Issues in Mental Health Nursing, 34:883–891, 2013 Copyright © 2013 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.814735
“We are All Fellow Human Beings”: Mental Health Workers’ Perspectives of Being in Relationships with Clients in Community-Based Mental Health Services ˚ Kristin Adnøy Eriksen, RN, MSc Stord Haugesund University College, Haugesund, Norway, and Karolinska Institute, Stockholm, Sweden
Maria Arman, RN, PhD Karolinksa Institute, Stockholm, Sweden
Larry Davidson, PhD Yale University, School of Medicine, New Haven, Connecticut, USA
Bengt Sundfør MoodNet, Tysvær, Norway
Bengt Karlsson, RN, PhD Buskerud University College, Drammen, Norway
Stable, trusting relationships are at the core of Norwegian community-based mental health services. Being acknowledged and respected may promote a client’s recovery. The aim of this study was to explore mental health workers’ experiences of relating to clients. The design involved multi-stage focus groups based on a participatory approach and using interpretative phenomenological analysis. Acknowledging the personhood of a client appears to offer opportunities for growth and development in the client as well as in the health worker, based on reciprocal processes of each person affecting the other and the health workers’ openness to understanding the other person.
A long-term relationship based on openness and trust is an important component of services for persons living with severe mental illnesses. Relationships may offer clients experi˚ ences of connectedness to other people (Adnøy Eriksen, Arman, Davidson, Sundfør, & Karlsson, 2013), and being acknowledged and respected in relationships with health workers may promote clients’ efforts to take charge of their own lives (Tondora, Miller, Guy, & Lanteri, 2009). According to Norwegian National guidelines, stable relationships marked by respect for the service user are supposed to be at the core of community based mental health services, with mental health workers being challenged to be people clients can trust (Sosial og Helsedirektoratet, 2005). ˚ Address correspondence to Kristin Adnøy Eriksen, Stord haugesund University College, Klingenbergvegen 8, N-5414 Stord, Norway. E-mail: [email protected]
Relationships with clients offer opportunities for experiences of recognition. There may be mutual validation based on awareness and acknowledgment of sharing a fundamental likeness as human beings. There is recognition of the “me” in the “other,” and this represents opportunities for both parties to come toward each other and take part in each others’ lives (Martinsen, 2006). Stern calls this an interpenetration of minds: There is a consciousness of sharing the same mental landscape, and this is linked to the clients’ opportunity “to be known and to share what it feels like to be them” (Stern, 2004, p. 97). In this way, relationships may strengthen clients’ identity and sense of self (Schibbye, 2009) and support their process of being autonomous and active agents who can make decisions based on their own values, preferences, and interests (Davidson, Rakfeldt, & Strauss, 2010). Martinsen points out that recognition of “me” in the “other” depends on ethical emotions: Life must be seen as worth caring for and protecting (Martinsen, 2006), and the client must become the health workers’ concern. The opportunity to experience recognition depends, in part, on emotional involvement. The challenge lies in being sufficiently affected in order to perceive morally relevant aspects in the other’s situation while, at the same time, keeping one’s personal boundaries and not being invaded by the other person’s feelings, opinions, and standards (Ekeberg, 2011). Moyle found that professional caring was sometimes provided without emotional attachment, and that health workers tended to distance themselves from the client (Moyle, 2003). This may be understood as a defensive
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strategy to shield one’s inherent integrity from being affected and violated, and may result in detachment and insensitivity towards patients’ interests (Ekeberg, 2011). Arman and colleagues (2004) suggest that both patients and caregivers have strong defenses they use to avoid confrontation with suffering. The caregiver has an opportunity to become a fellow human being in the common struggle, but this implies facing moral responsibility, as well as being open to the unavoidable suffering in life (Arman, Rehnsfeldt, Lindholm, Hamrin, & Eriksson, 2004). Recognition happens in every present moment; thus the health worker is challenged to recognize the client as he or she presents him- or herself “even and especially while remaining disabled” (Davidson, Tondora, Lawless, O’Connell, & Rowe, 2009, p. 15). To be able to recognize, or see once more, accept, distinguish, acknowledge, and strengthen (Schibbye, 2009), in every present moment, health workers need awareness that they are an unknowing stranger. The client’s world cannot be predicted or explained. The nature of the relationship depends on valuing the other’s human dignity and freedom to choose (Milton, 2008). Persons living with severe mental illness may experience that their freedom to define their own experiences is limited, as health workers may recognize and define matters according to their own perspectives, rather than striving to understand how the individual clients make sense of their own life ˚ (Adnøy Eriksen et al., 2013). Lorem and Hem (2012) call for a process of reciprocated feelings and attuned understanding for health workers—imagining themselves in the other’s place, being sensitive to many aspects of the client’s situation, being convinced that meaning exists in what the client is presenting. In this way clients may experience that they are significant and have intrinsic value and may, thereby, feel empowered (Lorem & Hem, 2012). Relationships involve at least two persons, each with his or her individual perspective, and these are constantly influenced and changed in mutual processes. The nature of the relationship is linked to experiences, attitudes, and values, and may be understood as a way of being as well as an enactment (Varcoe et al., 2004). The variable and fluctuating nature of relationships makes them hard to study and define. Exploring mental health workers’ knowledge about what it means to recognize their clients could contribute to further understanding of the mutual processes between health workers and clients. This is important as a reminder of the ethical challenge to promote dignity and avoid humiliation in mental health services, as well as being a contribution toward understanding how relationships might be opportunities to promote clients moving toward being autonomous and active agents. This study aims to reveal and express knowledge about the meanings of recognition of clients’ personhood and intrinsic value as human beings, based on mental health workers’ lived experiences of long-term relationships with clients. Questions guiding the research are: How do health workers understand their being in a relationship as an opportunity to accept and
acknowledge the client? How do they adapt and respond to the client’s being in a relationship? METHODS Design Multi-stage focus groups (Borg, Karlsson, & Kim, 2010; Hummelvoll, 2008) based on participatory philosophy were used as the design for this study. Research questions were answered in cooperation with experienced mental health workers, and the intention was to build new knowledge and see other perspectives. The same group of participants and researchers met every three weeks, four times, taking part in a process of exploration of meanings of recognition of clients’ personhood and intrinsic human value. The phenomenon of recognizing clients is understood based on the life-world descriptions in the groups. Dahlberg and colleagues’ (Dahlberg, Nystr¨om, & Dahlberg, 2008) philosophy of reflective life-world research guided the research process. The focus groups allowed room for dialogue about clients’ perceptions and experiences of being in relationships with health workers and how these may be understood as challenges to health workers. Clients’ perspectives were represented by findings and examples from an earlier study about clients’ experiences of recognition (and lack of recognition) in relationships ˚ ˚ with health workers (Adnøy Eriksen et al., 2013; Adnøy Eriksen, Sundfør, Karlsson, R˚aholm, Arman, 2012), and the participants added clinical examples to that. It was a reflection process to explore what recognition of personhood and intrinsic human value may be about, and how this is understood and can be implemented in clinical work. Data Collection A total of eight mental health workers, working in four different community-based mental health services, were recruited via the leader of each service. The participants were qualified nurses, with at least one year of further education; five participants had more than ten years’ experience of working with people with mental health problems, two had more than four years’ experience, and one had less than four years’ experience. The participants worked in day-centres; as consultants, meeting service users in formal dialogues in an office; or in the field, giving individual support to individual service users in their everyday lives. All participants worked in mental health services that encourage long-term relationships as a basis for the service, and were case managers for individual service users. The researcher is a nurse with experience of mental health work and a lecturer in nursing ethics, with formal education in research. The co-researcher (fourth author) has had experience as a mental health service user and mental health adviser. The same individuals participated in all four focus groups; however one participant was absent once and the co-researcher was absent twice.
