Challenges for unaccompanied asylum-seeking minors in Swedish compulsory institutional care

This qualitative thematic study aimed to examine the placement of unaccompanied asylum-seeking minors in compulsory institutional care in Sweden, to expand knowledge regarding their care and treatment. The dataset comprised official documents and anonymized journal documents from personnel detailing the experiences of twenty-five unaccompanied asylum-seeking minors in compulsory institutional care organized by the Swedish National Board of Institutional Care in 2015. The study identified three main themes: traumatic life events and mental health, alignment between needs, goals, and treatment, and language difficulties. The findings revealed a high prevalence of severe traumatic experiences among the asylum-seeking minors, with half having endured significant psychological and physical trauma. Mental health issues were inconsistently addressed, and prior traumas were often overlooked in care planning. The majority exhibited various mental health problems, underscoring the need for tailored interventions. The study highlights challenges in aligning unaccompanied asylum-seeking minors' individual needs, treatment goals, and provided care. Language barriers emerged as a critical concern, impeding effective communication and treatment. Approximately 80% of the asylum-seeking minors experienced difficulties in understanding and expressing themselves in Swedish. The limited use of professional interpreters further exacerbated this issue. The study underscores the need for targeted interventions to better support unaccompanied asylum-seeking minors within compulsory institutional settings.

Introduction

In the context of immigration and minority issues, Sweden experienced a significant influx of unaccompanied asylum-seeking minors (UAMs) during 2015, presenting complex challenges for social work and institutional care. These minors, who often arrive with traumatic pre-migration experiences and face a language barrier, require specialized trauma-informed care to address their mental health and social needs. An UAM is a person under the age of 18 who has been separated from both parents and is not being cared for by any adult responsible by law or custom for providing such care (UNHCR, 1997). In a study on the mental health needs of UAMs in Sweden, Ramel et al. (2015) found a higher risk of suicide as well as self-harm among this group of youth. In Sweden, it is the municipalities that are primarily responsible for UAMs; this includes providing their housing and schooling. A majority of the UAMs are placed in various forms of homes for care and housing.

The number of children seeking asylum in Sweden nearly tripled in 2015 compared to 2014 (7,000 vs. 23,000, respectively) and those years constituted a challenging situation for the affected Swedish institutions. The UNHCR (2016) defines unaccompanied minors as one of the most vulnerable groups in the asylum community: they have been separated from family when migrating or sent alone by desperate parents, and many of the minors have pre-migration experiences of trauma and poverty. The minors' journey to a country where they seek refuge is very often marked by traumatic events, such as sexual abuse, violence and witnessing murder, as well as the loss of parents and siblings (Fazel et al., 2012; Ghazinour et al., 2015). Because of their stressful pre-migration and migration experiences, UAMs often suffer from mental health issues as well as social problems (Seidel and James, 2019). In the arrival countries the UAMs face multiple bureaucratic and institutional challenges and are at risk of discrimination (Alemi and James, 2019).

Since 2015, UAMs have encountered a mix of successes and challenges during their establishment. Among the 35,000 applicants for asylum, ~20,000 were registered as of 2022 (Statistics Sweden, 2022). Notably, 70% of women and 80% of men are currently employed. The health care and social care sector stands out as the most common field of employment for both genders. However, for some UAMs, difficulties persist. Certain individuals hold temporary residence permits but face imminent deportation upon turning 18. Others remain in an asylum process, having lived in uncertainty for several years. Additionally, a subset of UAMs resides in the country without legal authorization, with no intention of leaving. Consequently, they face the risk of long-term exclusion and marginalization (National Board of Health Welfare, 2021).

In some cases, social services determine that there is a need for more controlled forms of care and treatment, such as compulsory institutional care organized by the Swedish National Board of Institutional Care (SNBIC).

The aim of this study is to describe and analyze the documentation of unaccompanied asylum-seeking minors' placement in compulsory institutional care at the Swedish National Board of Institutional Care, in relation to the organization's mission and guiding care principles.

The research questions guiding the study were:

• How is the placement of unaccompanied minors described by SNBIC staff, what treatments and interventions are carried out, and are they aligned with the documented assessed needs and goals of the unaccompanied minors?

