Sociology Mind
2013. Vol.3, No.2, 185-192
Published Online April 2013 in SciRes (http://www.scirp.org/journal/sm) http://dx.doi.org/10.4236/sm.2013.32025
Doing Care with Integrity and Emotional Sensibility—Reciprocal
Encounters in Psychiatric Community Care of Older People with
Mental Health Problems
Lis Bodil Karlsson1,2, Elisabeth Rydwik2,3
1Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden
2Research and Development Unit, Jakobsberg’s Hospital, Stoc kh ol m County Council, Järfälla, Sweden
3Deptartement of Neurobiology, Care Sciences and Society, Division for Physiotherapy, Karolinska Institute,
Huddinge, Sweden
Received November 11th, 2012; r evised December 28th, 2012; accepted January 11th, 2013
Copyright © 2013 Lis Bodil Karlsson, Elisabeth Rydwik. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is pr operly cited.
The article focuses on the experiences of community care workers in the encounter with older persons
suffering from mental health problems, such as mental illness and disability. The purpose is to describe
and discuss opportunities for and challenges to reciprocal encounters with these older people in commu-
nity care, based on statements from professionals interviewed. Structured conversations with five focus
groups were organised, consisting of 26 participants, including nurses’ assistants, assistant nurses, nurses,
social workers and occupational therapists. The participants in the focus groups highlight the essence of
being involved and create space for a reflective attitude. Clinical implications will be presented as well.
Keywords: Focus Group; Social Care; Mental Illness; Psychiatric Disability
Introduction
Since the major Swedish mental hospitals were closed and
the Psychiatric Care Reform of 1995 was implemented (Prop.
1993/94:218), new forms of municipal and social care have
developed in Sweden, such as supported housing, day care
centres and case managers (Berggren & Gunnarsson, 2010).
One consequence of the reform is that psychiatric clinics only
treat patients during an acute mental illness, while the social
services within the community are responsible for those dis-
charged from the clinics (Karlsson, 2009; Markström, Sand-
lund, & Lindqvist, 2004). A similar change has occurred in
other Western countries. This de-institutionalisation has in-
spired research on people with psychiatric disabilities as care
clients in the community, and has led to greater knowledge
from a client perspective regarding their opportunities to re-
cover from severe mental disorders (Barker & Buchanan-
Barker, 2011; Davidson et al., 2005; Deegan, 2003; Tierney &
Kane, 2011). The specific knowledge of professional social and
psychiatric care providers are a key aspect of this shift, as are
their methods of working in the community. Other aspects are
general attitudes towards mental health and the negative con-
sequences of stigma (Link & Phelan, 2001). The shift is occur-
ring in a different arena than the closed world of psychiatry—
specifically in the community and in people’s homes (Topor,
2005). Without denying the individuals’ mental suffering and
need for help, this should reasonably result in opportunities for
a more reciprocal encounter than previously (Topor, 2005: p.
29). This in turn affects the clients’ opportunities to act, as the
staff personnel are now on their turf, in their homes:
These changed encounters result in new knowledge. New,
reciprocal knowledge. Most of the problems remain. The old
roles do not vanish simply by changing venue. At t h e same time,
the professional and the client begin to get to know each other
in a new way. The focus is no longer on the client’s shortcom-
ings, flaws and symptoms, but instead on his abilities, knowl-
edge and his creative ways of dealing with his problems. This
knowledge is more complex, more nuanced. The problems are
placed in the context of their daily lives, giving them new
meaning (Topor, 2005: p. 29, our translation).
In this context, it is therefore essential to also focus on the
professionals’ experience. Expectations of reciprocity in the
encounter are not uncomplicated, and in this article we describe
and discuss the attitudes of professionals in care based on their
perspective nearly two decades after psychiatric care was
shifted to the community in Sweden.
When social-work researcher Andersson (2009a, 2009b) de-
scribes for example how residential support works for people
with mental health problems such as mental illness and dis-
abilities, she distinguishes between doing everyday tasks and
talking with clients (everyday conversation), which occurs in an
ongoing interaction—remembering that the “inter” implies mu-
tuality (2009b). Andersson emphasises that this mutuality in the
encounter between professional care provider and care user
does not mean an exchange of transactions, material or immate-
rial. Rather, it implies a mutuality that occurs “during the time
space in which the social interaction takes place” (2009a).
The sociologist Barron has coined the expression “a tradi-
tionally internalised care perspective” (Barron, 2009: p. 79) in

L. B. KARLSSON, E. RYDWIK
which staff members solely perceive people with mental dis-
abilities as care recipients—as objects. The opposite is critical
thinking, which is to say reflecting on what clients are commu-
nicating through their behaviour rather than simply dismissing
them as “difficult”. This thinking must be combined with criti-
cal action, explains Barron—in other words an awareness of
one’s position of power in the encounter, or as she writes,
“power-conscious care” (Barron, 2009: p. 66).
