user‐oriented mental health reform in sweden: featuring ‘professional friendship’

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User‐oriented mental health reformin Sweden: featuring ‘professionalfriendship’Ulrika Järkestig Berggren a & Evy Gunnarsson ba School of Social Work , Linnæus University , Kalmar, Swedenb Department of Social Work , Stockholm University , Stockholm,SwedenPublished online: 23 Jul 2010.

To cite this article: Ulrika Järkestig Berggren & Evy Gunnarsson (2010) User‐oriented mental healthreform in Sweden: featuring ‘professional friendship’, Disability & Society, 25:5, 565-577, DOI:10.1080/09687599.2010.489303

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Disability & SocietyVol. 25, No. 5, August 2010, 565–577

ISSN 0968-7599 print/ISSN 1360-0508 online© 2010 Taylor & FrancisDOI: 10.1080/09687599.2010.489303http://www.informaworld.com

User-oriented mental health reform in Sweden: featuring ‘professional friendship’

Ulrika Järkestig Berggrena* and Evy Gunnarssonb

aSchool of Social Work, Linnæus University, Kalmar, Sweden; bDepartment of Social Work, Stockholm University, Stockholm, SwedenTaylor and FrancisCDSO_A_489303.sgm(Received 24 April 2009; final version received 4 December 2009)10.1080/09687599.2010.489303Disability & Society0968-7599 (print)/1360-0508 (online)Original Article2010Taylor & Francis255000000August 2010Ulrika [email protected]

In developing new forms for society-based support for mental health service users,authorities implemented a service in Sweden, called Personligt ombud (PO), withthe assignment to support service users exercising their rights. The aim of thisarticle is to describe what service users find to be significant features of theirworking relationships with their PO. Using a phenomenological approach, 23users were interviewed sharing their experiences of their PO. The results show thatservice users describe their relationships with the PO as a ‘professionalfriendship’. The friendship-like feature refers to reciprocity in sharing lifeexperiences and forming a trustful relationship in which professional assistancecan be offered, promoting well-being and recovery. Conclusions are that the POprovides a service that calls for re-interpretation of professional and user roles,where both give and receive.

Keywords: case management; professional; friendship; mental health service;recovery; reform

Introduction

The deinstitutionalisation process of psychiatric care and subsequent difficulties formental health service users to have their rights as citizens recognized has broughtabout the need to invent and implement new forms of exercising society-basedsupport. Case management is a universal concept responding to that challenge(Holloway and Carson 2001; Stein and Craft 2007; Zwarenstein, Stephenson, andJohnston 2008). In Sweden, a new reform for providing society-based support hasbeen implemented since 2001 upon the request of user organisations emphasizing thatpersons with mental health impairments were in need of help in their efforts to exer-cise their citizenship, such as claiming their rights to service, care and support ineveryday life (Järkestig Berggren 2006). This new reform for support was called‘personligt ombud’, with the connotation of a ‘personal ombudsman’ offering short-term individual support. In professional practice this function is often called ‘PO’,which is used hereafter in this article.

Considering the function of the PO as being lobbied by service users themselves,the crucial point is how they comprehend and give meaning to this service. The aimof this article is consequently to describe the characteristics of the Swedish PO

*Corresponding author. Email: [email protected]

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566 U. Järkestig Berggren and E. Gunnarsson

through actual experiences of the service users and more particularly what they findto be significant and helpful features of their relationships with their PO.

Background

Swedish society-based support reform

The PO reform was authorized by the Government Commission (SOU 1992), criticis-ing the lack of responsibility for daily care and support by the municipal socialservices resulting in poor living conditions for mental health service users. TheCommission was inspired by case management models in the US and the UK (SOU1991). However, no specific case management model was chosen and therefore theSwedish PO was defined during the process of implementation (Järkestig Berggren2006). Comparing the Swedish model with existing models, some similarities thoughcan be found with the strengths model (Rapp and Goscha 2006), of which the mostobvious is the recognition of the service user as the director of the helping process(Järkestig Berggren 2006). The assignment of the Swedish PO, it should be empha-sized, was to form a short-term support, in order to identify and formulate the needsof the service users and, furthermore, to supervise the coordination of the support andcare from different caregivers. Most importantly, the PO should act on behalf of theservice user (National Board of Health and Welfare 2000).