• How does the unaccompanied minors' time in compulsory institutional care reflect the SNBIC's mission and overall guiding principles?

Compulsory care residential home for youth in Sweden

The youth are placed in what SNBIC calls a “special residential home for young people”, which in this paper will be referred to as a “SNBIC home”. Most youth in SNBIC homes have backgrounds involving criminal activities, substance abuse, and mental health problems (Andersson Vogel, 2012; SNBIC, 2020a). Crime is the predominant reason for placement, especially for boys (Andersson Vogel, 2012). SNBIC homes are locked facilities providing round-the-clock care for minors, due to behavior posing significant risks, until they reach 20.

About 1,000 children and youth are placed in SNBIC homes annually, undertaking comprehensive intervention in Swedish child and youth care (SNBIC, 2023). These children and youth are often deemed the most challenging group to treat within the Swedish social care system, emphasizing the importance of understanding their experiences and treatment at SNBIC (Andersson Vogel, 2012). Meeting psychiatric needs is a significant challenge, as around two-thirds have established diagnoses (SNBIC, 2020a).

Daily life at a SNBIC home involves school, social skills training, discussions, and one-on-one sessions (SNBIC, 2015a). Given the health challenges faced by minors in SNBIC homes, coordinating healthcare interventions with other measures is crucial. This includes access to medical professionals, assessments, drug rehabilitation, psychiatric evaluations, and dental care. Additionally, SNBIC homes offer guidance on stress management, sleep, diet, and physical activity (SNBIC, 2020b).

The Swedish National Board of Institutional Care: mission, guiding principles, and challenges

SNBIC (2020b) Operational Plan outlines their mission to be a transformative space, focusing on equipping minors for socially functional lives. Their mission statement emphasizes care, collaboration with social services, and the promotion of non-discriminatory and ethically guided practices (SNBIC, 2020b):

“We provide individually tailored compulsory care and enforce secure youth care. In collaboration with social services, we give young people and clients with severe and extensive psychosocial problems better conditions for a socially functional life free from addiction and crime. The care and treatment are equal and free from discrimination, carried out with good ethics and high quality. Our work is characterized by high accessibility and legal certainty.”

The SNBIC's mission and principles function as ethical guidelines for staff in the treatment and care of the admitted youth and they are based on respect, consideration, and clarity. Staff are thus expected to treat the youth with respect, approach them with openness, accept their differences, and value their knowledge and experience. Further, staff must provide care through active listening, understanding and unconditional support. Staff should also strive to be kind, considerate and committed. Lastly, the word “clarity” implies that the caregiver should express him- or herself in a caring way and provide such information as may be needed to enable collaboration. Also, staff must ensure that the admitted youth understand what is being communicated. Clarity also implies that caregivers follow through on their commitments and that their actions are trustworthy (SNBIC, 2015b).

In 2020, a comprehensive analysis by the Swedish Agency for Public Management uncovered disparities in care based on placement, along with reports of mistreatment. SNBIC faced challenges in adapting care for various groups, including those involved in serious or gang-related crime, and individuals with severe psychiatric or neuropsychiatric issues. Employees expressed that they feel like they provide a safe environment, but not enough care and treatment (The Swedish Agency for Public Management, 2020).

Addressing psychiatric needs remains a central challenge. The 2020 Operational Plan highlights that approximately two-thirds of young individuals have established psychiatric diagnoses, with a sizeable portion facing neuropsychiatric or intellectual functioning challenges (SNBIC, 2020b).

Unaccompanied asylum-seeking minors' placement in SNBIC homes

The number of UAMs who have been placed in compulsory care increased sharply in 2015 and 2016 (peaking at 255) but has decreased over the past few years (82 in 2019) (SNBIC, 2019). The number of UAMs placed in SNBIC homes has not been stated in their annual reports for 2020, 2021, 2022, and 2023.

UAMs are not to be considered a homogenous group, even though they share the experience of migration and being separated from their families. They differ widely in terms of several demographic factors, such as age, gender, ethnicity, as well as past and current experiences (Ivert and Magnusson, 2020).

