3.1. Elements of RIM Embedded in Positive Assessments
The home visit data contains both minimal (e.g., “very good”) and extended positive assessments (e.g., “you have been behaving very wisely”). These positive assessments were embedded in sequences in two ways: (a) as responses to client-initiated “good news” statements or (b) as responses to client-provided “good news” statements that follow the professionals’ question or advice. The coding of sequences resulted in two upper- and eight sub-categories that contain the elements of RIM (see Table 1
). This section describes the upper- and sub-categories of RIM constructed in the positive assessments provided during home visits.
Positive assessments are primarily used to encourage the client to conduct everyday routines and to behave in such a manner that resonates with the ideals of RIM. Accordingly, the first upper-category was titled “Encouraging Doing the Right Things”. This upper-category covers 65 of the positive assessment sequences. It contains the following sub-categories: “taking care of everyday matters”, “taking care of home”, “taking care of oneself”, and “behaving in a normal way in the community” (see Table 1
Some of the positive assessment sequences were provided to support the clients’ personal independency, goals, and plans in life (beyond just managing everyday routines and norms). This resulted in the development of another upper-category, “Encouraging Right Kind of Personal Growth”. This category contains 31 positive assessment sequences. It includes the following sub-categories: “doing life planning”, “doing illness-management”, “being self-governing and knowing agent”, and “being skillful community member”.
Some sub-categories are similar to each other thematically, but they represent different aspects of client agency promoted by RIM. In the first upper-category, the sub-categories are related to assessments that encourage clients to carry out routine tasks of normal everyday life. Sub-categories under the second upper-category focus more on more profound aims of a self-governed person and active citizenship. Table 1
summarizes the upper and sub-categories of RIM defined in this study.
3.2. Elements of RIM in Home Visit Interaction
In the following sub-sections, one example of each positive assessment sequence sub-category is analyzed in detailed in relation to the research questions. The EIR-based analysis demonstrates how the elements of RIM are constructed and used in home visit interaction. The analysis also reveals cultural expectations about what the right kind of agency means for a person to be “in recovery”. Before each data example, some background knowledge about the client’s situation and the functions of the home visit are provided.
3.2.1. Encouraging Doing the ‘Right’ Things
• Taking Care of Everyday Matters
In this data example a professional and a female client are discussing the client’s financial issues. The client has a difficult habit of making impulsive mail orders, which have a negative influence on her ability to take care of regular monthly payments.
PROFESSIONAL: So, when you get the unpaid (rent) payments taken care of, you may then try to put a little money aside.
CLIENT: And in July I will already pay July’s rent, so then it will be leveled!
PROFESSIONAL: Oh right, wonderful!
CLIENT: Yes, I counted it already in advance. This month I will still pay March’s (rent), so it is already paid.
The positive assessment sequence starts with the professional’s advice and suggestion that the client should put some money aside after the rent payments have been addressed (Turn 1). The client responds by discussing her current payment plan (Turn 2). The professional hears this as “good news” and responds with the minimal positive assessment “Oh right, wonderful” The client marks the positive feedback by providing more information about her payment schedule. What makes the client’s accounts (Turns 2 and 4) “good news” from a RIM-informed perspective? The client’s accounts indicate that her housing is now secured and sustained. She had experienced earlier challenges with taking care of money matters, as the professional mentions when she refers to “unpaid rent payments” (Turn 1), and the client considers it important to tell to the professional about her payment plan in the subsequent interaction. Additionally, the client portrays herself as a planning, systematic, and responsible agent, which can be seen as positive characteristics for a person “in recovery” process. The client is doing things that “ordinary” person would do, i.e., she pays her rent and shows a capacity to plan her actions. Both are important prerequisites for living independently and are thus considered “good news” for the professional. Supporting clients in their efforts to take care of their everyday matters and making positive assessments concerning these activities are crucial in RIM-oriented mental health work.
• Taking Care of the Home
The main focus during the home visit in this example is the female client’s health issues, including frequent urinary tract infections and weight loss. Additionally, the visit included discussion about the frequency of ordinary everyday chores.
PROFESSIONAL: How about the dishes?
CLIENT: The dishes have been taken care of.
PROFESSIONAL: The dishes have been taken care of. Okay, good, good.
This example represents a positive assessment sequence that starts when the professional asks a question. For the professional the “good news” is that the client states that the dishes “have been taken care of”. The professional constructs a repetitive, minimal positive assessment: “The dishes have been taken care of. Okay, good, good” (Turn 3). The positive assessment can be interpreted as a form of encouragement for the client to continue the activity that is seen as ‘the right’ thing to do to take care of the tidiness of the home. The professional’s opening question (Turn 1) indicates that the client has had problems doing the dishes in the past and that it is something to be checked on during the home visit. Because the floating support service is targeted at persons living in their own housing, in normal flats, taking care of home is an essential element of the “recovery in” process and something that is assessed by the professionals.
• Taking Care of Oneself
In the next example, the professional is visiting a female client. During routine discussions concerning the client’s daily activities, weekly schedule, and mental and physical condition, the client begins to brush her teeth.