The PO holds, as a salaried professional, a freestanding organisational position andis most commonly employed by the municipality or, in a few cases, by a user organi-sation. In addition, during the implementation process, the PO took on the assignmentto report recurring structural problems to the National Board of Health and Welfare(Järkestig Berggren 2006).

The efficacy of the PO model has been studied by Björkman, Hansson andSandlund (2002). The findings showed that service users in contact with their POdecreased their use of psychiatric inpatient services significantly, suggesting that therole of the PO does meet demands concerning coordination and efficiency in careservices.

Whilst the PO reform was inspired by the case management concept, somecomments on this association must be made. Case management, as an internationallywidely used concept, has been criticised for its ambiguity, since various models havebeen developed and because a negative connotation of service users being referred toas ‘cases’ in need of being ‘managed’ has emerged (Rapp and Goscha 2004).However, a task often referred to as an essential task of the case manager, is theassessment of service users’ needs and the coordination of services (Intagliata 1982;Rapp and Goscha 2004). Needs assessment in the Swedish welfare system is, though,the task of the local social worker or care manager; consequently the Swedish PO doesnot exercise any kind of public authority over service users.

Helpful relationships promoting recovery

In research using a first-person perspective on what mental health service users them-selves find helpful in the interventions performed by professionals, ‘helpfulness’ isalmost always analysed in terms of what is helpful in the process of recovery. Still,being a fairly new term, ‘recovery’ is sometimes contested and criticised for beingblurred in that it is described as an outcome as well as a process (Roe, Rudnick, andGill 2007). Analysing research on recovery, Schön (2009) found that research could

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Disability & Society 567

be categorized in three ways: as a measurable phenomenon focusing on methods andmodels, as a service user perspective focusing on the individual process related to thesocial context, and as a social perspective focusing on politics and practice in treat-ment service and support. Understood as an individual process from a service userperspective, recovery is about living a meaningful life as an integral member of thecommunity, despite and beyond the limits of the mental distress (Anthony 1993;Deegan 1993). Summing up the most mentioned characteristics of the concept of‘recovery’, they are about taking control over one’s life and learning to live with whatis perceived as distressful. The concept is focused on the interactive processesbetween the individual and the social environment. Consequently, recovery is takingplace and going on in everyday life in all the everyday roles and activities that peopleperform (Borg and Davidson 2008; Davidson, 2003; Kristiansen 2005; Onken et al.2007; Topor 2001). Earlier studies on how professionals can be helpful in the processof recovery have shown that service users appreciated professionals who could conveyhope, shared their professional power and were available whenever they were needed.Further, service users valued professionals who were flexible, regarding the diversityof methods in what helps, and who were willing to break the rules of what isconsidered the ‘professional’ role (Borg and Kristiansen 2004; Topor 2001).

The PO reform was never discussed in terms of contributing to recovery, perhapsbecause the focus of the reform was on forming a short-term support to ensure serviceusers their rights. Still, we find it fruitful to use the concept of recovery whilediscussing some of the themes of this study.

Methodological approach

The present article is inspired by a phenomenological approach, focusing on thesubjective dimension of receiving help from the PO. More precisely it focuses on theservice users’ lived experiences of their relationship with their PO as describedthrough narrative, open-ended interviews. As Davidson (2003) describes the phenom-enological approach, it provides a theoretical foundation based on meaning rather thancausality. The phenomenological approach and its focus are the original first-personexperiences that are prior to and provide the basis for theoretical and scientificconceptions: the meaning of the experiences themselves. The present article is basedon 23 qualitative interviews conducted with service users in contact with a PO for aminimum length of six months as the only criteria for selection. All POs within threecounties in the southeast of Sweden asked their service users if they wanted to partakein an interview, resulting in 20 persons being interviewed. Additionally, three personswere recruited from a user organisation, asking their members who had experiencesof a PO, for participation in the study. Most of the servicer users had long-time contactwith a PO, for two years or more, which meant that they could share their extensiveexperiences. Consequently, it also meant they had good experiences of a PO as ahelper and what they felt had helped them. The results of the study thus present whata PO means to service users when the relationship is of help. Of course not all serviceusers have positive experiences of a PO. Being a voluntary service though, we learnedfrom another project (Järkestig Berggren 2006) interviewing POs, that discontentedservice users quit the service early on and they have therefore not experienced a POfor the minimum length of time to participate in this study. A randomized selectioncould offer more varied experiences; however, as there are no registers of serviceusers other than POs’ memo notes, it is difficult to recruit randomly.