The Secure Encounters Project
To conduct new research on mental illness and disabilities
available to workers in the community welfare care and service
system, the Swedish government has invested a large amount of
money in education and development projects
(http://www.socialstyrelsen.se/english [National Board of Health
and Welfare]). Between 2009 and 2012 eight municipalities
served by the Stockholm County Council, together with a re-
gional Research and Development unit and a psychiatric clinic,
initiated the training project Secure Encounter with money
from this special initiative. The project trained front-line staff
personnel who encounter older people suffering from mental
health problems, such as mental illness and disabilities, in their
daily work in various community-run welfare care and social
services, such as day care centres, home care/help, care homes
etc. In total, 320 community care workers were trained. For
more information on the project we refer to the evaluation
(Rydwik, Karlsson, Strandberg, Mattson, work in progress [in
Swedish]). In another context we discuss the learning process
of the professionals after completing training (Karlsson &
Rydwik, 2013).
Aim and Research Question
Since the de-institutionalisation in Sweden, a recurring topic
of discussion has been the importance of the professional’s
approach, from the perspective of the client or user (Berggren
& Gunnarsson, 2010). Thus, it is vital in this context to under-
stand the staff’s experiences of opportunities for and challenges
to reciprocity in care. Our article focuses on the experiences of
community care workers in the encounter with older persons
suffering from mental health problems, such as mental illness
and disability. The purpose is to describe and discuss opportu-
nities for and challenges to reciprocal encounters with these
older people in community care, based on statements from the
professionals. Reciprocity can be defined as “the equality of
perceived investments in and outcomes from a relationship
relative to the persons’ own internal standards” (Prichard, 1969:
p. 180, referenced in Thomas & Rose, 2 010). In fa ct , rec ip roc ity
is not only a necessity from the users’ perspective, but also a
prerequisite for care workers to feel satisfaction with their daily
work (Thomas & Rose, 2010; Rönning, 2002).
Care, Recovery, and Mutual Relationships
Rönning (2002) explains that definitions of the term care
vary, in general along a scale in which one extreme is being
vulnerable to those in power and dependent on the paternalistic
whims of others. This is particularly interesting considering that
the caring scie nces are female dominated. The other extreme is
that care can be viewed as an expression of genuine humanity.
Rönning also feels that he sees three recurring aspects in the
definitions of care: The first emphasises that care is based on
emotions: “If there is no dedication to the other as a unique
human being, there is less reason to be concerned about his or
her well-being” (Rönning, 2002: p. 36). The second aspect is an
expectation of practical action. However, instrumental action
without emotion, or conversely solely emotion without ade-
quate action, cannot be viewed as true care. Rönning also links
practical action to practical competence. The third aspect high-
lights care as a “relational concept” in which the staff must
constantly maintain a balance between paternalism and indul-
gence. Yet all the while the relationship de facto involves re-
ciprocity: “The caregiver is also a receiver, not only of money
(as in formal relationships) but also of positive emotional feed-
back”. The feedback from the frail person may be very impor-
tant for the “giver” or “care worker” (Rönning, 2002: p. 36).
This reasoning emphasises reciprocity as a critical prerequisite
for care.
McCann and Baker (2001) studied how to develop interper-
sonal relationships with young community care consumers
suffering from psychotic illnesses. Although their research
deals with professionals’ interaction with young people, their
reasoning is significant to our study. In order to create a mutual
relationship with the nurses, McCann and Baker’s study devel-
oped different strategies related to the nurses’ own attitudes in
their daily work. The researchers point out the necessity of
attempting to understand the patient, which requires time, em-
pathy and being prepared to listen to the patient’s wishes and
experiences. The other aspect the researchers emphasise for a
mutual relationship is being friendly, in which honesty from the
nurses’ side is vital. The researchers highlight “the process of
tuning in”, which means that the nurses must consider their own
attitude in the encounter. Yet another aspect of the encounter is
“the process of self-disclosing”—revealing oneself as a person,
which disarms the encounter between professional and con-
sumer. One dimension of a mutual relationship is simply being
there for the person in need. Another is “maintaining confiden-
tiality”, which may mean that the nurse does not talk to the
consumer’s family about issues the consumer considers sensi-
tive. McCann and Baker (2001) prefer the word alliance be-
cause the relationship is characterised by an imbalance of
power, rather than the word partnership, although others do use
this word in the context, for example Borg and Kristiansen
(2004). The latter emphasise the importance of the relationship
between the professional and the consumer: “Mutual relating is
building a relationship based on trust and mutual respect. At the
same time, nurses need to be cognizant of and acknowledge
their strengths and limitations in mutual relating. /…/ The
process of mutual relation, is, at least partly, influenced by the
characteristic of consumers or nurses, or both” (Borg and Kris-
tiansen, 2004: p. 535).
