Exercise #59
Invisible Wounds: A Clinical Case Study
Authors: Assoc. Prof. Paloma Moral de Calatrava
60–90 minutes
Description
A clinical case study exploring Ulysses Syndrome through the story of Amira, a Syrian refugee in Italy, to develop cultural competence in healthcare settings.
Methodological Guide
Objectives
Develop clinical thinking skills in multicultural healthcare contexts. Recognize and analyze the physical, psychological, and socio-cultural dimensions of Ulysses Syndrome. Reflect on how cultural encounters shape the therapeutic relationship.
Expected Outcomes
Students will be able to identify the key features of Ulysses Syndrome in a clinical case, analyse cultural factors affecting care, and reflect critically on the therapeutic relationship in multicultural settings.
Exercise Procedure
<p>Amira is 29 years old, originally from Syria, and arrived in Europe three years ago. She lives in an overcrowded reception centre in northern Italy, where she is enrolled in an Italian language course. She speaks enough Italian to get by, although her accent and hesitations often prompt people to speak louder.</p>
<p>For months she has been feeling tired and empty. Her headaches come in waves, some nights she cannot sleep at all, she often skips meals, sometimes stays indoors for days, and has difficulty concentrating. The support counsellor at her reception centre gently suggests that she see someone, and refers her to a public health clinic.</p>
<p>At the clinic, Amira is received by Nurse Selam Tesfay, who came to Italy from Eritrea and speaks both Italian and Arabic. Inside the consultation room, Nurse Selam sits together with Dr. Elena Rossi, a psychiatrist. The two professionals attend Amira jointly. Nurse Selam switches into Arabic when Amira falters in Italian, helping her describe her symptoms and her recent history.</p>
<p>Amira speaks of her father, who died in Aleppo, and of her mother, left behind in Syria. She describes the border crossings, the isolation, the hunger, the shame of depending on government aid, and the long months in the overcrowded reception centre. Based on her story and symptoms, Dr. Rossi explains that what Amira is experiencing may be part of what clinicians sometimes call <strong>Migratory Mourning</strong>, and specifically the <strong>Ulysses Syndrome</strong>: a human response to prolonged, overwhelming adversity, not a sign of weakness or madness.</p>
<p>For months she has been feeling tired and empty. Her headaches come in waves, some nights she cannot sleep at all, she often skips meals, sometimes stays indoors for days, and has difficulty concentrating. The support counsellor at her reception centre gently suggests that she see someone, and refers her to a public health clinic.</p>
<p>At the clinic, Amira is received by Nurse Selam Tesfay, who came to Italy from Eritrea and speaks both Italian and Arabic. Inside the consultation room, Nurse Selam sits together with Dr. Elena Rossi, a psychiatrist. The two professionals attend Amira jointly. Nurse Selam switches into Arabic when Amira falters in Italian, helping her describe her symptoms and her recent history.</p>
<p>Amira speaks of her father, who died in Aleppo, and of her mother, left behind in Syria. She describes the border crossings, the isolation, the hunger, the shame of depending on government aid, and the long months in the overcrowded reception centre. Based on her story and symptoms, Dr. Rossi explains that what Amira is experiencing may be part of what clinicians sometimes call <strong>Migratory Mourning</strong>, and specifically the <strong>Ulysses Syndrome</strong>: a human response to prolonged, overwhelming adversity, not a sign of weakness or madness.</p>
Mode of Implementation
Individual written reflection, followed by optional group discussion.
Role of the Teacher
Introduce the case and the concept of Ulysses Syndrome. Facilitate post-exercise group discussion. Provide feedback on students' written reflections.
Theoretical Basis
The exercise is grounded in the concept of Migratory Mourning and, specifically, the Ulysses Syndrome — a chronic and multiple stress syndrome in migrants — which describes a human response to prolonged, overwhelming adversity rather than a psychiatric disease in the classical sense. It draws on trauma-informed care principles and on culturally sensitive clinical communication: language barriers, stigma around mental illness, and the meaning patients give to words such as 'depression' or 'syndrome' shape both the diagnostic encounter and the therapeutic alliance.
Practical Application
Students analyse a realistic clinical case, identify relevant cues, and reflect on the cultural dimensions of the encounter. This builds competence for real-world multicultural healthcare encounters.
Knowledge Transfer
Skills developed here transfer to any clinical setting where patients come from different cultural backgrounds, including refugee and migrant health services.
Reinforcement & Reflection
After completing the exercise, discuss as a class: What barriers to care did you identify? How can healthcare systems better support patients with Ulysses Syndrome?
Required Resources
This exercise (digital or printed). Optional: background reading on Ulysses Syndrome / Migratory Mourning.
Assessment / Evaluation
Written reflections assessed for depth of clinical reasoning, cultural sensitivity, and engagement with the case details.
Practical Tips
Encourage students to refer back to specific details from the case narrative when answering. Remind them there are no single 'correct' answers — the goal is thoughtful reflection.
Discussion Topics
What role does language play in the diagnostic process? How might Amira's loss of professional identity affect her health? What support structures could reduce migratory mourning?
Further Resources
Achotegui, J. (2004). Emigrar en situación extrema: El Síndrome del inmigrante con estrés crónico y múltiple (Síndrome de Ulises). Norte de Salud Mental, 5(21), 39–52.
Additional Remarks
The case is based on a refugee from Syria, but the clinical-thinking framework applies to other populations in forced migration; teachers can adapt the country of origin and reception context to their local situation. If the MultiCultiMed Platform is unavailable, the exercise can be run on paper with printed copies of the case and question sets. The teacher should be prepared to manage emotional reactions: students may identify strongly with Amira or with the professionals. Short pauses and a clear closing reflection help students leave the room with a sense of integration rather than distress.