There are various concerns regarding UAMs' placements in compulsory care. Ghazinour et al. (2021) pointed out that it was difficult for UAMs to understand why they were contained and that they lacked an understanding of what distinguishes a special youth home from a prison. Further, SNBIC staff have indicated that they think UAMs' problems seem milder and/or different from the problems of other admitted youths (Ghazinour et al., 2021). Padyab et al. (2020) questions the appropriateness of placing UAMs in a care system designed for youth significantly burdened by criminality, violence, and/or drug abuse.

Another critical issue is the language barrier that often exists between UAMs and the staff. Not sharing a common language can lead to the placed youth being isolated and unable to benefit from interventions or treatments. Not being able to communicate verbally also make it difficult for staff to design adequate interventions for UAMs. The language barrier has been highlighted in other studies, in which it is stated that UAMs often struggle with the Swedish language and that interpreters were rarely booked for important meetings or conversations (Ghazinour et al., 2021).

One challenge that UAMs typically face is a mentally and physically stressful asylum process, which involves a lot of uncertainty. Two studies have identified Sweden's asylum process for UAMs as one of the main causes of worry and distress for UAMs (Thommessen et al., 2015; Herz and Lalander, 2017). Ghazinour et al. (2019) have highlighted that the Swedish asylum system cause sickness among unaccompanied minors.

Little is currently known about UAMs placement in Swedish compulsory care. Research in the area is sparse and there is currently a lack of knowledge regarding details of their placements and the quality of care and treatment they receive. After reviewing existing literature, Seidel and James (2019) noted a lack of research in most areas related to UAMs in Sweden, stressing the scant literature on the experiences of UAMs, factors supporting resilience and integration, and interventions addressing their psychosocial needs. Also, as existing research has not yet been able to establish positive results from this constraining form of compulsory care, there has been a need for further studies for a long time (Andersson Vogel, 2012).

By analyzing UAMs' placement periods in SNBIC homes in the light of SNBIC's policies, guidelines, and operational values, this study aims to expand knowledge regarding the care and treatment of UAMs in Sweden, with a focus on areas in need of improvement.

Methods

Design

This study employed an abductive qualitative thematic approach (Thompson, 2022), drawing from personnel-written journal documents and policy documents related to the placement of unaccompanied asylum-seeking minors (UAMs) in compulsory institutional care in Sweden. Ethical clearance for this project was obtained from the Regional Ethics Review Board in Umeå (Number 2016/03-31Ö).

Data collection

Data concerning the UAMs consisted of anonymized journal documents written and comprised by SNBIC personnel. These entries pertained to the placement of 25 unaccompanied minors in various SNBIC homes spread across Sweden in 2015. The journals contained comprehensive information on admission and discharge, investigations, county court verdicts, assessments from psychologists and physicians, social services' notes, and, in some cases, an Adolescent Drug Abuse Diagnosis (ADAD) upon admission. Daily records of routine activities, as documented by SNBIC staff, were consistently detailed. The journal documents were compiled, anonymized, and made available to the authors through SNBIC. SNBIC funded the study but had no part in the research process.

To facilitate the analysis process, detailed written summaries of the journals (~51 pages of text) were utilized as primary data. These summaries were written by three of the authors.

The unaccompanied asylum-seeking minors

The 25 individuals described in the journals consisted of 21 men and four women. They originated from North Africa, the Middle East, and other African countries. Among them, four held a Swedish residence permit during the placement period, while for five, it remains unclear whether they possessed a residence permit or not. For the remaining 16 individuals, it appeared they did not possess a residence permit in Sweden. Of these, five individuals received a rejection decision and were scheduled for deportation. According to the journals, all 25 individuals were placed in an SNBIC home in accordance with Section 6 and/or Section 3 of the Swedish Care of Young Persons Act (LVU). The most frequently documented reasons for placement were “other socially destructive behavior” and “crime and abuse”. They were housed in 12 different SNBIC homes in different parts of Sweden over the course of 2015. Their tenure in these homes ranged from 23 to 249 days.