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Limits to the recognition of clients’ personhood and intrinsic value were exemplified by introducing four different case descriptions and quotes from a study on clients’ perspectives. The dialogues in the four focus groups were based on these examples. Clients’ narratives about being valueless, incomprehensible, misunderstood, and devalued helped the dialogue to go deeper. The interval between the groups was used to try out ideas and thoughts from the group in clinical practice, and experiences were talked about in the next group session. The participants received a summary from the previous group a few days before the next group. Each group began with all participants saying something about their reflections based on the last group, as well as having the opportunity to comment on the written summary. This was a way of ensuring a joint process and correcting the researcher’s comprehension and interpretation of what had been said (Borg et al., 2010). It was stressed that the conversation was open, that there were no correct answers, and that the individuals’ experiences and reflections were important (Krueger & Casey, 2009).
made. Statements from the material were moved into the preliminary themes, and descriptions of what was said about each theme were made. Data were then compared and combined into consistent themes (see Table 1) as a preliminary understanding of the data. Based on the process so far, a more interpretative dialogue with the material was performed. The themes and subthemes were compared and put together in a new way in order to obtain further meaning from the data and to more fully understand it. The aim was to understand the material as an answer to the research question and, at the same time, explain and take the total data set into consideration. In line with participatory philosophy, preliminary patterns of meanings were presented for members of the focus group. This dialogue guided the further process of trying out different ways of understanding and interpreting the meanings. This process included searching for ways the mental health workers were being rather than what they were doing. The interpreted meanings represent attitudes and values found to be essential to the recognition of personhood and intrinsic human value in long-term relationships with clients.
Analysis The analysis was based on Dahlberg et al.’s (2008) interpretative analysis of life-world, which emphasizes a phenomenological base for the hermeneutic process. The analysis is an act of understanding; the main rule is to be open. As the dialogue is concerned with details about the phenomenon, new questions and new details, as well as new horizons, may appear (Dahlberg et al., 2008). The hermeneutic process started in the dialogues in the focus group as group members (researchers and participants) aimed to be open to each other’s perspectives on the phenomenon in an attempt to see something new and expand their understanding. The ideas and case descriptions introduced in the group led to questions about how these could be responded to and interpreted in a clinical setting. The health workers added their own opinions, examples from clinical work, and theoretical knowledge to respond to the challenges or questions. The process continued as other group members supported, elaborated, or challenged using further examples, opinions, or other knowledge; in this process, new ways of expression and new perspectives about what the recognition of clients may entail were sometimes found. The further analysis is based on this group process, as the researcher (first author) went from being part of the dialogue in the groups (with a focus on details about what it means to recognize personhood and intrinsic human value) to analysing the data, and thus being in dialogue in the search for further clues about a “new whole” (Dahlberg et al., 2008, p. 284) that represents health workers’ knowledge of meanings of recognition of personhood and intrinsic human value. The transcribed focus groups, summaries, and field notes were read several times in order to gain a sense of the whole and to allow the researcher to become familiar with the data. A preliminary structure of themes and subthemes based on themes from the groups, as well as themes emerging in the analysis, was
Ethics As narratives from a previous project were used, permission was sought from the regional ethical committee for clinical research (reference number 2009/1316), and the changes were within the scope of the original permission granted. The current project is registered in the Norwegian Social Science Base (NSD number 26685) and was accepted on 6 April 2011. The participants received written information about the project and signed written consent forms. FINDINGS—INTERPRETED MEANINGS Recognition of personhood and intrinsic human value was found to be about being accepting and inclusive, being emotionally involved, and searching for each client’s perspective (Table 1). The health workers seemed to be aware that their ways of being could facilitate or reduce a client’s opportunities to present him- or herself. The six interpretations described below represent health workers’ various modes of being, their state of mind, and their attitude when striving to recognize the personhood of a client. The participants often quoted themselves or the client in their statements, and these are used to illustrate the different interpretations. The participants are called “health workers” and “she.” Being Humble and In Awe Being involved in clients’ lives and being exposed to human vulnerability seemed to increase health workers’ respect for the individual client (personhood), as well as for human value in general (intrinsic human value). Terms like “being in awe,” “feeling humble,” “respect,” and “admire” were used, indicating that human value was respected as holy and dignified and was something for which health workers showed reverence. Being
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TABLE 1 Themes and Statements Themes
Variations
Examples of Statements
Accept without judging—to accommodate
Acknowledgment Stop oneself from defining Stop oneself from offering solutions Be aware of not knowing the “truth”
Include everything as part of being a human being—to normalize
All humans are essentially human All experiences are human experiences No experiences are too “bad” to share A valued role as key to being “like other people”
Emotionally involved and not overwhelmed—to contain
Be professional Be empathic Tolerate strong emotions Remain calm Show concern Don’t turn away from the client
Client’s perspective as norm for relationship—to join
Shared process Tune in and join client’s world Client’s perspective decides pace, direction, and aim
. . . to meet them where they are, if not they will experience that I reject them Our theories about psychosis . . . Who knows what it really is? “I can’t understand it” . . . I don’t reject but allow room for it. . . . hold back on the urge to move on all the time. . . . accept . . . her way of handling everyday life. Not making it a sign of the illness. . . . make people feel that they are like other people. “This is a normal reaction to the illness you have, and there is hope and help . . .” “I can recognize this, I have seen this before,” they . . . are not alone in the world. “Other people may feel shame . . . is that something you recognize?” —in that way we make it normal. “. . . we are cool with it, so you can be cool with it as well.” naming something may be a relief . . . as he can recognize and think that other people think the same way. . . . not becoming overwhelmed. “We are competent people who can handle it.” . . . terrible to realize what her experiences were like. “I do not experience the war outside our door, and I think you can be safe.” “This suffering is terrible, and really takes all your strength.” “. . . constant thoughts about disaster. It has to be very bad.” . . . the anxiety that goes along with it! It is not hard to see that this is exhausting! It’s about sharing myself . . . Because it is impossible to have a good relationship with a person that is not sharing. . . . a sense of equality. . . . quote [Kierkegaard]: “to meet him where he is and start there” . . . and if you are in a psychosis that is where you start. . . . we cannot be on “net” [connect] if we are not on his channel. “. . . to move towards new horizons, the hermeneutic approach. . . . no need to release the whole psychosis . . . move somewhere behind . . . “What is this (really) about?” We need to join them in their world in order for us to understand. . . . help them understand themselves. Meaning and understanding. I am very careful [in order for him to] not make it necessary to protect himself.
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TABLE 1 Themes and Statements (Continued) Themes
Variations
Examples of Statements
Limits to acceptance—to close opportunities
Personal borders Borders in client Focus on solution and method Communicate need to change
Source of and limits to emotional involvement—to face vulnerability
Vulnerability induces respect Taking over feelings from client Emotional strain Losing hope Avoiding the burden of caring
There are boundaries in me and in the client. The way we communicate can make or move those boundaries . . . signal that they should not speak openly. . . . avoid asking the questions. . . . afraid we will make people worse or uncertain about how we should handle what they say. It is not always easy to respect them as they are in the present moment, including the symptoms. . . .too eager to tell them what the truth or reality is like . . . like a rejection, we close the opportunity. . . . signal that we strive for them becoming something else . . . not good enough as they are. . . . too focused on treatment, and the individual’s ideas about his life are forgotten. The case and the diagnosis and he [are] left on the sideline. Whose aim are we working towards, is it ours or the individual’s? Focus on solving a problem . . . need to accept the problem and focus on how to cope with it. And even accept it if the individual does not want to work with this problem. Their vulnerability affects me; at the same time it gives root to the respect that can be of help. It can be extremely tiring. It is like a psychological dialysis, and we can feel the strain of the individual. We may be overwhelmed . . . when we hear what their lives are like. If they lose their ability to control themselves, and I think: “When will it happen again?”—that fear really gets to you.
impressed by clients was reported to give the health worker a sense of contributing to something important; in this way, being in relationship with clients added meaning to the health workers’ lives. This experience of doing something worthwhile was reported to be an important motivational factor for being a mental health worker: . . . as I get insight in thoughts and feelings . . . I am really humble . . . and almost . . . sometimes I thank them for sharing . . . I am grateful because that is really . . . you see into the souls of people . . . one experiences to be in awe . . . I thank them for allowing me to join their journey.
willing to enter the relationship without definitions and readymade plans. The health workers were aware that they were learning from the clients and needed to hold back their own personal opinions. These relationships were understood as opportunities for dialogues of shared meaning as the health worker became engaged in wondering based on the client’s understanding of him- or herself. In these dialogues, knowledge based on theory or knowledge based on previous experiences might be shared as a way of seeing new perspectives. The health workers seemed to have a foundational attitude of expecting to see more and expand their own understanding.