In recent years the concept of recovery has gained ground as
a description of how we can view people who have suffered
from mental health problems. Reasoning about recovery can de
facto give an understanding of the care relationship, even for
people over 65. Borg and Kristiansen (2004) write of the neces-
sity to help people with mental illness based on their own terms
and thinking in terms of recovery instead of “the usual pattern
of trying to assess, adjust, and fit service-users into existing
services” (Borg and Kristiansen, 2004: p. 501). In fact, the staff
personnel need to get the consumer involved rather than just
being the object of measures. At the same time, the profession-
als need to be open to differences between individuals and
aware of the unpredictability of life. Recovery is not something
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L. B. KARLSSON, E. RYDWIK
that professionals do with or for the person. Rather, a “mutual
relationship” requires an awareness that context and relation-
ships are crucial, which Borg and Kristiansen view as an ex-
pression of “a true, collaborative partnership” (Borg and Kris-
tiansen, 2004: p. 501).
Borg and Kristiansen emphasise that the essence of a recip-
rocal relationship is a focus on “the service user as a person and
fellow human being, not as an ill individual affected by a
chronic disease” (Borg and Kristiansen, 2004: p. 202). The
researchers refer to philosopher Martin Buber’s reasoning that
both parties create the relationship during the encounter and
therefore what happens between the individuals is crucial: “A
reciprocal relationship between helper and service user will
involve a view of the affected person as capable and resource-
ful” (Borg and Kristiansen, 2004: p. 503).
In order to interpret our data we will further briefly connect
to some theoretical issues developed by Goffman (1959/1990),
such as his interpretation of face to face communication.
Goffman states that people generally avoid open conflicts and
prefer to strive to achieve consensus and unanimity. People’s
sense of tact leads them to take protective measures to avoid
making others and themselves looking bad or causing any em-
barrassment. Goffman uses the theatrical performance in order
to understand the techniques for impression management; peo-
ple or the actors enter a scene, the place where dramatic action
takes place. A team is when individuals collaborate in the
preparation of a routine, that is, a predetermined pattern of
behavior. Each team’s mission is to preserve the stability of
how to perceive the situation and if necessary to hide some
information. Goffman speaks of conspiratorial activities partly
carried out in secret. Region is a distinct place by perception
and perception barriers, thus demarcated from view or sound
isolation. Front region or front stage is where the behavior is
influenced by standards, such as moral norms or rules of not
disturbing. Back region or backstage is a behind the scene
where the facts pressed arrive in days. Here people can relax
and be themselves. Each team’s goal is to maintain the de-
finition of the situation. All team members must be loyal, dis-
ciplined and take caution. These are defense techniques of im-
pression management. A team member may change her/his
behavior in order to save the situation, even distort facts. For
example, if the person is lying, and are caught doing this, s/he
needs to dismiss this with a playful attitude. Dramaturgical
discipline required of each member of the team is to maintain
its appearance. Good dramaturgical discipline is about the
ability to manage voice and gestures, without revealing any true
feelings.
Based on the referenced research, we would like to propose
that the prerequisite for reciprocity is to know how, why and
when to act in the encounter with the consumer. It should be
emphasised in this context that a lack of reciprocity in relation
to colleagues, managers and organisation can lead to burnout
(Thomas & Rose, 2010)—a result of an imbalance between the
professional’s efforts and the professional benefit received.
Research Approach
Using focus groups is an established method of collecting
data on the group level about perceptions of a specific phe-
nomenon (Morgan, 1997). We organised five focus groups with
26 participants, of which 21 were women and 5 men. Partici-
pants were front-line community staff personnel who encounter
older people with mental health problems in their daily work,
such as nurse’s assistants, assistant nurses, nurses, social work-
ers, and occupational therapists. The number of participants in
the groups varied from two to seven. The discussions were 90 -
120 minutes long and were all recorded.
Since it was vital in our study to understand the staff’s ex-
periences of opportunities for and challenges to reciprocity in
care it was obvious that focus groups should be our first option.
Data collected in focus groups are usually multifaceted and rich,
as the method invites the participants to engage in a discussion
in which phenomena taken up in the talks are examined in de-
tail and usually from a variety of perspectives. This is how our
five focus groups were conducted; thus, we received not only
assessment data as a basis for a future report (Rydwik et al.,
2012) but also a rich collection of empirical data in which the
participants talk about their attitudes towards and approach to
the old persons suffering from mental health problems. Essen-
tial questions concerned how the education project had influ-
enced their relations to the older clients, relatives of the older
persons and other colleagues on a daily basis and created the
possibility of reciprocity. Many, sometimes long, narratives
emerged during the talks as the participants in the focus groups
examined opportunities and obstacles in the care relationship.
These talks were later transcribed verbatim.
We used a hermeneutic method of interpreting our transcrip-
tions, based on the principle that the meaning of one part can
only be understood if it is placed in the context of the whole
(Alveson & Sköldberg, 2000). That is to say, one person’s
statement can only be interpreted in relation to her entire story.