Analysis

A qualitative thematic analysis, as outlined by Braun and Clarke (2006), was employed to discern, analyze, and elucidate recurring patterns within the data. The analysis was abductive, aiming to capture significant patterns in relation to the specific research questions. The first author conducted the original analysis, and it was discussed among all authors and adjusted. The analytical framework centered around core SNBIC documents outlining the agency's mission and guiding principles. These documents, namely the Operational plan and Ethical guidelines, were procured from the SNBIC official website.

The dataset encompassed both detailed summaries and anonymized original journals (accessible only in paper format). There was a continuous back-and-forth process between the journal summaries, the original journal documents, and the SNBIC guiding principles. The original journal documents were thoroughly read to attain a comprehensive understanding of the data, and the detailed summaries were examined repeatedly.

The analysis commenced with abductive coding of the text in the summaries in relation to the analytical framework; specifically, SNBIC's mission and guiding principles. The SNBIC principles guiding the analysis were “Individually tailored compulsory care” and “Respect, consideration, and clarity”.

Preliminary themes were established, and codes were consolidated and tabulated. As themes emerged, the original text was re-examined to ensure internal validation. The themes were constructed based on their relevance to the research questions (Braun and Clarke, 2006).

In the Results section, the inclusion of representative text passages (quotes) from the journal summaries enhanced the transparency and trustworthiness of the findings and data interpretation. Each quote was assigned a unique number (1–25) to facilitate internal validity by enabling traceability back to the personnel-written original journals.

While the analysis was qualitative, the number of UAMs within a specific theme was incorporated as a descriptive complement to the findings.

Results

The analysis resulted in three themes: traumatic life events and mental health; alignment between needs, goals, and treatment; and language difficulties.

Traumatic life events and mental health

The UAMs had experienced a variety of severe traumatic events. Nearly half of the UAMs (n = 11) had experienced various forms of psychological and physical trauma in their lives, and for the remaining seven cases there was no written documentation of previous trauma.

There are reports of lived experience of abuse and hardship among the UAMs, in many cases from a young age. There are descriptions of having been subjected to physical and/or verbal abuse by relatives or others, exposed to severe abuse and sexual abuse, and of having been homeless as children or in miserable domestic conditions. They are also described as being traumatized by experiences in the home country and/or by traumatic events during their migration journeys. There are accounts of lost relatives, of family members being abused and killed, and of losing their entire family or family members in violent incidents, such as bombings, murders, or disappearances in their home country. There are descriptions of losing someone close to them, for example, witnessing family members or friends dying while leaving their home country, seeing a close friend drown or siblings disappear while fleeing across the Mediterranean. In the journals, these traumatic experiences were described as follows:

“Lived as a street child in [country in North Africa] since the age of 12. The father was murdered, the mother and siblings disappeared.”—No. 5

“Difficult escape across the Mediterranean, lost younger brother during the trip. Suspected of having been trafficked.”—No. 15

Despite the accounts of traumatic experiences, the treatment provided to some of the UAMs is unclear, non-existent, or too vaguely described, and that previous trauma is not recognized or discussed in relation to care and treatment.

As described in the journal documents, the majority of the UAMs had various documented mental health problems, such as post-traumatic stress disorders, neuropsychiatric disorders, suicide risk, self-harm behaviors, and depression. A review of the journals shows that 16 of the UAMs suffered from some form of mental health problem, and in some of the journals a mental health problem was given as the main reason for the SNBIC placement. The remaining four of the UAMs had no known or manifest mental illness or problem. For some of the UAMs it was evident that their wellbeing and mood had deteriorated during the placement period.

Examination of the journals showed that the girls' mental health problems appeared to be different from those of the boys. The girls had psychiatric problems (two of them would highly likely have received neuropsychiatric diagnoses, while one had PTSD, aggressive behavior, and socially destructive behavior) whereas there were no documented problems with addiction or criminality. There were only four girls in the data, but the difference is nonetheless worth noting. The most common problems for the boys were criminality, addiction, socially destructive behavior, and suicidal and self-harming behaviors. Apart from planned activities to address mental health issues, there was little written on how the staff handled UAMs suffering from mental disorders or psychiatric problems and what specific treatment and support the UAMs received.