Being Willing to Risk One’s Own Understanding The search for the client’s perspective, and the desire to accept without judging, meant that the health worker had to be
The knowledge I have developed during the years . . . comes from the clients . . . and allowing users’ experiences to emerge is extremely important . . . I listen and am open.
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Being in Process This expectation of expanding knowledge might be a way of being in process. Each health workers strived to be in a constant process of personal and professional development. In the group dialogues, ideas were expressed as suggestions rather than statements, illustrating attitudes of being in process rather than having reached a conclusion. This seemed to be an approach to how these health workers understood the client, as well: They strove to sustain their expectations that the client would develop and find new opportunities and that his or her situation would change. This process of inconclusiveness, or of being open to new possibilities in the present moment, was linked to upholding and inducing hope. I need to be there in the moment . . . be in touch with what is here and now . . . and to be with myself in the encounter with people. We need to join them in their world in order for us to understand, but also to help them understand themselves. Meaning and understanding may be a help to move on.
Being Courageous The health workers talked about daring to confront clients and daring to be confronted with responses from clients. Being open to what is presented, and inviting clients to be open, meant responding to what clients (and sometimes health workers as well) experienced as shameful, shocking, and out of the ordinary. Sometimes the health worker became a witness to issues she was not prepared to handle. There also was concern about inducing negative processes in the client. Courage was needed, as being in relationships with clients sometimes involved crossing the clients’ personal borders. Additionally, courage was needed so the health worker could be prepared to be moved out of her own comfort zone. I confronted her . . . She didn’t get upset, she actually said: “You really understand me,” even if I had pointed out I was not able to understand, as her life is so different from anything I have experienced. It can be extremely tiring. It is like a psychological dialysis, and we can feel the strain of the individual. We may be overwhelmed sometimes, even as professionals, when we hear what their lives are like.
Being a Positive Counter Force Even if the client’s perspective was the norm for the relationship, this did not include accepting the client’s devaluing of him- or herself. The health workers understood the relationship as one that provided opportunities to get across messages like “you are ok,” “I think you are interesting,” and “I like being with you” as a counter force to negative messages clients might receive from society and in spite of the negative images the
client might have of him- or herself. This could be expressed to the client in words or through underlying messages to the client as the health worker invested her time and energy in being involved in the client’s everyday life. In this sense, the health worker used herself as a positive force to reinstate or strengthen her clients’ personhood and intrinsic value. Providing a valued role, through work or responsibility, and being active in giving positive feedback on clients’ development also were thought by our participants to be important positive counter forces for clients. . . . that we say as professionals, “This is important to me,” and they experience “I am useful” and “someone needs me.” . . . to give that acknowledgment, and see who they are, and reflect to them who they are.
Being Aware of Limitations to Providing Recognition Self-reflection and talking to colleagues about clinical situations were seen as essential in order to stay open to clients, to keep hoping, to keep searching for new perspectives, and to endure emotional strain. There was awareness of the health workers’ own limits to emotional involvement, as well as limits to each individual’s ability to provide recognition. The health worker might need to distance herself from the client in order to cope with her own reactions. It also might be hard to adjust the level of involvement and sort her own emotions from the client’s emotions. “Taking over” the client’s emotions and perspectives might lead to a loss of hope and not seeing opportunities for change. The group also discussed that the health worker’s personhood might be a limitation, as many clients would not “see themselves” or identify with health workers who were primarily middle-aged, middle-class women. And, even if a long-term relationship made it possible to “join” with the client and understand his or her perspective, there was a danger of the relationship becoming locked in some patterns, with set rules and roles, but no new aims. It is hard work keeping the thought about new chances and keep hoping that we will connect again. Things may be locked up, and an open conversation does not seem possible. They keep repeating the same thing over and over again, every time we meet and, in the end, you can’t stand talking to them. Sometimes you have to face your limitations and admit that we can’t help everybody.
INTERPRETATION AND DISCUSSION We keep saying “them” and “us.” But we are, in fact, all human beings and fellow human beings.
Providing recognition meant that health workers showed their own humanity and personhood in ways that confirmed clients’ personhood and supported the clients’ processes of reclaiming their identity. Health workers emphasized “being persons” in ways that would give clients experiences of being individuals who were appreciated and valued by the health worker and who would be (had the potential to be) appreciated by others
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in general. Health workers aimed to accommodate and make space for clients to present themselves and were open to being affected by their clients in these relationships. Responding to clients by providing unconditional acknowledgment was found to be understood as a demonstration to clients that they were significant and valued. Being in a relationship with an aim to recognize clients’ personhood and intrinsic value as human beings was understood as a way of reinforcing clients’ identities and self-respect. The relationships consist of reciprocal processes of the health worker and client each affecting, and being affected by, each other. Both parties contribute and receive, even if what is given and gained by each person is not the same. The further discussion focuses on two processes of affecting and being affected in relationships: First, the process of affecting impacts recognition by each person feeling respected and increasing self-respect; second, the process of affecting impacts recognition by each person being open to and accepting the opportunities to change and develop.
Being Respected and Self-Respect Recognition, understood as a positive counter force, aims to prove to a client that he or she has the same value as other people in spite of that client’s experiences of being different ˚ (Yu & Shim, 2009), incomprehensible, or worthless (Adnøy Eriksen et al., 2013), and in spite of being marginalized in society (Rowe & Pelletier, 2012). Showing respect and value to the client “even and especially while remaining disabled” (Davidson et al., 2009, p. 17) may help the client accept his or her life situation and not be ashamed of him- or herself. Caring and unconditional acceptance seem to be ways of neutralizing some of the negative impacts of living with mental distress and, thus, increasing clients’ self-respect. Since they don’t always live up to society’s standards, clients may experience rejection, and as society tends to value only the strong and perfect and to reject that which is weak or judged as different, clients may also experience stigmatization because of their mental disorder (Granerud & Severinsson, 2003). Being affected and developing a deep respect for intrinsic human value gave health workers an alternative perspective: Recognition means including the whole person, and vulnerability and weakness may be valued as part of human life. Health workers’ sustained focus on recognition, rather than definitions and treatment plans, may be a positive contribution to diminishing stigmatization and increasing clients’ self-respect and could ideally provide new opportunities for inclusion for clients. Rowe and Pelletier (2012) argue that thinking of individuals with neurological or mental disorders as irrational diminishes their citizenship status. In order for individuals to be included as citizens or valued members of the community, they need opportunities to take up the rights and duties as citizens, rather than being focused on treatment of a cluster of symptoms (Rowe & Pelletier, 2012).