The whole is made up of various parts and can only be ex-
plained from the parts. The hermeneutic method is circular,
which means that the researcher alternates between the whole
and the parts, leading to a deeper understanding of both. Our
analysis of the collected data started with a read-through of
each transcription in order to focus on passages about the pro-
fessionals’ encounters with the care users and their relatives.
We began by thinking about what questions the participants
actually answered. One could say that we as researchers were in
a silent dialogue with the text. In practice, we read through the
transcripts line by line to answer what question was behind
every statement. The questions arose from a pre-understanding,
but evolved during the process of working with them. Why did
the participants speak, act and react as they did? Did the par-
ticipants give intentional responses? Unintentional ones? Then
we compared similar sections and interpreted how they resem-
bled each other. Being in dialogue with the text thus means
adopting an exploratory attitude while at the same time being
both close to and detached from the collected data. Various
partial interpretations relate to an overall interpretation pattern
as well as to facts and questions we pose regarding the material,
according to Alvesson and Sköldberg (2000). Partial interpreta-
tions can thus be a part of an overall pattern, although no inter-
pretation is found to be definitive—all must always be viewed
as preliminary.
We followed the generally accepted ethical principles in
connection with the recording of these conversations, such as
informed consent. Any kind of data that might reveal the par-
ticipants’ identities or personal circumstances were removed
(Kvale & Brinkman, 2009). The project was approved by the
ethics committee at Karolinska Hospital in Solna, Sweden

L. B. KARLSSON, E. RYDWIK
(2009/1382-31).
Results
When we present our results below, we will first focus on the
prerequisites for the professionals’ work, which is about
awareness of the client’s feelings and what happens in the rela-
tionship between professional and client. The results clearly in-
dicate the necessity of professionals maintaining a moral dis-
tance and therefore understanding that they don’t always need
to state obvious truths, but should modify their statements out
of consideration for the client. In the encounter with family
members, professionals must also understand and respect that
they in turn have emotions to be dealt with. Sometimes a pro-
fessional must also stand as a buffer between the client and a
family membe r dema ndi ng certain measures.
Sensitivity to the Older Person’s Needs
Working with older people suffering from mental health
problems is enormously challenging and is never the same,
according to the participants in our focus groups. Or as one of
them—an assistant nurse in community care—points out, “no
one day is like another, especially when you’re out in the field,
visiting different areas, houses, people. Everything varies”.
Working with older persons with mental health problems on a
daily basis requires a unique kind of sensitivity, our participants
stress. Every client expects the professional to make them feel
special. Therefore it is necessary to be sensitive to the older
person’s needs in their daily work.
Returning to our initial promise of problematising the possi-
bilities of creating a reciprocal encounter between the care user
suffering from mental health problems and caregivers, we must
emphasise that simply knowing about methods or special tech-
niques does not create a reciprocal relationship. Nor do we
think it is enough that the caregivers state their good intentions.
Fine words may often cover up a lack of reciprocity, rather than
eliminating it.
The participants in our focus group agree that their approach
to the clients and their families is the essence of their daily
work. One assistant nurse working at a residence for people
with mental health problems describes her attitude as continu-
ously showing respect in the encounter. She illustrates this with
a short story of one of her residents, who sometimes wets the
bed at night, and the staff who have developed an approach that
eases the resident’s feelings of shame:
He’s ashamed. He’s ashamed to tell us. So he conceals it.
You need to take a different approach, so he doesn’t feel
ashamed. So if I knock on his door and say, “Say, I have a
washing machine that’s available. Do you have anything that
needs washing? Just toss me whatever you’ve got and I’ll take
care of it.”
This assistant nurse is undeniably aware of the client’s vul-
nerability and how his shame leads him to want to hide his wet
bedclothes and pyjamas. If this were allowed to continue the
client would eventually lead to a life of squalor. But chastising
him or holding forced inspections of his bed sheets would in no
way promote reciprocity. Therefore, the assistant nurse focuses
instead on eliminating his shame, rather than the need to wash
his bedclothes. Contrary to what one might think on first read-
ing of this story, the assistant nurse is not focused on interven-
tion or on a course of action; rather, she is interested in ap-
proaching the man at his current emotional level—and therefore,
from the moment he opens the door to his room, she must start
communicating. We propose that this attitude de facto reflects
an awareness of the other’s feelings and how they affect the
opportunity, and in fact are a requirement, for a reciprocal rela-
tionship. At the same time, her closing sentence says something
special: “Just toss me whatever you’ve got and I’ll take care of
it”. Is her statement patronising? An expression of superiority?
In our view, she catches the client off-guard, but her primary
focus is on eliminating the feeling of shame, then she acts to
take the bedclothes. Ergo, she avoids amplifying the man’s
shame. She takes protective measures to keep the man from
looking bad. She has and demonstrates a sense of tact (Goffman,
1959/1990).