PROFESSIONAL: All right, good. This would also be a kind of an important thing to remember to take care of brushing your teeth every day.
CLIENT: Yes, I try.
PROFESSIONAL: Keep the plug in the wall socket so that the toothbrush will recharge.
CLIENT: Yes, I always try.
PROFESSIONAL: All right, that’s already a lot.
In the beginning of the positive assessment sequence, the professional advises and reminds the client about the importance of brushing her teeth daily. The client responds by accepting the given advice and expresses that she will try to act accordingly (Turn 2). The professional continues by giving a second round of advice regarding how to operate an electronic toothbrush (Turn 3), and as a response the client again emphasizes that she is trying to remember to keep the electric toothbrush plugged in to charge (Turn 4). The professional treats the client’s response as “good news” and something worth strengthening via extended a positive assessment: “All right, that’s already a lot” (Turn 5). The client agrees with this evaluation by saying “yes”. It can be assumed that successful mental health work based on RIM relies on “trying” clients who are ready to make an effort to improve their well-being and coping. “Trying” can be interpreted as a culturally valued characteristic. It indicates that the person wants to do things that are widely culturally accepted as “right”, yet s/he is not always capable to carry them out. During the home visits, the floating support service professionals support and direct the clients in many ways regarding personal hygiene, clothing, nutrition, eating habits, and exercise. Thus, taking care of oneself is a central element in the “recovery in” process.
• Behaving in A Normal Way in the Community
In the next example, a female client and a professional are discussing the client’s impulsive and manic behavior, and its effects on the surrounding community.
PROFESSIONAL: In what kind of condition have you been, all things considered?
CLIENT: Pretty good.
PROFESSIONAL: As there have been changes in medication and in other things?
CLIENT: Yes, I haven’t been talking any rude things and I have not been ringing anyone’s doorbell.
PROFESSIONAL: So, you have been behaving very wisely, yeah?
CLIENT: I still sang sometimes on the balcony. I apologize if someone hears.
PROFESSIONAL: Yes, it easily resounds, if you sing loudly because here is so much those high-rise apartment buildings.
The positive assessment sequence starts with a question from the professional addressing the client’s current condition. The client disclosures that she has been feeling ”pretty good” (Turn 2) and how this can be observed from changes in her behavior (Turn 4). The professional interprets the client’s description of her current state as “good news” and responds with an extended positive assessment: “So, you have been behaving very wisely, yeah”. Interestingly, the client responds by “confessing” that the positive behavior change has not been total and she apologizes for her possible disturbing behavior (Turn 6) as a ”good” and ”normal” community member should do. One crucial element of RIM is to support the clients to act in relation to other community members and close ones as is seen acceptable and normal. In this way, RIM-based orientation aims to ease the client’s integration to the community.
3.2.2. Encouraging Right Kind of Personal Growth
• Doing Life Planning
In the next example, a male client and a professional are discussing plans for the approaching summer. The client currently studies at a Bible academy for four hours per day. He is wondering whether or not it would be too demanding for him to simultaneously continue his studies and to have a summer job.
PROFESSIONAL: Yes, so there would probably be a possibility, let’s say to be a camp leader.
CLIENT: Mm, and then also the Lutheran church has these summer camps where they always need staff for the summer. And then there was, the city also had something (a work offer), I can’t now remember what it was, but something I should know how to do.
PROFESSIONAL: Yes. But you already have experience as you have been going to for example a center or what was there where you were arranging those group activities and everything like that, so yes, for sure you have competences. But then of course according to your strengths it is important that you do not take too large a task for yourself.
CLIENT: Yeah, yes that’s it. But as all is just fine now, that I have four hours a week there and additionally all kinds of things going on, so in the end it is almost like having a part-time job.
The positive assessment sequence starts with professional advice that addresses the client’s future work options (Turn 1). The client continues discussing and planning his future life plans that could involve working for the Lutheran Church (Turn 2). The professional’s extended positive assessments (Turn 3) of “you have already experience”, “so yes, for sure you have competences” encourages the client to see himself as a competent and fit person for the planned summer activities. In that way the professional strengthens the client’s agency and image of being a capable person. However, in the end of Turn 3 the professional expresses caution to avoid overextending beyond the client’s strengths. The client responds to this reservation by saying that he is a strong agent capable of at least holding a part-time job (Turn 4) to which the professional responds with a minimal positive assessment “Indeed” that expresses acceptance and agreement. The example demonstrates one essential element of RIM: strengthening the client’s self-governing agency by constructing positive visions of the future tasks and responsibilities. The professional expresses that the client is capable of carrying out his plans, but at the same time notices and expresses the possible risks of exhaustion and failure. The image of a strong, active agent that plans his/her future also resonates with the Western idea of an active citizen.
• Doing Illness Management
In the next example, a professional is visiting a male client who has heavily misused pain and sedative drugs in his previous history. During the home visit, the client is telling a story about how he managed to resist a desire to go to the bar.