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Respecting and valuing intrinsic human value was shown to increase health workers’ self-respect as well. The health worker is aware of gaining something, not only from the respect she may experience from an individual client, but also from the realization that life, in general, is worth caring for and protecting (Martinsen, 2006). She experiences involvement in securing human dignity (Honneth, 1992) and is proud of herself as she gets close to and involved in caring for what she respects and values. This can be explained as a process that starts with a deep awareness of our universal connection to one another and leads to a desire to increase another’s welfare, which, again, may increase one’s self-esteem, mental health, and ego-autonomy (Mastain, 2006). Arman and Rehnsfeldt suggest that caring in this way may move the health worker closer to the essence of his or her personality and give the worker the opportunity to live in a more authentic manner (Arman & Rehnsfeldt, 2006). These processes of affecting others through respecting them and gaining self-respect may motivate health workers to keep trying to form open and trusting relationships with clients, even if doing so is sometimes experienced as demanding or exhausting.
Being Open to Opportunities to Change and Develop The findings point to two variations of openness: being affected emotionally and developing new understanding. Both of these aim to give clients opportunities to develop their sense of self. Emotional involvement is thought to prove to the client that he or she is worth caring about, and the client being able to affect the health worker may give the client experience of being valued and significant. Being open to new perspectives and seeking to accommodate what clients present are meant to give clients opportunities to present themselves openly, without having to worry about what to reveal in their relationship ˚ with a health worker (Adnøy Eriksen et al., 2013). That health workers are prepared to accept alternative understandings may give clients the experience of making sense and of being active agents. Health workers offer emotional, human contact and practical interaction, and clients are given opportunities to find articulated meaning (Lorem & Hem, 2012). Each client experiences being known (Stern, 2004), and may be given the opportunity to recognize him- or herself in “the other” (in this case, the health worker). This has been found to contribute to restoring a person’s feeling of being valued as a human being (Berggren & Gunnarsson, 2010). Persons living with severe mental illness have been found to sometimes experience existential loneliness (Nilsson, N˚aden, & Lindstr¨om, 2008) and to be engaged in an ongoing struggle to be ˚ recognized by other people (Adnøy Eriksen et al., 2012). This may explain why recognition was understood by health workers as stretching beyond one’s own perspectives and beyond being safe and comfortable. Additionally, health workers accepted that being in relationship with clients takes courage and endurance. Recognition may sometimes be a willingness to see and hear
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what has typically been rejected. The health workers challenge their own urges to avoid confrontation with suffering (Arman et al., 2004); they are willing to tolerate uncertainty (Seikkula & Olson, 2003) and wish to stretch beyond what they are able to comprehend. This can be described as an awareness of not understanding, but yet expecting there to be something to understand (Lorem & Hem, 2012), or as an awareness of being an unknowing stranger. Clients’ voices are given room without right-or-wrong thinking, and the goal is to generate joint understanding rather than consensus (Seikkula & Olson, 2003). In this way, openness may contribute to a consciousness of sharing the same mental landscape (Stern, 2004). The openness the health workers aim to have in their relationships with clients may be part of a more general approach to life. In the focus groups, the participants showed openness to new ideas and typically offered suggestions rather than conclusions. Being willing to develop a new understanding is, to some extent, accepting indecisiveness. Borg et al. (2010) found that deeper understanding of practice might be gained by delving into variations in ideas, approaches, and perspectives regarding clinical issues, and by keeping questions open and not related to what is typically defined as psychiatric diagnoses or practice guidelines (Borg et al., 2010). The most important practice guideline in mental health work may thus be to value human dignity and protect clients’ freedom to choose (Milton, 2008), as this may give clients a strengthened sense of self (Schibbye, 2009) and opportunities to be autonomous and active agents in their own recovery process (Davidson et al., 2010). This also may provide opportunities for health workers to grow and develop, depending on their willingness to be affected by, and their expectations of learning from, being in relationships with clients.
METHODOLOGICAL CONSIDERATIONS The participants in the study probably represent an elite group of mental health workers. They had long-term experience and volunteered for this study based on their interest in “recognition” and “being in relationships.” Their insight was developed through caring fellowships in which recognition and being in relationships were foundational pillars; this insight may be useful. The findings represent health workers’ knowledge as a product of the process of self-reflection, their lived experiences with integrating theoretical knowledge in clinical work, and their experiences with being in co-created moments with clients. In this sense, the findings are not only theoretical or hypothetical opinions, but rather a presentation of health workers’ identities as moral agents. Health workers’ ethical responses to clients have been found to be based on deep personal convictions about what the health worker deems to be “good” (Varcoe et al., 2004). As the focus of this study was “knowledge about meanings of recognition,” the findings illustrate health workers’ good intentions and what they have experienced to be good ethical
responses, rather than their lived, practical, experiences with recognition. This is not a description of community-based mental health services. In real life, health workers are probably not always courageous; they may misinterpret clients’ perspectives and they may only partially sustain emotional involvement. At the same time, pointing out what would be good in the process of recognition may allow readers to see the challenges and aims of being in relationships with mental health clients.
CONCLUSION This study indicates that relationships between clients and health workers may become bridges of connectedness to other people, opportunities, and experiences of shared likeness (Martinsen, 2006). In this sense, recognition is proof of humanity, an experience of being a human being like other human beings ˚ (Adnøy Eriksen et al., 2012). Health workers saw themselves as counter forces to clients’ negative experiences of degradation and rejection. Recognition of personhood and intrinsic human value should not be a task for professionals but rather something to be taken for granted, and a more universal sense of belonging may depend on values and expectations in society, as well as recognition by other people in general. It is suggested that relationships that have a focus on recognition depend on reciprocal processes of affecting and being affected. Being a human being in a relationship in a way that invites the other person into the relationship provides opportunities for growth and development in the client as well as the health worker. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES Ådnøy Eriksen, K., Arman, M., Davidson, L., Sundfør, B., & Kalrsson, B. (2013). Challenges in relating to mental health professionals: Perspectives of persons with severe mental illness. International Journal of Mental Health Nursing. doi: 10.1111/inm.12024 Ådnøy Eriksen, K., Sundfør, B., Karlsson, B., R˚aholm, M. B., & Arman, M. (2012). Recognition as a valued human being: Perspectives of mental health service users. Nursing Ethics, 19(3), 357–368. Arman, M., & Rehnsfeldt, A. (2006). The presence of love in ethical caring. Nursing Forum, 41(1), 4–12. Arman, M., Rehnsfeldt, A., Lindholm, L., Hamrin, E., & Eriksson, K. (2004). Suffering related to health care: A study of breast cancer patients’ experiences. International Journal of Nursing Practice, 10(6), 248–256. Berggren, U. J., & Gunnarsson, E. (2010). User-oriented mental health reform in Sweden: Featuring “professional friendship.” Disability & Society, 25(5), 565–577. Borg, M., Karlsson, B., & Kim, H. S. (2010). Double helix of research and practice—developing a practice model for crisis resolution and home treatment through participatory action research. International Journal of Qualitative Studies on Health and Well-Being, 5(1), 1–8.
BEING IN RELATIONSHIP WITH COMMUNITY-BASED CLIENTS Dahlberg, K., Nystr¨om, M., & Dahlberg, H. (2008). Reflective lifeworld research (2nd ed.). Lund, Sweden: Studentlitteratur. Davidson, L., Rakfeldt, J., & Strauss, J. S. (2010). The roots of the recovery movement in psychiatry: Lessons learned. Chicester, UK; Hoboken, NJ: Wiley-Blackwell. Davidson, L., Tondora, J., Lawless, M., O’Connell, M., & Rowe, M. (2009). A practical guide to recovery-oriented practice. New York, NY: Oxford University Press. Ekeberg, V. (2011). Mature care and the virtue of integrity. Nursing Philosophy, 12(2), 128–138. Granerud, A., & Severinsson, E. (2003). Preserving integrity: Experiences of people with mental health problems living in their own home in a new neighbourhood. Nursing Ethics, 10(6), 602–613. Honneth, A. (1992). Integrity and disrespect: Principles of a conception of morality based on the theory of recognition. Political Theory, 20(2), 187–201. Hummelvoll, J. (2008). The multistage focus group interview: A relevant and fruitful method in action research based on a cooperative inquiry perspective. Norsk Tidsskrift for Sykepleieforskning, 1, 3–15. Krueger, R. A., & Casey, M. A. (2009). Focus groups: A practical guide for applied research. Thousand Oaks, CA; London, England; New Dehli, India: Sage. Lorem, G. F., & Hem, M. H. (2012). Attuned understanding and psychotic suffering: A qualitative study of health care professionals’ experiences in communicating and interacting with patients. International Journal of Mental Health Nursing, 21(2), 114–122. Martinsen, K. (2006). Care and vulnerability. Oslo, Norway: Akribe. Mastain, L. (2006). The lived experience of spontaneous altruism: A phenomenological study. Journal of Phenomenological Psychology, 37(1), 25–52.