Alignment between needs, goals, and treatment

The principle of individual care and treatment was central to the analysis since SNBIC's (2020b) main task is to provide individually tailored care and treatment for the UAMs, to help them develop socially functional lives without substance abuse and criminal behavior. Based on the SNBIC's objectives, an assessment was made as to whether there is consistency between needs, goals, and treatment. In many of the cases it was difficult to discern the alignment between needs, goals, and treatment. Only in a few cases was the consistency between needs, goals, and treatment clearly evident, making it possible to assess that the SNBIC was able to provide adequate care and treatment for the individuals. In most cases the connection was weak and hard to find. In several cases, there were no individually tailored treatments to be found for those with mental health problems. Instead, the focus was on everyday social activities.

The results show that in 12 out of 25 cases there was some sort of alignment between needs, goals, and treatment, which means that treatment designed for the needs of the individual youth was being carried out.

In the remaining 13 cases the results showed that needs, goals, and treatment were not in alignment. However, for at least one of the UAMs it was difficult to assess the alignment, as that youth only stayed in the SNBIC residence for 23 days.

Below you will find two examples of cases in which the alignment between the needs, goals, and treatment was lacking.

In the first example (No. 7), it is stated that the UAM needs care and treatment for suicide attempts, physical behavior, psychiatric problems, and self-harming behavior. However, the only need specified in the treatment plan was “functional activities in daily life”. It is also stated that the SNBIC's task is to conduct a psychiatric examination, provide a psychologist interview, and ensure that the youth is drug-free and takes Swedish language studies. However, there is no documentation of goals to which these efforts can be related. In the journal documents one cannot identify any treatments or concrete efforts focused on mental health, crime, or substance abuse.

In the second example (No. 12), the needs of the UAM are specified as receiving treatment for drug addiction and being supported in refraining from violence and crime. The treatment for this person consisted of group conversations and individual motivational conversations about how he wanted to be treated when angry. According to the social services, treatment focusing on physical abuse and crime was to be provided to this youth, but in the journal the SNBIC states that they did not have assignments in these areas, and consequently, there were no goals to be met.

There are a few cases in which the cooperation between the SNBIC and the social services was suboptimal, even though SNBIC documentation states that “staff must cooperate with the social services” (SNBIC, 2020b). In one case, the SNBIC and the social services had different views on what treatment should be given to an individual, and in another case, it took 7 weeks for the admitted UAM to meet the social services administrator assigned to the case.

There are also several cases in which there was a lack of targeted treatment for psychiatric and addiction problems. In one journal the stated goal of the placement was vaguely stated as:

“The care must continue until he has a more stable mental state or until he is deported.”—No. 5

Language difficulties

The journal data was analyzed based on what the SNBIC (2015b) states in its organizational ethical guidelines regarding treatment, in which the guiding principles of respect, consideration and clarity are presented. The Ethical Guidelines states that “the staff must express themselves comprehensibly and ensure that the client understands what they mean”; furthermore, it states that staff must listen actively and show that they are trying to understand (SNBIC, 2015b).

However, it is evident that the language difficulties among the UAMs are extensive and that little is done to accommodate this in meetings, treatments, and conversations. Based on the journals, 20 of the UAMs are described as having varying degrees of difficulty with understanding and making themselves understood in Swedish, that is, their knowledge of Swedish is described as deficient or non-existent. Only two of the UAMs seemed to have mastered Swedish; as for the remaining three, insufficient information was provided about their language comprehension. In some of the journals, it could be discerned that the youth participated in various activities despite obvious language barriers, for example in journal No. 21:

“Participates actively in daily program activities despite language difficulties. Despite language difficulties, he does his best to understand and make himself understood. Always tries to make himself understood even though he does not speak Swedish”.—No. 21

The language barrier negatively impacts the UAMs' everyday lives, particularly regarding their care and treatment. There are specific cases in which the lack of language comprehension led to a deterioration in the UAM's mood and wellbeing, and impeded treatment success. Despite the social services' promoting the use of interpreters, it appears that the SNBIC rarely used them. Instead, staff who spoke the same language would help when needed, and body language and pictures were relied on for communication.

