutic Assessment

The Cultural Formulation Interview (CFI), included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, is a person-centered instrument for systematically appraising the impact of cultural factors in psychiatric assessment. A number of key areas in the future development of the CFI have been identified in order to ensure further clinical uptake. In this paper, we suggest that applying a Therapeutic Assessment (TA) approach in using the CFI—i.e., framing the interview in a way that gives primacy to its self-transformative potential by explicitly focusing on those issues that are seen as the most urgent, relevant, and meaningful by the patient—could prove helpful in alleviating patients’ suffering beyond what is achieved by merely collecting relevant cultural information that may inform diagnosis and subsequent treatment interventions. The TA methodology has been designed as a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health problems or psychosocial well-being; these questions are then allowed to guide the assessment process and the interpretation of the findings. We suggest a number of potential modifications to the related Outline for Cultural Formulation and to the CFI content that could strengthen a TA-inspired focus. With this paper, we do not claim to offer a definitive integration of the TA approach in using the CFI but hope to further the discussion of a therapeutic potential of the instrument.