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Milton, C. L. (2008). Boundaries: Ethical implications for what it means to be therapeutic in the nurse-person relationship. Nursing Science Quarterly, 21(1), 18–21. Moyle, W. (2003). Nurse-patient relationship: A dichotomy of expectations. International Journal of Mental Health Nursing, 12(2), 103–109. ˚ (2008). The tune of want in the Nilsson, B., N˚aden, D., & Lindstr¨om, U. A. loneliness melody—loneliness experienced by people with serious mental suffering. Scandinavian Journal of Caring Sciences, 22(2), 161–169. Rowe, M., & Pelletier, J. (2012). Citizenship: A response to the marginalization of people with mental illnesses. Journal of Forensic Psychology Practice, 12(4), 366–381. Schibbye, A. L. (2009). Relasjoner: Et dialektisk perspektiv p˚a eksistensiell og psykodynamisk psykoterapi (2 utg ed.). Oslo, Norway: Universitetsforl. Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: Its poetics and micropolitics. Family Process, 42(3), 403–418. Sosial og Helsedirektoratet: Psykisk Helsearbeid for Voksne i Kommunene [Social and Health Directory: Mental Health Care for Adults in Municipalities], IS-1332. (2005). Stern, D. N. (2004). The present moment in psychotherapy and everyday life. New York, NY: W. W. Norton & Company. Tondora, J., Miller, R., Guy, K., & Lanteri, S. (Eds.). (2009). Getting in the driver’s seat of your treatment: Preparing for your plan. New Haven, CT: Yale Program for Recovery and Community Health. Varcoe, C., Doane, G., Pauly, B., Rodney, P., Storch, J. L., Mahoney, K., et al. (2004). Ethical practice in nursing: Working the in-betweens. Journal of Advanced Nursing, 45(3), 316–325. Yu, M-Y., & Shim, W. (2009). Couples with schizophrenia “becoming like others” in South Korea: Marriage as part of a recovery process. Family Process, 48(3), 429–440.
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“We are All Fellow Human Beings”: Mental Health Workers’ Perspectives of Being in Relationships with Clients in Community-Based Mental Health Services ˚ Kristin Adnøy Eriksen, RN, MSc Stord Haugesund University College, Haugesund, Norway, and Karolinska Institute, Stockholm, Sweden
Maria Arman, RN, PhD Karolinksa Institute, Stockholm, Sweden
Larry Davidson, PhD Yale University, School of Medicine, New Haven, Connecticut, USA
Bengt Sundfør MoodNet, Tysvær, Norway
Bengt Karlsson, RN, PhD Buskerud University College, Drammen, Norway
Stable, trusting relationships are at the core of Norwegian community-based mental health services. Being acknowledged and respected may promote a client’s recovery. The aim of this study was to explore mental health workers’ experiences of relating to clients. The design involved multi-stage focus groups based on a participatory approach and using interpretative phenomenological analysis. Acknowledging the personhood of a client appears to offer opportunities for growth and development in the client as well as in the health worker, based on reciprocal processes of each person affecting the other and the health workers’ openness to understanding the other person.
A long-term relationship based on openness and trust is an important component of services for persons living with severe mental illnesses. Relationships may offer clients experi˚ ences of connectedness to other people (Adnøy Eriksen, Arman, Davidson, Sundfør, & Karlsson, 2013), and being acknowledged and respected in relationships with health workers may promote clients’ efforts to take charge of their own lives (Tondora, Miller, Guy, & Lanteri, 2009). According to Norwegian National guidelines, stable relationships marked by respect for the service user are supposed to be at the core of community based mental health services, with mental health workers being challenged to be people clients can trust (Sosial og Helsedirektoratet, 2005). ˚ Address correspondence to Kristin Adnøy Eriksen, Stord haugesund University College, Klingenbergvegen 8, N-5414 Stord, Norway. E-mail: [email protected]
Relationships with clients offer opportunities for experiences of recognition. There may be mutual validation based on awareness and acknowledgment of sharing a fundamental likeness as human beings. There is recognition of the “me” in the “other,” and this represents opportunities for both parties to come toward each other and take part in each others’ lives (Martinsen, 2006). Stern calls this an interpenetration of minds: There is a consciousness of sharing the same mental landscape, and this is linked to the clients’ opportunity “to be known and to share what it feels like to be them” (Stern, 2004, p. 97). In this way, relationships may strengthen clients’ identity and sense of self (Schibbye, 2009) and support their process of being autonomous and active agents who can make decisions based on their own values, preferences, and interests (Davidson, Rakfeldt, & Strauss, 2010). Martinsen points out that recognition of “me” in the “other” depends on ethical emotions: Life must be seen as worth caring for and protecting (Martinsen, 2006), and the client must become the health workers’ concern. The opportunity to experience recognition depends, in part, on emotional involvement. The challenge lies in being sufficiently affected in order to perceive morally relevant aspects in the other’s situation while, at the same time, keeping one’s personal boundaries and not being invaded by the other person’s feelings, opinions, and standards (Ekeberg, 2011). Moyle found that professional caring was sometimes provided without emotional attachment, and that health workers tended to distance themselves from the client (Moyle, 2003). This may be understood as a defensive
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strategy to shield one’s inherent integrity from being affected and violated, and may result in detachment and insensitivity towards patients’ interests (Ekeberg, 2011). Arman and colleagues (2004) suggest that both patients and caregivers have strong defenses they use to avoid confrontation with suffering. The caregiver has an opportunity to become a fellow human being in the common struggle, but this implies facing moral responsibility, as well as being open to the unavoidable suffering in life (Arman, Rehnsfeldt, Lindholm, Hamrin, & Eriksson, 2004). Recognition happens in every present moment; thus the health worker is challenged to recognize the client as he or she presents him- or herself “even and especially while remaining disabled” (Davidson, Tondora, Lawless, O’Connell, & Rowe, 2009, p. 15). To be able to recognize, or see once more, accept, distinguish, acknowledge, and strengthen (Schibbye, 2009), in every present moment, health workers need awareness that they are an unknowing stranger. The client’s world cannot be predicted or explained. The nature of the relationship depends on valuing the other’s human dignity and freedom to choose (Milton, 2008). Persons living with severe mental illness may experience that their freedom to define their own experiences is limited, as health workers may recognize and define matters according to their own perspectives, rather than striving to understand how the individual clients make sense of their own life ˚ (Adnøy Eriksen et al., 2013). Lorem and Hem (2012) call for a process of reciprocated feelings and attuned understanding for health workers—imagining themselves in the other’s place, being sensitive to many aspects of the client’s situation, being convinced that meaning exists in what the client is presenting. In this way clients may experience that they are significant and have intrinsic value and may, thereby, feel empowered (Lorem & Hem, 2012). Relationships involve at least two persons, each with his or her individual perspective, and these are constantly influenced and changed in mutual processes. The nature of the relationship is linked to experiences, attitudes, and values, and may be understood as a way of being as well as an enactment (Varcoe et al., 2004). The variable and fluctuating nature of relationships makes them hard to study and define. Exploring mental health workers’ knowledge about what it means to recognize their clients could contribute to further understanding of the mutual processes between health workers and clients. This is important as a reminder of the ethical challenge to promote dignity and avoid humiliation in mental health services, as well as being a contribution toward understanding how relationships might be opportunities to promote clients moving toward being autonomous and active agents. This study aims to reveal and express knowledge about the meanings of recognition of clients’ personhood and intrinsic value as human beings, based on mental health workers’ lived experiences of long-term relationships with clients. Questions guiding the research are: How do health workers understand their being in a relationship as an opportunity to accept and