Understanding Process Thinking and the Importance
of Trust
A female group leader in home help services talks about the
complexity of their everyday work. The community support
unit cannot simply ask the home help services to carry out a
task, or send an order from: “This is human beings we’re deal-
ing with. People about whom we need to have as much infor-
mation as possible so that we can get through to them as soon
as possible”. Throughout the focus group interviews, showing
tact in the encounter with the older persons comes up as an
essential element (Goffman, 1959/1990). In order to even be
able to initiate practical action, the professional must reach out
to the clients and earn their trust, which in turn requires a
genuine meeting. Respect has to be there before practical care-
giving is even possible, or as an assistant nurse in home help
services says:
Some of them [the elderly] need help around the house, but
they don’t want it. They absolutely do not want it. So I mean,
you have to win them over somehow. You have an assignment,
to go there and tidy up, you’ve got maybe fifteen minutes to do
it in, and the cleaning is important so she doesn’t live in
squalor. The food is very important, otherwise she won’t eat.
But everyone knows that you can’t start out with the food and
the tidying before you’ve earned their trust. If you know they
don’t want you there, then you have to come in and sit down.
Have a chat and be pleasant, maybe have a coffee. Do what
they want, not what’s in your assignment for the day. Forget
the assignment for a while, maybe two, three times. Don’t
worry if it gets dirty. You can tackle that later, the dirt in the
flat.
In everyday work it is easy to forget the “human element”, as
some assistant nurses and nurse’s assistants say—sitting down
with a cup of coffee and exchanging a few words. Cutbacks and
restructuring in home help services tend to focus solely on dis-
tributing medicines: “The pills aren’t the important thing in all
this, it’s those five minutes when you sit down with them and
maybe they put on some coffee and you chat with them. That’s
what they need, more than pills”, an assistant nurse emphasises.
A social worker points out the necessity of process thinking,
which involves taking one step at a time in the encounter with
the client. This ensures that the client is involved too, even if
the working process initially seems far too slow. However,
taking one step at a time also ensures a reasonable workload.
Otherwise the tasks can become overwhelming. “You can’t
keep thinking that you have to do everything—that’s too much.
I could never get through the day. You have to take it bit by
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L. B. KARLSSON, E. RYDWIK
bit.” What is needed in the context is thus to be aware of proc-
esses going on in the relationship between individuals, not just
between professional and client. This kind of approach also
helps to lighten the professional’s own workload (Rönning,
2002). For example, one does not need to be anxious to do
everything in a hurry; rather, it is important to affirm and sum-
marise the other’s perspective, whether dealing with a family
member or an older person in need of assistance and support.
In order to create a relationship in the encounter with the
clients, the overall requirement may be simply to allow for
quality time to have a chat, adopt a process-thinking and striv-
ing to gain the person’s trust before even initiating any practical
action. Under the next heading, we share with the reader a
longer excerpt showing how the discussions in the focus groups
evolve in a dialogue between the participants and in relation to
the moderator. The excerpt illustrates situations when it is by
definition difficult to create reciprocity with the client, as when
the older person is suffering from a psychosis and/or a dementia
disorder. The encounter is just as much about identifying the
older person’s mental and emotional state at the moment while
not allowing the person to lose face (Goffman, 1959/1990).
White Lies and Modifications of the Truth—
Maintaining a Moral Distance
An assistant nurse, here called Tina, works at a supported
housing facility. She is flexible and responds in a delicate way
without trying to create order or showing any moralising atti-
tude. If the older person is in her own psychotic world, handing
Tina a series of objects that only exist in her own mind, Tina
just accepts the imaginary gifts. The following excerpt is quite
long, but clearly illustrates how Tina and Nike, another assis-
tant nurse who works in the home health services, reason about
the necessary attitude in relation to their clients:
Tina: This lady is hallucinating wildly. She is sitting there
just gathering things, like this. [Tina illustrates with hand ges-
tures.] Today I had my pockets packed with things she gave me.
I just took them from her and put them in my pocket. Of course
there’s nothing there. But it calms her down. Everything is OK
when I take these [imaginary] things she gives me.
Moderator: But what else can you do?
Tina: Actually those [other colleagues] who don’t under-
stand this will probably say that “there is nothing there, your
hands are empty”. Because of course she doesn’t have anything
in her hands, but I pretend to receive things and I put them in
my pocket.
Nike: Yes, because to her they are real.
Tina: Yes, because to her these things do exist. This morning
she had a little child in her bed, and she was searching in her
bed when I entered. She got up and started to search. You just
have to play along.
I work with people with dementia. This is something I’ve
done a long time—not protesting, because in their world it is
actually real. “Going home to Mum or Dad” or wanting to go
home or to work. When darkness falls, it all comes up, just like
that. There’s no point in saying, “Your Mum and Dad aren’t
alive anymore.” That would just cause more harm and trouble,
because it causes grief that they have to go through every time,
eighteen times a da y. /…/
I often say, “I will never get to heaven because I lie all day,
every day.” /…/ When the lady says: “But I have to go home to
Mum and Dad”, I say, “Oh no, it’s so dark outside and the
roads are very slippery, can’t you stay here tonight and then go
tomorrow?” “Yes, well, perhaps that’s a good idea.” /…/
You live with the idea that your Mum and Dad are there at
home and then I come and say, “But your Mum and Dad are
not alive anymore, they’ve been dead for a long time.” It’s a
huge blow every sin g l e time I tell them.