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The interviews were conducted in a place chosen by the informant, most often inthe informant’s home, but once at a library, once in a café and twice in the office ofthe user organisation. All interviews, lasting between 50 minutes and two hours, weretaped. Afterwards all interviews were transcribed in full text for analysis.

Participants

All participants experienced severe mental health impairments and they all hadextensive experiences of psychiatric care and social services, though none of theparticipants had been admitted to hospital care during the past two years at the time ofthe interview. Six of the informants were men and three persons had other ethnicalorigin than Swedish; ages ranged from 19 to 62. The duration of contact with the POvaried between eight months and two years. All respondents had somewhere to stayeven though the lodgings were temporary for two of them. Most informants had adisability retirement income or received sickness benefits. Some participants,however, did not have a regular income, which then was expressed as a major prob-lem. None of them had a regular job, but some had part-time sheltered jobs. Almostall informants lived alone, only two had a partner and nobody had underage childrenliving with her or him. Thus, the participants live in exposed situations on all socio-economic aspects. Nevertheless, most participants expressed that they were livingmost of the time under circumstances they could cope with, given assistance fromrelatives, health care professionals and their POs.

Analysis

During the data collection phase of the study an open approach to the phenomenon asit presented itself was attained by the interviewer (Järkestig Berggren), first, by beingconstantly aware of the open attitude central to a phenomenological approach andgiving over to listening to the informant; secondly, by using open questions like ‘couldyou tell me about your experiences of your PO’ to allow the informants to steer thecontent of the interview; and lastly, by exploring the informants’ stories in-depth byslowing the pace of the interview occasionally using questions aiming to reflect on orclarify what has been said. Asking for examples is a useful technique to promote clar-ification (Giorgi 1997).

The entire research project had a reference group with the representation of threeservice users that together with the researcher were involved in the setting of theproject design and in the subsequent discussions during the early process of analysis.The discussions focused on themes suggested by the researcher, of which the serviceusers revealed primarily the impact of long-term and individually-designed support aswell as the impact of lack of tangible assets, such as money, for the experience ofdistress. The interviews were analyzed in six steps, inspired by Polkinghorne (1989).First, all transcribed interviews were read through to acquire a feeling for them.Secondly, phrases that directly pertain to the experiences with a PO were extracted.Thirdly, the phrases of the informants were transformed into themes using the wordsof the researchers in order to capture the meaning of service user descriptions. Thediscussions with the reference group took place at this stage. Then, the themes fromevery interview were clustered in some overlapping themes that were analyzed anddiscussed jointly by the two authors. This resulted in an overarching theme beingdeveloped: ‘professional friendship’. In a fifth step that theme was examined and

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found to contain meanings referring to only ‘professional’ and others only to ‘friend-ship’, while a third theme referred to an interaction between these two. Finally, in anattempt to provide the reader with the means of validating the findings, as well as torelate the emotion of service user descriptions in the article, quotations are presented.In using quotations, the authors explored the diversity and uniqueness of the themesrather than strove for coherence (Willig 2007).

Central findings: professional friendship

In describing and giving meaning to a PO most participants tried to explain by usingcomparisons and calling their PO someone who ‘is like a friend’, or ‘professionalfriend’. The relationship is described as supportive, mutual and emotionally recipro-cative. Some of the meanings given to the PO relate to the original assignment, tocoordinate and advocate the needs of the service user, then being a professionalfeature. Other meanings relate to a private sphere, such as the PO offering a recipro-cative relationship, always being available, like a friend whom you can call anytime.In some themes these meanings interact with each other, that is, in providing a safeand relaxed relationship in which service users can talk about their distress. Anotherinteractive meaning is when the PO adds material resources through means ofprofessional skills, such as, applying for grants, or through manners of friendship,such as, buying a lunch or giving a gift.

In the following text the meaning of the PO will be presented first in theprofessional theme, secondly in the friendship-like theme and lastly in the themewhere these two interact. Before entering this threefold presentation we would like tohighlight the overall features of ‘professional friendship’, beginning where theparticipants started their interviews by giving an overarching story of what their POmeans to them, comparing their PO with other professionals whom they have met inpsychiatric care or social care services.

