Social dignity in community-based mental health services

Background: An essential element of community-based mental health services is the relationship between service users and mental health workers. This thesis explores how service users’ personhood and intrinsic human value are recognised or at risk in those relationships. There is focus on “Recovery” and “Ethics of caring”, and the concept “Social dignity” is used as a perspective.

Purpose: The overall purpose was to explore mental health service users’ experience-based knowledge about being recognised, and to describe and suggest how this knowledge was and could be foundation for mental health workers’ knowledge and clinical work. In Paper I, the aim was to explore how service users describe and make sense of their encounters with other people. Paper II described service users’ understanding of being in relationships with professionals and how these relationships limited or enhanced recovery. Paper III aimed to reveal and express knowledge about 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. And Paper IV explored examples of mental health workers’ processes of development and learning.

Method: Project A: “Dignity in everyday life” and project B: “Focus on experience-based knowledge” are based on phenomenological hermeneutical lifeworld research. In project A, 11 service users were interviewed about their experiences of being recognised and how they would like to be recognised, and “Interpretative Phenomenological Analysis” with focus on analysis of singular cases guided the analysis. In project B, 8 experienced mental health workers participated in multi stage focus groups (four sessions) to develop knowledge about what is involved in recognising service users in community-based mental health services. “Interpretative analysis of lifeworld” and “Phenomenological hermeneutical method for researching lived experience” guided the analysis.

Findings: Recognition depended on experiences of being valued and significant, and that the service user’s participation in the relationship was acknowledged by the mental health worker. The service users lived in a “struggle to be me” and a “struggle to be recognised”, and experiences of being in relationships in which they were recognised were a great relief (Paper I). The struggle to be recognised was a dilemma between on the one hand being open and risking to lose the right to be a narrator in his or her life; and on the other to protect own identity and risk being isolated and alone. Opportunities to be open and trusting in relationships with mental health workers were found to be related to factors which contribute to recovery (Paper II). Mental health workers’ modes of “being”, give opportunities for service users to be open and trusting. Being in relationship with the aim to promote dignity led to enhanced self-respect for service users as well as mental health workers (Paper III). Openness and indecisiveness were important factors for developing practical wisdom, and processes of development and change were nurtured by re-evaluation of experiences, thus contributing to develop and maintain dignity promoting practices (paper IV).

Conclusion: Integrating service user’s experience-based knowledge as a foundation for mental health workers’ knowledge and clinical work depends on health workers being open to and impressed by the service user in each present moment; allowing service users to be narrators in own life; and awareness that services users’ perspectives and experiences represent a unique insight that needs to be valued. The main aim for dignity promoting practices is not primarily to induce development or change in the service user, rather to recognise and value him or her in his or her present state. By being in relationship with the service user, the mental health worker can acknowledge the service user as an active agent and demonstrate to him or her that his or her life is significant. Openness and trust can be nurtured by acknowledging the service user’s personal struggle; by understanding withdrawal and speaking to internal voices (as well as other “symptoms”) as human experiences rather than merely signs of illness; and by recognising the person’s intrinsic human value. Bearing this in mind, mental health workers need to engage in ongoing development processes towards openness, as it is in the present moment in each encounter that the services may succeed or fail.

List of scientific papers

I. Eriksen, K. Å., Sundfør, B., Karlsson, B., Råholm, M. B., & Arman, M. (2012). Recognition as a valued human being: Perspectives of mental health service users. Nursing Ethics. 19 (3), 357-368.
https://doi.org/10.1177/0969733011423293

II. Ådnøy Eriksen, K., Arman, M., Davidson, L., Sundfør, B., & Karlsson, B. (2013). Challenges in relating to mental health professionals: Perspectives of persons with severe mental illness. International Journal of Mental Health Nursing.
https://doi.org/10.1111/inm.12024

III. Ådnøy Eriksen, K., Arman, M., Davidson, L., Sundfør, B. & Karlsson, B. “We are all fellow human beings”: Mental health workers’ perspectives of being in relationships with clients in community based mental health services. Issues of Mental Health Nursing. [Accepted]
https://doi.org/10.3109/01612840.2013.814735

IV. Ådnøy Eriksen, K., Dahl, H., Karlsson, B. & Arman, M. (draft) Strengthening practical wisdom - elements in mental health workers’ processes of development and learning. [Manuscript]