Nike: Yes, especially if you have dementia.
Tina: Well, since they don’t remember.
Nike: No. I usually just agree. They may be hallucinating
that they have a cat or that they have a baby or that they have
some boy coming to dinner or whatever.
Moderator: But what happens if they say that they want to
lay the table for this boy coming to eat dinner tonight, what do
you do then?
Tina: We just do it.
Nike: We just do it.
Tina: Or I might say, “Oh, he just called and said that he
can’t come tonight because the roads are so slippery.” Some-
times it works, sometimes it doesn’t. If it doesn’t, then you have
to lay the table.
Nike: And sometimes when you come the table is already
laid out with nice china and everything.
Tina: But is this really lying? Or is it bending the truth? Or a
white lie? Or what can we call it?
Moderator: Yes, because you just said that it is true in their
world?
Nike: Yes, in their world it is like that. And sometimes you
are not permitted to clear the table. No, no. It’s up to the boy,
who was visiting and didn’t do his part. It’s his job to clear the
table. So you have to let it be, and then when I come back the
next time and she is not in the kitchen, then I clear the table.
Well, there’s no point in doing something else because then
she just gets cross. She can throw him [the imaginary boy] out
too if she pleases. She can be very unkind towards certain staff
if you don’t know how to handle her.
Tina’s and Nike’s colleagues sometimes feel compelled to
tell their clients the truth, even if it means telling the client that
her parents are dead, which may mean that the person receives
the terrible news over and over again at brief intervals
throughout a whole day. Tina describes how she had to work on
her attitude to prevent herself lecturing the client on what is
true or not. For Tina and Nike, the older persons are not purely
objects of care, but also people with human emotions. Being
close to the older clients and understanding their situation af-
fects the relationship. Even if the older person is not always
very nice, a professional must not compromise on her approach
to the client. Tina and Nike also avoid telling painful or hurtful
truths. Both are willing to pretend or lie—“all day, every day ” —
to protect the client’s feelings, since lying can be described as a
protective action (Goffman, 1959/1990), the lies must be classi-
fied as “white lies”. In Sweden, as elsewhere in the world, lying
is considered wrong and immoral, or as Tina puts it in cultural
terms, you “won’t get to heaven”. But Tina and Nike do not fall
to the temptation to state obvious truths, nor do they try to con-
vince the older client of what is real. Rather, both assistant
nurses maintain a moral distance—in particular to their own
actions, meaning that it is okay to lie as long as it is out of con-
cern for the client’s feelings. The attitude of these assistant
nurses can be compared with Day et al.’s interviews with peo-
ple with dementia disorders, who were not averse to lies as long
as the staff personnel were aware of why they were lying, and
that it was out of concern for the older client (Day et al., 2011).

L. B. KARLSSON, E. RYDWIK
Awareness of the Family Members’ Feelings
A home help services coordinator, Amina, explains that she
has developed an approach in which she avoids becoming de-
fensive when family members call to complain about the ser-
vices. Instead, she tries to structure the discussion by asking
“those follow-up questions”. She exemplifies this with a short
story about putting up with and bearing the family members’
emotions and accepting their experiences by listening—without
making excuses or bel i ttling the complaints.
One family member was very angry that her mother hadn’t
had a shower. The trick is to ask, “What do you think hap-
pened?” And then listen, because she was really upset. So I
listened. I asked t hose follow-up q u estions.
We came to an understanding and we concluded the discus-
sion on a positive note.
The coordinator understands the daughter’s bitterness, but
does not judge it. She simply comments on the existing situa-
tion, without getting upset or defensive. She goes out of her
way to ask the daughter how she perceives the situation. At the
same time the coordinator shows her willingness to listen and
ask follow-up questions, as well as to tolerate the daughter’s
anger without dismissing or belittling it. This is what psycho-
therapists call holding (Slochower, 1996). The coordinator
makes sure that the conversation does not have to result in the
daughter staying upset. They can come to an agreement. Not
about why the mother didn’t have a shower, but simply about
the daughter’s right to express her feelings and her interpreta-
tion of the situation.
It is not a requirement that the professional must always do
or perform something at every encounter with a client or a fam-
ily member, before a reciprocal relationship has been estab-
lished. Simply being there and listening is a good first step, and
in fact a necessity for establishing reciprocity between the pro-
fessional and the client or family member. It is meaningless to
focus solely on getting things done to make the client—or the
client’s family—happy. Really, the professional does not al-
ways know what is best or what should be done, despite their
training and many years of experience. Sometimes you need to
wait and assess the situation. The best way to do that is by ask-
ing “those follow-up questions”. The client does not need to
take a proactive role either; one occupational therapist ex-
plained that it was often the reverse, that it was about “teaching
the person to resolve their own problems”. What the participants
in the focus groups are discussing is the complexity of working
with people who have mental health problems, as one nurse
points out; You don’t just barge in and say, “Off we go, time
for a shower!”