Most informants began by expressing a difference between their PO contacts andcontacts with nurses in psychiatric care and social workers in social care services, asto whom they took sides with. The participants expressed that the POs emphasizedservice users’ knowledge of the particular situation as the basis for forming help andservices; in contrast, the participants experienced professionals from otherorganisations as merely following the administrative and economic guidelines of theirorganisations. Liz thus described these specific features.

My PO shows consideration for me and my needs. I mean, the authorities have their rulesto follow and if there is anything that goes beyond them, they don’t care. That is thedifference. My PO does help me with my needs, the authorities do not. They say they do,but they do not at the end of the day.

Stig, having long-term experiences of psychiatric care, compared his relationship withhis PO to that with psychiatric staff. He talked of his relationship with the PO asfriendship-like, since his PO brought up suggestions that he thought would help, butleft the authority of deciding to Stig.

He is not as military acting; he is more like a friend. We can talk about things the wayfriends do. John suggested that I should apply for home care, but I’m the one whodecides. He doesn’t force me.

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Comparing her PO and the mental health services support, Helen mentioned thatif she would need anything beyond perfunctory care and support, she could not expectto receive assistance from the professional health care staff. The PO, however, issensitive to her priorities and would provide a variety of support, sometimes evenbeyond her expectations. Helen, as well as many other service users, expressed thatshe received help from her PO to solve her problems as a whole, not just in parts, ascompared to help received from other professionals. Following this experience Helenalso narrates a memory of her PO, Karen, who helped her out when she was movingfrom a mental hospital to her own flat.

I asked my nurse then if she could assist me on the day when I was to move out, yousee, I was so scared and I had hallucinations as I sometimes have, but no. I contactedKaren. She was very positive then and she assisted me on the day of my move, helpingcarrying stuff and I thought, ‘This is too much’… I had asked my nurse, if she wouldassist me, I don’t mean carrying furniture like Karen also did, but just being a supportto me if I would have hallucinations or so… But the professionals from psychiatric carerefused.

Initially, Helen experiences disappointment when the psychiatric nurse did not stepout of her professional context, the hospital, in order to fulfil Helen’s request, givingsupport to her as patient in a new and intimidating situation. Helen, turning to her PO,encountered a positive experience in receiving help from her, with practical tasks aswell as psychological support, thereby changing a stressful situation into a positiveexperience of mastering a demanding move.

Professional

The formal, professional, assignment of the PO was described as that of a coordinatorof care and services as well as that of an advocate. Some informants have experiencedthat the PO also helped them to raise their own voice in their demands for rights. ThePO can be used as a witness in needs assessment situations and has become a rolemodel on how to act when interacting with professionals. Furthermore, informantsdescribed how their POs helped them achieve power over their own lives throughnegotiations with social services or health care staff concerning care, housing, main-tenance or child care. Participants point out that they are encouraged to have their sayand to argue for their needs.

Ellen is a woman with vast experiences of being a patient in psychiatric care aswell as a client in social services in her old municipality. In moving she applied fordaily activities in her new municipality. When she was asked to partake in a meet-ing to perform a needs assessment for establishing her needs for daily activity, sherefused as she found the needs assessment process quite offensive, arguing that shehad been entitled to such services before and she demanded that her own knowl-edge of her needs should be accepted without assessment by yet another profes-sional. Ellen describes how her PO helped her gain access to her right of a dailyactivity.

No one should decide on what I can or can’t do or what I need or do not need. Only Ican know that. No one at social services that I have met twice can tell what I need. I don’tthink they can. My PO helped me with that. She helped me a lot. We talked about it a lotwhen we first met. She conveyed my point of view to the social worker and we visitedall possible places without any needs assessment.

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Ellen received help formulating her knowledge of her situation from her PO whoalso advocated her point of view in meetings with the social worker. In supportingservice users to formulate their own knowledge of themselves, the PO engages serviceusers in empowerment processes. While partaking in meetings together with their PO,service users describe that their PO often becomes a witness to what has been decidedon. Furthermore, they express gaining knowledge from their PO about their rights aswell as strategies on how to achieve them. An example of this is Lotte who contacteda PO when she was divorcing her husband, and needed assistance in applying for anapartment, among other things that involved contact with social services.

My PO became a guide. I learned from her how to speak to get through on the phone.When I applied for an apartment I rang every second call, so I would learn how to speakfor my sake with officials. In the end I was as good as she!