“It has been noted on several occasions that the boy has great difficulty communicating in Swedish. He becomes irritated and frustrated, and misunderstandings often occur. It is difficult for the boy to understand rules and routines. A statement from a psychologist at the SNBIC home states that language difficulties constitute major obstacles to the boy's development and that difficulties in making himself understood are linked to his mental state.”—No. 17

The UAMs' understanding of why they had been placed in an SNBIC home varied. For nine UAMs it was documented that they did understand why they were placed in an SNBIC home, for six of them it was documented that they did not have this understanding, and for the remaining ten UAMs there was no information on this aspect. Further, nine of the UAMs were described as disputing the stated reasons for the placement.

“The youth does not share the social services' view of her problems. Does not understand why she was placed in a special youth home. Successfully appealed the decision and the county court did not extend the care mandate relating to the Care of Young Persons Act.” No. 9

Discussion

SNBIC has a difficult and complicated task: to bring about change for young individuals with severe social problems. Our analysis of the SNBIC's documents pertaining to 25 UAMs in relation to the agency's mission and guiding principles highlights areas in need of improvement.

Not adequately dealing with traumatic life events and mental health

A central finding was the high number of UAMs suffering from mental health issues: 16 of 25 individuals. However, these individuals rarely seemed to receive individual psychological or psychiatric treatment. Despite previous traumatic life events, those experiences were not mentioned or discussed in relation to care and treatment. It is also important to highlight the known consequences detention can have for young individuals' mental health. There are studies showing that being detained pending asylum/deportation can cause psychological effects that are very severe (e.g., Ryan et al., 2009; Tazreiter, 2010; Ghazinour et al., 2015). Tazreiter (2010) indicates that there are high levels of self-harming behavior among children in detention. The combination of traumatic experiences and being in detention has also been identified by SNBIC staff as particularly problematic (Backlund and Thorén, 2021). Backlund and Thorén (2021) contend that for some of the youth being detained could be traumatic and worsen their anxiety and mental illness. At the same time, the staff point out that they do not feel adequately equipped to deal with serious mental illness and trauma, and that they find it difficult to establish effective communication without psychiatric resources (Backlund and Thorén, 2021).

This is in line with a Swedish government report showing that the admitted youth have limited access to regional psychiatric health care during their SNBIC residence, and that the biggest problems concern the SNBIC's collaboration with regional psychiatric health care (The Swedish Agency for Public Management, 2020). According to the report, many of those who are taken into compulsory care at the SNBIC have psychiatric problems and need psychiatric care during their stay to be able to benefit from other forms of treatment at the SNBIC.

In 2019 the Swedish National Board of Health and Welfare (NBHW, 2019) concluded that psychiatric conditions are prevalent among young people in SNBIC homes. At that time, 71% of the admitted youth had at least one established psychiatric diagnosis, 45% had at least two documented diagnoses, and 20% had at least three diagnoses.

The survey showed that 40% of young people had been in an acute psychiatric condition in the past 6 months. NBHW (2019) found that there is a risk of the youth in SNBIC homes not receiving health and medical care of a standard equal to that of other minors in Sweden.

Serious traumatic experiences and PTSD are described characteristic for UAMs as a group (Backlund and Thorén, 2021). The perception is that UAMs feel mentally worse and carry deeper trauma than other young persons in SNBIC homes. This is in line with the results of present study, in which serious trauma seems to distinguish UAMs from other admitted youth.

In a study on unaccompanied refugee adolescents' everyday experiences upon settlement in Denmark, it was found that they experienced psychosocial challenges related to emotional distress, stigma, and loneliness, while dealing with previous traumatic experiences and uncertainty about their future (Jarlby et al., 2021). Worth noting is that findings from an international literature review on substance abuse and criminality among UAMs suggest that untreated mental health problems, stressful living conditions, and a lack of support and agency might put UAMs at risk for substance abuse and criminality (Ivert and Magnusson, 2020). In interviews with staff, self-harming behaviors, and substance abuse problems among UAMs are seen as strategies for relieving their anxiety and worry, which are partly linked to the asylum process (Backlund and Thorén, 2021). In the present study the wellbeing and mood of some of the UAMs seemed to deteriorate during the placement period, possibly due to their uncertain asylum situations.