Being a Buffer between the Client and Family
Members
When a professional understands that interventions are not
all that matters, they may also tolerate serving as a buffer be-
tween the clients and their family members who not only have
expectations, but also make demands. Puck works as an assis-
tant nurse on a night shift. She talks about a man who sits up all
night and his sister regularly calls the home help services to
complain; “He has a sister who is hysterical about his sleeping
at night.”
Puck: He sits up listening to opera and drinking two or three
beers. I think he has a pretty nice life. The only thing we usually
do there is ask if he’d like a sandwich with his beer. Rather
than forcing him into bed.
The sister got really angry at me when I said that we used to
ask if he might like to go to bed, but we’ve stopped asking, be-
cause he doesn’t want to. If he ever does want to rest, he
doesn’t tell us. But we do make sure he has what he needs. She
probably thought I was bonkers when I said that I think it’s an
unusually good quality of life to have a beer at night and listen
to opera and be served a sandwich.
To me that’s quality of life and I’m happy to give it. That’s
something I stand by. She can report me if she wants, I stand by
what I do. I just make sure he is as comfortable as he can be
and that he doesn’t hurt himself.
I try not to force him to go to bed. If he wants to sit up, then
don’t come and try to make him go to bed, if he wants to listen
to opera and drink beer. Sometimes I can say; “Can you turn
down the volume a bit, not everyone likes this kind of music.”
Puck’s narrative illustrates her approach in the encounter
with the sister and the man who “sits up listening to opera and
drinking two or three beers”. She does avoid an open conflict
with the sister, but she clearly takes a side. Puck even points
out that she may well is the catalyst, giving the man the oppor-
tunity to “drink his beer”. She does not moralise about the older
man and has no intention of forcing or trying to influence the
man or intervene by asking him to go to bed, stop drinking or
turn off the music. Puck is clearly the central figure in the story
because she tolerates the sister’s anger and is aware of the risk
of being reported. When Puck asks the man to lower the vol-
ume, this is an expression of what Goffman (1959/1990) calls
taking a protective attitude towards the older man so that he can
continue to find satisfaction in his everyday life. Put differently,
Puck can be said to serve as a buffer between the client and his
sister who wants him to change his life.
Discussion
The reasoning in our five focus groups shows how the staff
members come to the understanding that their approach and
encounters contain dimensions of both talking and doing. Very
often, the talking is a necessity before the doing is even possi-
ble. On an overall level, the staff members describe their pro-
fessional attitude in order to arrive at a mutual understanding at
the very moment that they encounter the care clients in their
homes or talk to their relatives on the telephone. This cannot be
done in any other way than by being focused and anticipating
responses throughout the encounter. Thus, the participants in
the focus groups express the value of interacting and creating
mutual relationships. Clients and their family members are
unique individuals with specific needs and wishes. This under-
standing also implies an awareness of the importance of gen-
tleness (Mcann & Baker, 2001), and that each staff member has
an essential role to play as a shield or buffer against the incom-
prehension of others, such as demanding relatives.
Challenging situations to the professionals in the focus
groups are when the older person in community care is in an
acute state of anxiety, is being psychotic and/or confused be-
cause of dementia. However, a moralizing attitude is hardly
helpful, but will rather complicate the possibility of creating a
reciprocal relation. Other challenging situations are when rela-
tives are demanding action. The optimal challenge is to put up
with the idea that responding to the client should be considered
as not doing anything. What at first could be viewed as an ex-
190

L. B. KARLSSON, E. RYDWIK
pression of negligence and of not doing is in fact being con-
scious about the position of the other person. It is an emotional
and professional work, but not in order to fix, since rectification
does not have any intrinsic value or a value on its own. The
professional have to wait and assess the situation even though
relatives and colleagues are expecting the professional to be
action oriented. An instrumental attitude, i.e. caring without
emotion and awareness about the care receivers emotions is
abominable (Rönning, 2002), professionals should instead fo-
cus on the process of caring. All this doing must be impreg-
nated by sense of tact (Goffman, 1959/1990).
The home of an old person with mentally health problems
could be considered as back stage (Goffman, 1959/1990). When
a staff member enters the home it turns into a public place, a
front stage, since the staff can, for example, gossip about the
older person back stage. If the old person does not feel well the
home is even less private, since s/he is unable to control how
s/he is perceived and therefore dependent on the attitudes of the
staff maintaining protective measures to avoid embarrassment.