In working together to find solutions to her need of a new home, Lotte used her PO asa role model, learning how to communicate her needs to authorities. While practicingwith the support of her PO, she gained confidence in her own ability to speak for herself.

Friendship

This theme is highlighted by the informants as being a distinct feature of the POdiffering from almost all other experiences with professionals, since the relationshipwith the PO involves sharing experiences of life together. In essence the relationshipwith a PO is denoted by participants as mutual, consisting of two individuals sharingexperiences, shortcomings and happy moments with each other. Lotte, thus, empha-sizes the importance of reciprocity in the relationship while sharing experiences ofbeing a human: ‘She can give to me that she is human. She is nothing else but herselfand she can share that as a human. She also has her faults. We don’t experience anydistance’.

Lotte’s statement confirms that she and her PO share a common ground of no onebeing superior to the other. Her PO can be wrong and apologize for it as well. Further-more, she described their relationship as mutual, intending no professional distancebetween them. While sharing experiences an emotional reciprocity is created. Afemale service user told of how her shared experiences with her PO, both beingmothers with daughters of the same ages, restored her feelings of being valued as ahuman being.

Some informants have experiences of POs inviting them occasionally in to theirprivate lives. One man narrated that his PO had attended his birthday party bringing agift. Ann was also invited to the home of her PO.

At one time she invited me to her home so I could see where she lived. I think she hasdone so with all the service users that she has contact with. She is very generous andsharing.

Despite this private experience, Ann, along with several other service users,comments that she recognizes the special characteristics of this relationship: ‘I wouldnot however dream of calling her at home. There is the limit, that I would not do’.While speaking of the ‘limit’ she also gives a meaning to the notion of ‘professionalfriendship’. Despite the experienced mutuality there are limits to these relationshipsthat are narrower than those of a private friendship.

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In general users find their POs denoted by their availability, creating an atmo-sphere of security for them. Lisa counted on her PO for two years when she felt herpanic attacks coming.

She has helped me so much during all this time. To spare my mother I called my POanytime when I felt fear creeping up on me and she always answered.

Finding the PO available most of the day promotes a feeling of security that is anessential resource for service users in reflection and self-determination processes.Ellen says accordingly: ‘The mere fact that she is there, you have to do the job your-self, but if you are supported in starting your way back, you dare start thinking!’

The relationship with the PO resembles friendship when the support is readilyavailable. Helping service users in their struggle to cope with distress and lack ofresources is a friendship-like feature interacting with the professional skills andassignments of the PO.

The interaction between professional and friendship

In reporting our findings, which began with an introduction of the theme of ‘profes-sional friendship’ by means of the comparison of the PO with other professionals, wefound that the informants distinguished the PO from other professionals in that the POis on their side, acting from the service users’ perspective. The difference is related tothe specific friendship-like manner giving the necessary environment for forming thecharacteristic help of the PO, which would otherwise not exist. Based on this trustful,friendship-like relationship, in combination with professional skills and resources,informants saw their PO as helpful in their coping with distress and lack of materialresources.

Friendly reception and emotional reciprocity are not only of importance to theservice in establishing a relationship with the PO, but also, participants say, in promot-ing their well-being and in coping with their problems. Some regard their POs as themain reason preventing them from having to be admitted to psychiatric in-patient care.This is the case of Stig, who had instant support from his PO at times when he was ill:‘I felt I didn’t have to be in the hospital. I called my PO instead and he visited me athome’.

A distinct feature in service user meetings with POs is the relaxed manner in whichdiscussions on mental health problems are conducted. Discussing mental problemswith the PO instead of a friend, some informants say, is a strategy avoiding stigmati-zation. Moreover, participants discussed their symptoms in order to find strategies tocope with the symptoms. Following this strategy Ann discusses hallucinations thatbother her, and together they discovered that she can lessen their impact by listeningto a special kind of classical music. ‘We have talked a lot of my hallucinations andtogether we found this way of lessening them when I feel them coming’. In character-izing the approach of POs, informants point out the reciprocity of the relationship asopposed to a therapeutic approach, in which the service user is the only one to giveaway personal information. This was the case of Frida, who shared her experiences ofmotherhood with her PO, both having children of the same age. In addition, the rela-tionship is denoted by participants as being active, since they do things together withtheir POs while discussing experiences. Ann described her experiences of her POaccordingly:

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We do talk at the same time as we do this stuff. She is like a… she has been a therapistand a doctor, all in one. As with my therapist, we didn’t come any further. But my POand I, we moved on. It’s like when we went to fix my coffee machine, we talked in thecar; it’s like killing two birds with one stone.