acknowledge the client? How do they adapt and respond to the client’s being in a relationship? METHODS Design Multi-stage focus groups (Borg, Karlsson, & Kim, 2010; Hummelvoll, 2008) based on participatory philosophy were used as the design for this study. Research questions were answered in cooperation with experienced mental health workers, and the intention was to build new knowledge and see other perspectives. The same group of participants and researchers met every three weeks, four times, taking part in a process of exploration of meanings of recognition of clients’ personhood and intrinsic human value. The phenomenon of recognizing clients is understood based on the life-world descriptions in the groups. Dahlberg and colleagues’ (Dahlberg, Nystr¨om, & Dahlberg, 2008) philosophy of reflective life-world research guided the research process. The focus groups allowed room for dialogue about clients’ perceptions and experiences of being in relationships with health workers and how these may be understood as challenges to health workers. Clients’ perspectives were represented by findings and examples from an earlier study about clients’ experiences of recognition (and lack of recognition) in relationships ˚ ˚ with health workers (Adnøy Eriksen et al., 2013; Adnøy Eriksen, Sundfør, Karlsson, R˚aholm, Arman, 2012), and the participants added clinical examples to that. It was a reflection process to explore what recognition of personhood and intrinsic human value may be about, and how this is understood and can be implemented in clinical work. Data Collection A total of eight mental health workers, working in four different community-based mental health services, were recruited via the leader of each service. The participants were qualified nurses, with at least one year of further education; five participants had more than ten years’ experience of working with people with mental health problems, two had more than four years’ experience, and one had less than four years’ experience. The participants worked in day-centres; as consultants, meeting service users in formal dialogues in an office; or in the field, giving individual support to individual service users in their everyday lives. All participants worked in mental health services that encourage long-term relationships as a basis for the service, and were case managers for individual service users. The researcher is a nurse with experience of mental health work and a lecturer in nursing ethics, with formal education in research. The co-researcher (fourth author) has had experience as a mental health service user and mental health adviser. The same individuals participated in all four focus groups; however one participant was absent once and the co-researcher was absent twice.
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Limits to the recognition of clients’ personhood and intrinsic value were exemplified by introducing four different case descriptions and quotes from a study on clients’ perspectives. The dialogues in the four focus groups were based on these examples. Clients’ narratives about being valueless, incomprehensible, misunderstood, and devalued helped the dialogue to go deeper. The interval between the groups was used to try out ideas and thoughts from the group in clinical practice, and experiences were talked about in the next group session. The participants received a summary from the previous group a few days before the next group. Each group began with all participants saying something about their reflections based on the last group, as well as having the opportunity to comment on the written summary. This was a way of ensuring a joint process and correcting the researcher’s comprehension and interpretation of what had been said (Borg et al., 2010). It was stressed that the conversation was open, that there were no correct answers, and that the individuals’ experiences and reflections were important (Krueger & Casey, 2009).
made. Statements from the material were moved into the preliminary themes, and descriptions of what was said about each theme were made. Data were then compared and combined into consistent themes (see Table 1) as a preliminary understanding of the data. Based on the process so far, a more interpretative dialogue with the material was performed. The themes and subthemes were compared and put together in a new way in order to obtain further meaning from the data and to more fully understand it. The aim was to understand the material as an answer to the research question and, at the same time, explain and take the total data set into consideration. In line with participatory philosophy, preliminary patterns of meanings were presented for members of the focus group. This dialogue guided the further process of trying out different ways of understanding and interpreting the meanings. This process included searching for ways the mental health workers were being rather than what they were doing. The interpreted meanings represent attitudes and values found to be essential to the recognition of personhood and intrinsic human value in long-term relationships with clients.
Analysis The analysis was based on Dahlberg et al.’s (2008) interpretative analysis of life-world, which emphasizes a phenomenological base for the hermeneutic process. The analysis is an act of understanding; the main rule is to be open. As the dialogue is concerned with details about the phenomenon, new questions and new details, as well as new horizons, may appear (Dahlberg et al., 2008). The hermeneutic process started in the dialogues in the focus group as group members (researchers and participants) aimed to be open to each other’s perspectives on the phenomenon in an attempt to see something new and expand their understanding. The ideas and case descriptions introduced in the group led to questions about how these could be responded to and interpreted in a clinical setting. The health workers added their own opinions, examples from clinical work, and theoretical knowledge to respond to the challenges or questions. The process continued as other group members supported, elaborated, or challenged using further examples, opinions, or other knowledge; in this process, new ways of expression and new perspectives about what the recognition of clients may entail were sometimes found. The further analysis is based on this group process, as the researcher (first author) went from being part of the dialogue in the groups (with a focus on details about what it means to recognize personhood and intrinsic human value) to analysing the data, and thus being in dialogue in the search for further clues about a “new whole” (Dahlberg et al., 2008, p. 284) that represents health workers’ knowledge of meanings of recognition of personhood and intrinsic human value. The transcribed focus groups, summaries, and field notes were read several times in order to gain a sense of the whole and to allow the researcher to become familiar with the data. A preliminary structure of themes and subthemes based on themes from the groups, as well as themes emerging in the analysis, was
Ethics As narratives from a previous project were used, permission was sought from the regional ethical committee for clinical research (reference number 2009/1316), and the changes were within the scope of the original permission granted. The current project is registered in the Norwegian Social Science Base (NSD number 26685) and was accepted on 6 April 2011. The participants received written information about the project and signed written consent forms. FINDINGS—INTERPRETED MEANINGS Recognition of personhood and intrinsic human value was found to be about being accepting and inclusive, being emotionally involved, and searching for each client’s perspective (Table 1). The health workers seemed to be aware that their ways of being could facilitate or reduce a client’s opportunities to present him- or herself. The six interpretations described below represent health workers’ various modes of being, their state of mind, and their attitude when striving to recognize the personhood of a client. The participants often quoted themselves or the client in their statements, and these are used to illustrate the different interpretations. The participants are called “health workers” and “she.” Being Humble and In Awe Being involved in clients’ lives and being exposed to human vulnerability seemed to increase health workers’ respect for the individual client (personhood), as well as for human value in general (intrinsic human value). Terms like “being in awe,” “feeling humble,” “respect,” and “admire” were used, indicating that human value was respected as holy and dignified and was something for which health workers showed reverence. Being
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TABLE 1 Themes and Statements Themes
Variations
Examples of Statements
Accept without judging—to accommodate
Acknowledgment Stop oneself from defining Stop oneself from offering solutions Be aware of not knowing the “truth”
Include everything as part of being a human being—to normalize
All humans are essentially human All experiences are human experiences No experiences are too “bad” to share A valued role as key to being “like other people”
Emotionally involved and not overwhelmed—to contain
Be professional Be empathic Tolerate strong emotions Remain calm Show concern Don’t turn away from the client
Client’s perspective as norm for relationship—to join
Shared process Tune in and join client’s world Client’s perspective decides pace, direction, and aim
. . . to meet them where they are, if not they will experience that I reject them Our theories about psychosis . . . Who knows what it really is? “I can’t understand it” . . . I don’t reject but allow room for it. . . . hold back on the urge to move on all the time. . . . accept . . . her way of handling everyday life. Not making it a sign of the illness. . . . make people feel that they are like other people. “This is a normal reaction to the illness you have, and there is hope and help . . .” “I can recognize this, I have seen this before,” they . . . are not alone in the world. “Other people may feel shame . . . is that something you recognize?” —in that way we make it normal. “. . . we are cool with it, so you can be cool with it as well.” naming something may be a relief . . . as he can recognize and think that other people think the same way. . . . not becoming overwhelmed. “We are competent people who can handle it.” . . . terrible to realize what her experiences were like. “I do not experience the war outside our door, and I think you can be safe.” “This suffering is terrible, and really takes all your strength.” “. . . constant thoughts about disaster. It has to be very bad.” . . . the anxiety that goes along with it! It is not hard to see that this is exhausting! It’s about sharing myself . . . Because it is impossible to have a good relationship with a person that is not sharing. . . . a sense of equality. . . . quote [Kierkegaard]: “to meet him where he is and start there” . . . and if you are in a psychosis that is where you start. . . . we cannot be on “net” [connect] if we are not on his channel. “. . . to move towards new horizons, the hermeneutic approach. . . . no need to release the whole psychosis . . . move somewhere behind . . . “What is this (really) about?” We need to join them in their world in order for us to understand. . . . help them understand themselves. Meaning and understanding. I am very careful [in order for him to] not make it necessary to protect himself.