CLIENT: Well, one example, once I thought I was coming from (a name of a residential area). I had had very much all sorts of things going on, and so... Then I got this terrible... nearby is a small bar and it ‘pulled’ me like a magnet and I was thinking what will I do now... that things will only go badly, so I called my dad and right away when I told the situation to him, it ‘snapped’, it stopped like a ‘cold turkey’ that ‘pulling’. And after that I got to come home peacefully. That is effective.
PROFESSIONAL: Indeed, that is your way to manage, and so yes, it really does the trick.
The client describes a difficult situation and how he managed successfully to overcome it by calling his dad (Turn 1). For the professional the story is “good news” as she gives the client encouraging feedback by providing an extended positive assessment: “Indeed, that is your way to manage, and so yes, it really does the trick”. By doing this, the professional emphasizes that the client possesses successful techniques to manage his addictions, and thus is capable of governing himself in a favorable way and becoming a strong agent in the struggle against obsessions. This reflects an important element of RIM, which is to strengthen clients’ agency by communicating support for their ability to manage illnesses and addictions.
• Being a Self-Governing and Knowing Agent
In the next example, a professional and a male client are discussing a previously planned excursion to a day-activity center. The professional has identified that the client needs more social activities included in his weekly schedule to decrease social isolation. During the conversation, the professional begins to wonder how eager the client truly is to take part in the considered activity.
PROFESSIONAL: Right. So, just tell straight out, are you going to go and become familiar with the activity center just to please us support workers, or are you going there because you want to?
CLIENT: Perhaps mainly to please the support workers.
PROFESSIONAL: Okay. So, what is yours, honestly, your will, your desire and your wish?
CLIENT: That, at the moment I don’t want to go (to the day activity center).
PROFESSIONAL: You don’t?
CLIENT: I would not want to go.
PROFESSIONAL: Okay, it is good that you said this at this point, there is no point that we go to the activity center, that you go there, if you go there just to please me, or you assume that it is something that I would wish you to do. So, there is no use, it doesn’t lead anywhere.
CLIENT I don’t know about the end of the summer, if then I would be more willing.
PROFESSIONAL: That is really good, very good that you said it, what do you think and feel about that, what feelings do you have.
The example starts with the professional asking a question to determine the client’s real will, desires, and wishes concerning the trip to the activity center (Turns 1 and 3). In the interaction, the professional is “fishing” for the client’s real opinion three times (Turns 1, 3 and 5), and accordingly the client expresses three times (Turns 2, 4 and 6) that his motive is just to please the professionals and that he actually does not want to go along with the current plan. For the professional a “resisting client “who expresses his true thoughts is “good news”. Thus, she responds by providing extended positive assessments: “Okay, it is good that you said it at this point”; “That is really good, very good that you said it, what do you think and feel about that, what feelings do you have.” It can be interpreted from the interaction that for the “recovery in” process, a client who is too adapting and pliable is a problem, because one aim of the RIM is to restore a client’s self-determination and right to make decisions according to his/her own will. This element of RIM is accomplished in this professional-client interaction first by prompting the client to form an independent view and then by justifying his (resisting) opinion by responding to it with a positive assessment.
• Being Skillful Community Member
In the next example, the female client is organizing her jewelry-making equipment when the professional begins to discuss this special interest and skill that the client has. One main theme of the home visit is the difficulty that the client faces in keeping her home in order and how this increases her stress level.
PROFESSIONAL: How does it feel being asked to take part in that kind of activity (to be one of the leaders of a bauble course)?
CLIENT: Yes, I will go alright, or there will probably be more than one (course), because probably not everyone will necessarily fit in.
PROFESSIONAL: But, so, after all, you can be proud of yourself that you have been asked to that kind of, that in my opinion, it is a great thing. Surely it will be fun.
CLIENT: Yes, at least something a bit different.
PROFESSIONAL: Yeah. And as you apparently are good at this jewelry making, after all, it is great, then you have a possibility to share your own expertise with others.
CLIENT: This organizing thing at home comes at a good time, now all the missing pieces of jewelry may be found.
Once again a positive assessment sequence begins with the professional’s question, this time concerning the client’s feelings and inner thoughts about the request to be a leader of a leisure time course (Turn 1). The client responds with a neutral statement regarding the opportunity (Turn 2) to which the professional responds with an extended positive assessment that is meant to strengthen the client’s self-esteem and to emphasize the significance of the “good news” (i.e., the client has been asked to take a responsible role): “you may be proud of yourself that you have been asked to do that kind of, that in my opinion, it is a great thing. Surely it will be fun.
” The client does not directly reflect the given positive feedback but reacts more to the last part of Turn 3 and defines the situation itself as positively something new. Maybe the client’s modesty triggers the professional to make another extended positive assessment: “And as you apparently master well this jewelry making, after all, it is great, then you get to share your own expertise with others.
” This constructs the client as a skillful and valuable community member, who has know-how to be shared with others. Interestingly, the client once again ignores the positive feedback and compliment and moves to reflect on the good timing of her current project (organizing things around the home). One element of RIM includes advancing client’s belief in his/her capacities and value as a beneficial member of the community. Furthermore, positive assessments like those provided in this example may be interpreted as reinforcing the cultural expectation that human well-being is related to integration and having valuable roles in the community [8