Ann states that her relationship with her PO, enacted through discussions about herproblems during joint engagements in everyday activities, has been more importantfor her well-being than her therapeutic treatment ever was.

Another function of conveying hope is indicated by Magnus with reference to hissituation of being homeless: ‘She was there, fixed it all, the contract and theapartment. Yeah, helped me all through, but most of all she reassured me and helpedme look forward’.

Infusing hope into a hopeless situation is considered by Magnus an essentialfeature of his PO services. Pursuing a housing arrangement while assuring him of asolution to his desperate situation, the PO helped Magnus to restore his expectationsfor his future.

Self-determination processes, supported by the availability of the PO, are alsoconfirmed by Fia who describes her PO as always being present, helping her gainawareness of her life situation and the potentiality of choices in a life previouslymarked by drugs and homelessness. These conversations yield new rewarding oppor-tunities according to Fia, though she still has to struggle at times to remain in her newlife situation. Most importantly, today she recognizes herself as determining her ownlife course.

We talked and I had to explain to her, when I didn’t see any meaning in my life. I justwanted to get stoned and hide from the world. Then she asked me silly questions. Whatare you to do if you take drugs then? And I had to answer her, realising how stupid mythoughts were. She asked me silly questions, which are not silly at all… I have neverthought about those things, never looked upon them the way I do now.

In summing up, the characteristics of the relationship with the PO, friendliness,emotional reciprocity and availability, are instrumental in creating a trustful atmo-sphere, allowing service users to discuss their mental health problems, questions ofself-determination as well as purpose of life pursuits. At this point the concept ofrecovery emerges as a possible description as to what is taking place in the relation-ship between the service user and the PO.

Another interacting theme mentioned by informants is ‘coping with lack ofmaterial resources’. Many service users are experiencing lack of tangible assets intheir everyday life, leading to assignments for their POs to obtain resources in one wayor another. Participants told how POs have helped to negotiate with lenders for aninstalment plan, and to raise users’ income by applying for allowances and donationsfrom various charity organizations. The POs then use their professional knowledge,networks and even personal belongings. At times though, the informants describe howthey find themselves in desperate situations trying to make ends meet. At this pointseveral informants relate how their POs contribute with their private money by givingsmall amounts to buy food or buying a lunch for them in situations of acute need. Oneof these stories was told by Arne: ‘She has helped me so I did not have to pay someof my bills, very expensive dentist’s bills. She helped me wash my curtains and I evengot clothes from her. I got clothes from her husband’. Subsequently Arne tells how hisPO helps him with his financial problems, applying for various allowances, negotiat-ing an instalment plan and also sharing with him her private means.

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Moreover, some informants comment on POs using their official car for the benefitof the service user, for example, by driving them to the doctor or to various socialmeetings for leisure. Though not being an official assignment for the PO, participantsargue that resources spent on leisure are means to diminish distress. Accordingly,Laila tells about her day out last summer:

It is really very important to have the possibility to see something else if only for the day.Last summer I went with my PO and another PO and her service user on a day out. Athome it was raining cats and dogs but down there the sun was shining. Yes, it was unfor-gettable, we all thought. It was my day of leave. My vacation last year was that day andI have lived on it.

In her story, Laila sums up the special meaning of a PO for many service users, thefriendship-like approach, doing social and everyday activities, which has an impact ontheir well-being and quality of life. While adding resources to the daily life of serviceusers, POs provide them simultaneously with the possibility of making choices andpartaking in social occasions. Without these resources service users are confined tosolitude in their homes. Adding resources touches directly upon the social dimensionof the lives of service users and on their possibilities to fulfil normal roles in life: as aparent, a friend and as a citizen exercising rights and fulfilling duties.

Concluding, the meaning of a PO to service users is a friendship-like professionalsupport, promoting service users’ power over their own lives, adding resources, less-ening distress and promoting well-being. A PO could be understood as offering asupport that enhances recovery processes and lessens the impact of social exclusion.