A psychotic, confused and demented elderly person may no
longer care about the region in which s/he is. The older
people’s vulnerability and inadequacy asks even higher de-
mands on staff. The question is whether it is for the sake of the
elderly. Or for the staff’s sake? Perhaps the attitude is related to
one’s own future role as older? But there is also another inter-
pretation. The staff would not itself be exposed, which in itself
is not rational behavior. The staff would actually let the elderly
maintain their dignity. Consistently emphasized during the
interviews are that the elderly who suffered from mental illness
are also “human beings”. Even if the elderly do not care
themselves the staff members do. Employee behavior brings an
ethical dimension to the work. They are equally interested in
ethics as a higher allusion. They do not consider the older
disadvantageous because their work would then have a different
content. It would actually reduce their status. Actually, one
could say that their reasoning indicates a status marker, where
the staff recognizes the value of, or the status of one’s work.
Staff members have their own status to argue.
We began this article by reasoning—with a reference to
Topor (2005)—that the de-institutionalisation reasonably ought
to create conditions for a more reciprocal interaction between
care staff and older people with mental health problems, such
as mental illness or disabilities. But institutional thinking isn’t
just about four walls, a floor and ceiling, nor does it imply that
people live in their flats completely separate from the rest of
society. Institutional thinking is obviously conveyed in the
daily actions, feelings and reflections of professionals. The staff
members’ approach is crucial here, as is their awareness of their
attitudes. The essence of our results seems to be that an old
mentally ill or disabled person who becomes a care recei ver has
the right to keep face and therefore their dignity (Goffman,
1959/1990). Without moralising, or truthfully informing the
older client that her parents are long dead, or explaining that
there is no boy coming to dinner. And without telling the client
to stop drinking beer, shut off the music and go to bed, or chas-
tising the client for wetting his pyjamas or bed. Professionals
do not need to be moral police; however, they do need to deal
with and reflect on their own morals. Our results show that the
interviewed professionals are able to approach these older cli-
ents on the clients’ own terms. This can be interpreted as main-
taining a relationship in the interface between people, in a re-
ciprocity, which requires insight into and understanding of what
it means to be a part of the alliance in the everyday encounters
between older people with mental health problems (McCann &
Baker, 2001).
However, we also want to emphasise other aspects of under-
standing our data. The narratives in the focus groups reveal
how the participants put their professional attitude to the test,
and also how they analyse their feelings and moral attitudes
above all in relation to their clients. This is comparable to
MacCann and Bakers expression, the process of tuning in. The
professionals in our study demonstrated what we would like to
call an emotional and moral consciousness, in part by relating
to their discomfort and possibly feelings of inadequacy, along
with various demands and expectations for their doing, in the
company of colleagues. It was not always pleasant to put up
with family members who had differing opinions on the need
for care or how quickly actions needed to be carried out; it was,
however, strength to be open to the wishes of the care users.
Based on the reasoning of the focus group participants, one can
never be satisfied with the level of reciprocity; it cannot be
static, but requires an understanding of the conditions of the
alliance. It is also essential to obtain emotional feedback, as
highlighted by Rönning (2002)—quite simply to ensure the
satisfaction of the caregivers themselves.
Altogether, everyone in the different focus groups highlights
the essence of being involved. The participants present narra-
tives about how they view themselves in this sense. So an ad-
dendum to Barron’s (2009) comment could be the necessity of
developing conditions for a “critically reflective care perspec-
tive”, or in other words, critically scrutinising one’s thoughts
and actions, and above all one’s feelings and empathetic capac-
ity. This reflection requires an emotional and moral sensitivity,
an ability to examine one’s attitudes and responses, which we
have designated emotional and moral consciousness. The care-
givers participating in the focus groups are not just doers; they
have compassion too. By interpreting data based on Anders-
son’s (2009a, 2009b) and Barron’s (2009) thinking we can
understand the value of critically reflective care, in which the
staff relate to their own and others’ expectations and demands
in order to provide good care. This means that we not only need
to develop new methods, we must also create space for a reflec-
tive attitude. This should be a natural understanding based on
how we should treat elderly people with mental health prob-
lems, i.e. the essence of critically reflective care.
Clinical Implications
Prerequisites for a reciprocal relation out of our study are in
short:
 Make a connection with the client, before even thinking of
being action or task oriented.
 Think in several steps—the situation does not have to be
arranged at once.
 Sometimes the personnel have to be a buffer against family
members who want their ways of arranging things. Re-
member that the old person actually is the principal con-
stituent.
 Keep moral distance, never try to rear the clients with men-
tal health problems or oppose truths that at the moment are
irrelevant.
 Be conscious about shame—relieve and ease instead of
confirming the feeling
 Tricks of the trade can be useful, but integrity and emotional

L. B. KARLSSON, E. RYDWIK
192
sensibility is essential in psychiatric community care of older
people with mental health problems.
Acknowledgements
We would like to give a special thanks to Susanne Brand-
heim and Therese Karlsson, Ph.D. candidates, and other col-
leagues within social work at Karlstad University, Sweden, for
comments on an early draft of this article and also to our peer
reviewer for excellent propositions on our article.
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