It is questionable whether the UAMs traumatized by previous life events and suffering from psychiatric problems should be placed in this form of compulsory care. Some of the interventions, such as providing structured daily routines, seemed to be beneficial for UAMs, whereas initiatives based on the Swedish language and cultural norms, such as helping them become drug free and abandon criminal lifestyles, were less likely to succeed (Eriksson et al., 2021).

Lack of individually tailored care and alignment between needs, goals, and treatment

Individually tailored care for the UAMs appears to have been insufficient or lacking in many cases. The alignment between needs, goals, and treatment was not clear for all the UAMs. This in line with the conclusions of the government analysis (The Swedish Agency for Public Management, 2020), in which SNBIC staff themselves stated that they did not feel they could provide individual care and treatment for the UAMs. Söderqvist et al. (2014) emphasize that the SNBIC programs were not designed in consideration of the specific needs of UAMs, but rather for minors requiring care with stricter conditions. As UAMs have different backgrounds, they also have different needs. A lack of language skills contributes to UAMs' difficulty participating in activities such as conversation-oriented treatment (Eriksson et al., 2021). Jarlby et al. (2021) note that psychosocial support needs to be adapted to UAMs' individual needs to respond to their mental health in an optimal way and that the support activities should be the focal point of the UAMs' daily lives.

Backlund and Thorén (2021) point out that both the SNBIC and the social services struggle to meet the needs of UAMs within the framework of their existing activities, which has led to conflicts about which organization should be responsible for the care of UAMs. Kaunitz and Jakobsson (2016) indicated that the UAMs were placed in compulsory care based on more vague grounds than the young persons who were born in Sweden. Further, the assignments from the social services pertaining to the UAMS were not as precise compared to other admitted persons. SNBIC placements for UAMs were in some cases perceived as “storage” due to a lack of other alternatives (especially for the UAMs whose asylum applications had been rejected). In a comprehensive report on UAM placement in SNBIC homes this is analyzed further, and two contradictory perceptions regarding the motives for placement appear: (1) that the complexity of UAMs' problems justifies the placement and (2) that UAMs are placed on too vague grounds, or are even placed inappropriately (Eriksson et al., 2021). Staff expressed the view that “UAMs are not criminal or abusive enough to be in SNBIC homes” and that their problems with drugs and crime are milder and/or different than those of the other minors (Eriksson et al., 2021).

The language barrier

Inadequate language skills are one of the greatest and most acute challenges for UAMs in compulsory care, which is confirmed by several other Swedish studies (Kaunitz and Jakobsson, 2016; Backlund and Thorén, 2021; Eriksson et al., 2021).

A central aspect of UAMs' ability to take part in the daily activities is that they understand Swedish. UAMs with psychiatric or other mental health needs can be left particularly vulnerable and lonely due to the lack of a common language and its close link to the availability and success of treatments. Language difficulties were documented for nearly all the UAMs (at least 20 out of 25) in this study. The lack of fluency in Swedish creates challenges in communication, treatment, interventions, and other programs. Interpreters seem to be rarely used, instead, the SNBIC relies on staff who speak the same language. In some cases, frustration, and conflict among the UAMs appears to be the result of linguistic misunderstandings. The reasons why interpreters were rarely used are given in the report by Eriksson et al. (2021): using interpreters in treatment activities was considered “inconvenient” and obtaining professional interpreters was hard. Kaunitz and Jakobsson (2016) mentions that this is partly due to a shortage of qualified interpreters in Sweden.

It became clear that the SNBIC did not live up to the framework of its ethical values, which highlight the importance of admitted youth being able to understand staff. The staff must “ensure that the client understands what they mean” (SNBIC, 2015b).

According to Kaunitz and Jakobsson (2016), the language barrier significantly affects the agency's ability to provide adequate care, particularly in crises and to the UAMs who feel the worst. The combination of mental illness and linguistic confusion among UAMs can even be perceived as dangerous. The staff may find it difficult to respond to individuals who are acting out, or to individuals experiencing anxiety and distress, which can cause frustrations and conflicts (Kaunitz and Jakobsson, 2016).