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TABLE 1 Themes and Statements (Continued) Themes
Variations
Examples of Statements
Limits to acceptance—to close opportunities
Personal borders Borders in client Focus on solution and method Communicate need to change
Source of and limits to emotional involvement—to face vulnerability
Vulnerability induces respect Taking over feelings from client Emotional strain Losing hope Avoiding the burden of caring
There are boundaries in me and in the client. The way we communicate can make or move those boundaries . . . signal that they should not speak openly. . . . avoid asking the questions. . . . afraid we will make people worse or uncertain about how we should handle what they say. It is not always easy to respect them as they are in the present moment, including the symptoms. . . .too eager to tell them what the truth or reality is like . . . like a rejection, we close the opportunity. . . . signal that we strive for them becoming something else . . . not good enough as they are. . . . too focused on treatment, and the individual’s ideas about his life are forgotten. The case and the diagnosis and he [are] left on the sideline. Whose aim are we working towards, is it ours or the individual’s? Focus on solving a problem . . . need to accept the problem and focus on how to cope with it. And even accept it if the individual does not want to work with this problem. Their vulnerability affects me; at the same time it gives root to the respect that can be of help. It can be extremely tiring. It is like a psychological dialysis, and we can feel the strain of the individual. We may be overwhelmed . . . when we hear what their lives are like. If they lose their ability to control themselves, and I think: “When will it happen again?”—that fear really gets to you.
impressed by clients was reported to give the health worker a sense of contributing to something important; in this way, being in relationship with clients added meaning to the health workers’ lives. This experience of doing something worthwhile was reported to be an important motivational factor for being a mental health worker: . . . as I get insight in thoughts and feelings . . . I am really humble . . . and almost . . . sometimes I thank them for sharing . . . I am grateful because that is really . . . you see into the souls of people . . . one experiences to be in awe . . . I thank them for allowing me to join their journey.
willing to enter the relationship without definitions and readymade plans. The health workers were aware that they were learning from the clients and needed to hold back their own personal opinions. These relationships were understood as opportunities for dialogues of shared meaning as the health worker became engaged in wondering based on the client’s understanding of him- or herself. In these dialogues, knowledge based on theory or knowledge based on previous experiences might be shared as a way of seeing new perspectives. The health workers seemed to have a foundational attitude of expecting to see more and expand their own understanding.
Being Willing to Risk One’s Own Understanding The search for the client’s perspective, and the desire to accept without judging, meant that the health worker had to be
The knowledge I have developed during the years . . . comes from the clients . . . and allowing users’ experiences to emerge is extremely important . . . I listen and am open.
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Being in Process This expectation of expanding knowledge might be a way of being in process. Each health workers strived to be in a constant process of personal and professional development. In the group dialogues, ideas were expressed as suggestions rather than statements, illustrating attitudes of being in process rather than having reached a conclusion. This seemed to be an approach to how these health workers understood the client, as well: They strove to sustain their expectations that the client would develop and find new opportunities and that his or her situation would change. This process of inconclusiveness, or of being open to new possibilities in the present moment, was linked to upholding and inducing hope. I need to be there in the moment . . . be in touch with what is here and now . . . and to be with myself in the encounter with people. We need to join them in their world in order for us to understand, but also to help them understand themselves. Meaning and understanding may be a help to move on.
Being Courageous The health workers talked about daring to confront clients and daring to be confronted with responses from clients. Being open to what is presented, and inviting clients to be open, meant responding to what clients (and sometimes health workers as well) experienced as shameful, shocking, and out of the ordinary. Sometimes the health worker became a witness to issues she was not prepared to handle. There also was concern about inducing negative processes in the client. Courage was needed, as being in relationships with clients sometimes involved crossing the clients’ personal borders. Additionally, courage was needed so the health worker could be prepared to be moved out of her own comfort zone. I confronted her . . . She didn’t get upset, she actually said: “You really understand me,” even if I had pointed out I was not able to understand, as her life is so different from anything I have experienced. It can be extremely tiring. It is like a psychological dialysis, and we can feel the strain of the individual. We may be overwhelmed sometimes, even as professionals, when we hear what their lives are like.
Being a Positive Counter Force Even if the client’s perspective was the norm for the relationship, this did not include accepting the client’s devaluing of him- or herself. The health workers understood the relationship as one that provided opportunities to get across messages like “you are ok,” “I think you are interesting,” and “I like being with you” as a counter force to negative messages clients might receive from society and in spite of the negative images the
client might have of him- or herself. This could be expressed to the client in words or through underlying messages to the client as the health worker invested her time and energy in being involved in the client’s everyday life. In this sense, the health worker used herself as a positive force to reinstate or strengthen her clients’ personhood and intrinsic value. Providing a valued role, through work or responsibility, and being active in giving positive feedback on clients’ development also were thought by our participants to be important positive counter forces for clients. . . . that we say as professionals, “This is important to me,” and they experience “I am useful” and “someone needs me.” . . . to give that acknowledgment, and see who they are, and reflect to them who they are.
Being Aware of Limitations to Providing Recognition Self-reflection and talking to colleagues about clinical situations were seen as essential in order to stay open to clients, to keep hoping, to keep searching for new perspectives, and to endure emotional strain. There was awareness of the health workers’ own limits to emotional involvement, as well as limits to each individual’s ability to provide recognition. The health worker might need to distance herself from the client in order to cope with her own reactions. It also might be hard to adjust the level of involvement and sort her own emotions from the client’s emotions. “Taking over” the client’s emotions and perspectives might lead to a loss of hope and not seeing opportunities for change. The group also discussed that the health worker’s personhood might be a limitation, as many clients would not “see themselves” or identify with health workers who were primarily middle-aged, middle-class women. And, even if a long-term relationship made it possible to “join” with the client and understand his or her perspective, there was a danger of the relationship becoming locked in some patterns, with set rules and roles, but no new aims. It is hard work keeping the thought about new chances and keep hoping that we will connect again. Things may be locked up, and an open conversation does not seem possible. They keep repeating the same thing over and over again, every time we meet and, in the end, you can’t stand talking to them. Sometimes you have to face your limitations and admit that we can’t help everybody.
INTERPRETATION AND DISCUSSION We keep saying “them” and “us.” But we are, in fact, all human beings and fellow human beings.