Conclusions

Three themes were found in our study: the professional, the friendship-like and theinteraction between these two in the overarching theme of ‘professional friendship’.The theme of friendship-like as well as the overarching theme of ‘professional friend-ship’ as the meaning of the PO for service users challenges the common picture ofwhat it is to be a professional and also what is the role for the service user. Usuallythe notion of ‘professional’, as derived from Parsons (1951), is understood as a role inwhich the professional is to control her or his counter transference impulses and notget involved in a reciprocative relationship with her or his clients. However, laterresearch challenges this view: Topor (2001) shows that professionals who contributeto recovery do so by means of infringing the rules of professionalism and taking sidewith the client forming a reciprocative relationship. Also Borg and Kristiansen (2004)found that professionals who are of help in the recovery process make efforts out ofthe ordinary and they form relationships of giving and taking. Borg and Davidson(2008) point at the nature of how human relationships exist through ‘sharing, caringand reciprocity’. The traditional client role, as being one of receiving and being theone to be helped, they found was in need of reinterpretation. In accordance, the aspectof ‘friendship’ in our study challenges the traditional view of professional relation-ships. There needs to be a reinterpretation of professionalism, since it is through thereciprocity and trust created that the informants feel that they are being helped, andfurthermore, it is through the friendship-like relationship that the professional assign-ment can be achieved. It was obvious that this relationship is going on in the every-day life of the service users; it takes place while cleaning the kitchen, driving to thedrugstore, and in meetings with psychiatric staff or a care manager. Emotional

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support and practical help are inextricable as shown by Beresford, Adshead and Croft(2007), who also highlight the friendship-like approach as well as the importance ofreciprocity when asking service users of palliative care about the support from asocial worker.

The findings of this article ask for reinterpretation of the client role as well.Traditionally the client role is viewed as a role of helplessness and in need of assistingcompetence and knowledge (Parsons 1979). The adaptation to a client role also dimin-ishes other roles (Goffman 1961) and allows no other strategies for action thanadaptation to the rules of the organisation (Salonen 1997). The findings challenge thisview of the client role; the informants of this study value and strive to share and givealso in the relationship with the PO. The client role connected to the PO furtherdemands that the knowledge of the client is recognized and employed as the basis ofthe PO assignment within that particular relationship.

The findings of this article suggest that the essence of the service users’ meaningof a PO can be understood as a support in their recovery process. This is an interestingfinding, since the PO service was never discussed during implementation in terms ofrecovery. Nevertheless, service users state that the PO enhances their well-being andtheir capacity for living an active everyday life. In analyzing service users’ descrip-tions of their PO, the recovery process can be connected to some specific courses ofactions that are described in the themes: entering in a relationship built on reciprocalprofessional friendship, encouraging service users to speak their minds which includestaking sides with the service user in negotiations with authorities, empowering serviceusers to gain control over their own lives in everyday matters. Also, recognition isgiven to the fact that service users, living on low income, need more resources to beable to partake in society.

Considering the concept of recovery, other studies refer to the above-mentionedelements as profound parts of what constitutes the concept of recovery (Borg andKristiansen 2004; Topor 2001; Onken et al. 2007). In an attempt to clarify theelements of recovery, Onken et al. (2007) mention self-determination, coping skills,wellness, finding meaning and purpose of life, as well as social functioning andempowerment. Also the access to resources is recently a highlighted aspect of recov-ery (Onken et al. 2007; Roe, Rudnick, and Gill 2007) and would be an importantendorsement since resources present the possibility of choosing among meaningfuloptions. All these elements occur within social relationships that are found to be thecore experience of promoting recovery: social relationships with friends, family andprofessionals (Schön, Denhov, and Topor 2009).

Returning to the PO-reform, it was designed to be a short-term support; however,it has been shown by this study and by the studies of the National Board of Health andWelfare (2008) that in many cases the support forms a long-term relationship formany service users. Following the wishes of the service user, a long-term support isoften formed, one that compensates service users for being an exposed group in lackof resources, for example, lacking personal support networks, financial resources andbeing exposed to stigmatization. The long-term relationship thus provides serviceusers with pre-requisites to enter into a recovery process.

Hence, in further developing the PO model, user demands of long-term support inthe recovery process should be recognized. Since the PO services are designed to beof support to service user interests only, the service users’ description, definition andvaluation are to have a major impact on the elaboration of this new mental healthservice.

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user‐oriented mental health reform in sweden: featuring ‘professional friendship’

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