The language barrier makes it difficult for the UAMs to take part in the provided treatments, which has a negative effect on the individuals' sense of autonomy. The SNBIC Ethical Guidelines states that “clients must be involved in their treatment and be able to influence their everyday life” (SNBIC, 2015b), which according to our results does not seem to be the case. As many of the UAMs could not understand or make themselves understood in Swedish, being involved in and influencing their everyday life presented obvious challenges.

According to Kaunitz and Jakobsson (2016) there seems to be a widespread perception among the SNBIC's managers that it is the confinement that in some cases triggers anxiety and that the UAMs, partly due to language confusion, barely know where they are and why they are there. Some of the young people become desperate when they discover that they have agreed to things that are the opposite of what they want (Eriksson et al., 2021). Perceptions among staff were that certain placements acted as confinement of the UAMs and that some of these minors even believed that they were imprisoned (Kaunitz and Jakobsson, 2014). Similar views are expressed in the report by Backlund and Thorén (2021) in which several of the UAMs described their SNBIC home in terms of a prison and even as “punishment”.

Not having a shared language is an overriding problem that has an impact on the UAMs' health and wellbeing during their placement in SNBIC homes and constitutes a pivotal problem that needs to be addressed.

Conclusions

The UAMs' placement in compulsory care is a complex issue. This study did not aim to achieve a comprehensive picture of the situation, but rather to pinpoint a few important areas in which improvements could be made. To answer the research questions there appeared to be a lack of alignment between UAMs' needs, goals, and treatment. Issues related to traumatic life events, mental health and the language barrier were not properly dealt with, revealing areas that are not in line with SNBIC's mission and care philosophy.

There appeared to be a lack of individually tailored treatment and care—despite obvious psychiatric problems among the UAMs which required professional specialized care. Compulsory care in confinement does not constitute the best care for young people with mental illness and neuropsychiatric diagnoses, especially as confinement tends to lead to deteriorating mental health in children and adolescents undergoing an insecure asylum process.

The findings suggest that the greatest challenge facing the SNBIC is to meet the needs of a vulnerable group with whom they do not share a common language. There are significant language difficulties, which has a negative impact on the UAMs' treatment, communication between UAMs and staff, and the UAMs' ability to make their voices heard. When it comes to the type of serious infringement on personal integrity that compulsory care entails, it is especially important that young people are given the opportunity to understand and make themselves understood.

Implications

Recognition of UAMs' diverse backgrounds is imperative, necessitating tailored interventions that prioritize psychiatric assessments and address prior traumas. Regarding UAMs' autonomy, enabling effective communication regarding their needs is pivotal. Not having the means to communicate is an aspect that distinguishes them from other youth at SNBIC homes. To address this, a targeted approach could involve implementing specialized programs for UAMs in SNBIC homes, including intensive Swedish language training and enhanced interpreter services. Additionally, augmenting staff education in language and culture would yield significant benefits.

Methodological considerations

The qualitative analysis in this study has been conducted rigorously and is described in detail, which provides valid and valuable results. Even though the analysis was conducted in a systematic way, we advise to approach the results with caution, recognizing that they may not fully capture the experiences of all UAMs subjected to compulsory care in Sweden.

Moreover, it is important to bear in mind that the UAMs were selected by SNBIC and the journals chronicling the activities of UAMs during their placement period were authored by SNBIC staff. Consequently, there exists the potential for certain issues, particularly those unfavorable to the employees or SNBIC, to be underrepresented in these records. This underscores the need for a nuanced assessment of the findings.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Author contributions

IS: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing. MG: Conceptualization, Funding acquisition, Validation, Visualization, Writing – original draft, Writing – review & editing, Methodology, Supervision. ME: Conceptualization, Funding acquisition, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing. MP: Conceptualization, Validation, Visualization, Writing – original draft, Writing – review & editing, Funding acquisition. JS: Conceptualization, Project administration, Validation, Writing – original draft, Writing – review & editing, Visualization.

Funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. The article was funded by the Swedish National Board of Institutional Care. The funders were not involved in the design, analysis, or writing of the scientific article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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