Providing recognition meant that health workers showed their own humanity and personhood in ways that confirmed clients’ personhood and supported the clients’ processes of reclaiming their identity. Health workers emphasized “being persons” in ways that would give clients experiences of being individuals who were appreciated and valued by the health worker and who would be (had the potential to be) appreciated by others
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in general. Health workers aimed to accommodate and make space for clients to present themselves and were open to being affected by their clients in these relationships. Responding to clients by providing unconditional acknowledgment was found to be understood as a demonstration to clients that they were significant and valued. Being in a relationship with an aim to recognize clients’ personhood and intrinsic value as human beings was understood as a way of reinforcing clients’ identities and self-respect. The relationships consist of reciprocal processes of the health worker and client each affecting, and being affected by, each other. Both parties contribute and receive, even if what is given and gained by each person is not the same. The further discussion focuses on two processes of affecting and being affected in relationships: First, the process of affecting impacts recognition by each person feeling respected and increasing self-respect; second, the process of affecting impacts recognition by each person being open to and accepting the opportunities to change and develop.
Being Respected and Self-Respect Recognition, understood as a positive counter force, aims to prove to a client that he or she has the same value as other people in spite of that client’s experiences of being different ˚ (Yu & Shim, 2009), incomprehensible, or worthless (Adnøy Eriksen et al., 2013), and in spite of being marginalized in society (Rowe & Pelletier, 2012). Showing respect and value to the client “even and especially while remaining disabled” (Davidson et al., 2009, p. 17) may help the client accept his or her life situation and not be ashamed of him- or herself. Caring and unconditional acceptance seem to be ways of neutralizing some of the negative impacts of living with mental distress and, thus, increasing clients’ self-respect. Since they don’t always live up to society’s standards, clients may experience rejection, and as society tends to value only the strong and perfect and to reject that which is weak or judged as different, clients may also experience stigmatization because of their mental disorder (Granerud & Severinsson, 2003). Being affected and developing a deep respect for intrinsic human value gave health workers an alternative perspective: Recognition means including the whole person, and vulnerability and weakness may be valued as part of human life. Health workers’ sustained focus on recognition, rather than definitions and treatment plans, may be a positive contribution to diminishing stigmatization and increasing clients’ self-respect and could ideally provide new opportunities for inclusion for clients. Rowe and Pelletier (2012) argue that thinking of individuals with neurological or mental disorders as irrational diminishes their citizenship status. In order for individuals to be included as citizens or valued members of the community, they need opportunities to take up the rights and duties as citizens, rather than being focused on treatment of a cluster of symptoms (Rowe & Pelletier, 2012).
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Respecting and valuing intrinsic human value was shown to increase health workers’ self-respect as well. The health worker is aware of gaining something, not only from the respect she may experience from an individual client, but also from the realization that life, in general, is worth caring for and protecting (Martinsen, 2006). She experiences involvement in securing human dignity (Honneth, 1992) and is proud of herself as she gets close to and involved in caring for what she respects and values. This can be explained as a process that starts with a deep awareness of our universal connection to one another and leads to a desire to increase another’s welfare, which, again, may increase one’s self-esteem, mental health, and ego-autonomy (Mastain, 2006). Arman and Rehnsfeldt suggest that caring in this way may move the health worker closer to the essence of his or her personality and give the worker the opportunity to live in a more authentic manner (Arman & Rehnsfeldt, 2006). These processes of affecting others through respecting them and gaining self-respect may motivate health workers to keep trying to form open and trusting relationships with clients, even if doing so is sometimes experienced as demanding or exhausting.
Being Open to Opportunities to Change and Develop The findings point to two variations of openness: being affected emotionally and developing new understanding. Both of these aim to give clients opportunities to develop their sense of self. Emotional involvement is thought to prove to the client that he or she is worth caring about, and the client being able to affect the health worker may give the client experience of being valued and significant. Being open to new perspectives and seeking to accommodate what clients present are meant to give clients opportunities to present themselves openly, without having to worry about what to reveal in their relationship ˚ with a health worker (Adnøy Eriksen et al., 2013). That health workers are prepared to accept alternative understandings may give clients the experience of making sense and of being active agents. Health workers offer emotional, human contact and practical interaction, and clients are given opportunities to find articulated meaning (Lorem & Hem, 2012). Each client experiences being known (Stern, 2004), and may be given the opportunity to recognize him- or herself in “the other” (in this case, the health worker). This has been found to contribute to restoring a person’s feeling of being valued as a human being (Berggren & Gunnarsson, 2010). Persons living with severe mental illness have been found to sometimes experience existential loneliness (Nilsson, N˚aden, & Lindstr¨om, 2008) and to be engaged in an ongoing struggle to be ˚ recognized by other people (Adnøy Eriksen et al., 2012). This may explain why recognition was understood by health workers as stretching beyond one’s own perspectives and beyond being safe and comfortable. Additionally, health workers accepted that being in relationship with clients takes courage and endurance. Recognition may sometimes be a willingness to see and hear
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what has typically been rejected. The health workers challenge their own urges to avoid confrontation with suffering (Arman et al., 2004); they are willing to tolerate uncertainty (Seikkula & Olson, 2003) and wish to stretch beyond what they are able to comprehend. This can be described as an awareness of not understanding, but yet expecting there to be something to understand (Lorem & Hem, 2012), or as an awareness of being an unknowing stranger. Clients’ voices are given room without right-or-wrong thinking, and the goal is to generate joint understanding rather than consensus (Seikkula & Olson, 2003). In this way, openness may contribute to a consciousness of sharing the same mental landscape (Stern, 2004). The openness the health workers aim to have in their relationships with clients may be part of a more general approach to life. In the focus groups, the participants showed openness to new ideas and typically offered suggestions rather than conclusions. Being willing to develop a new understanding is, to some extent, accepting indecisiveness. Borg et al. (2010) found that deeper understanding of practice might be gained by delving into variations in ideas, approaches, and perspectives regarding clinical issues, and by keeping questions open and not related to what is typically defined as psychiatric diagnoses or practice guidelines (Borg et al., 2010). The most important practice guideline in mental health work may thus be to value human dignity and protect clients’ freedom to choose (Milton, 2008), as this may give clients a strengthened sense of self (Schibbye, 2009) and opportunities to be autonomous and active agents in their own recovery process (Davidson et al., 2010). This also may provide opportunities for health workers to grow and develop, depending on their willingness to be affected by, and their expectations of learning from, being in relationships with clients.
METHODOLOGICAL CONSIDERATIONS The participants in the study probably represent an elite group of mental health workers. They had long-term experience and volunteered for this study based on their interest in “recognition” and “being in relationships.” Their insight was developed through caring fellowships in which recognition and being in relationships were foundational pillars; this insight may be useful. The findings represent health workers’ knowledge as a product of the process of self-reflection, their lived experiences with integrating theoretical knowledge in clinical work, and their experiences with being in co-created moments with clients. In this sense, the findings are not only theoretical or hypothetical opinions, but rather a presentation of health workers’ identities as moral agents. Health workers’ ethical responses to clients have been found to be based on deep personal convictions about what the health worker deems to be “good” (Varcoe et al., 2004). As the focus of this study was “knowledge about meanings of recognition,” the findings illustrate health workers’ good intentions and what they have experienced to be good ethical
responses, rather than their lived, practical, experiences with recognition. This is not a description of community-based mental health services. In real life, health workers are probably not always courageous; they may misinterpret clients’ perspectives and they may only partially sustain emotional involvement. At the same time, pointing out what would be good in the process of recognition may allow readers to see the challenges and aims of being in relationships with mental health clients.
CONCLUSION This study indicates that relationships between clients and health workers may become bridges of connectedness to other people, opportunities, and experiences of shared likeness (Martinsen, 2006). In this sense, recognition is proof of humanity, an experience of being a human being like other human beings ˚ (Adnøy Eriksen et al., 2012). Health workers saw themselves as counter forces to clients’ negative experiences of degradation and rejection. Recognition of personhood and intrinsic human value should not be a task for professionals but rather something to be taken for granted, and a more universal sense of belonging may depend on values and expectations in society, as well as recognition by other people in general. It is suggested that relationships that have a focus on recognition depend on reciprocal processes of affecting and being affected. Being a human being in a relationship in a way that invites the other person into the relationship provides opportunities for growth and development in the client as well as the health worker. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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