Acknowledging communication: a milieu-therapeutic approach in

mental health care

Solfrid Vatne & Elisabeth Hoem
Accepted for publication 1 November 2007
Correspondence to S. Vatne:
e-mail: solfrid.vatne@himolde.no
Solfrid Vatne PhD RN
Associate Professor
Department of Health and Social Science,
Molde University College, Molde, Norway
Elisabeth Hoem RN
Postgraduate student
Department of Adult Psychiatry, Nordmre
and Romsdal Health Trust, Molde, Norway
VATNE S. & HOEM E. ( 2008) VATNE S. & HOEM E. ( 2008) Acknowledging communication: a milieu-
therapeutic approach in mental health care. Journal of Advanced Nursing 61(6),
690698
doi: 10.1111/j.1365-2648.2007.04565.x
Abstract
Title. Acknowledging communication: a milieu-therapeutic approach in mental
health care
Aim. This paper is a report of a study to develop milieu therapists acknowledging
communication in their relationships with patients.
Background. Gundersons therapeutic processes in milieu therapy have come into
use in a broad range of mental health contexts in many countries. Research in
nursing indicates that validation needs a more concrete development for use in
clinical work.
Methods. Schibbyes theory, Intersubjective relational understanding, formed
the theoretical foundation for a participatory action research project in 20042005.
The data comprised the researchers process notes written during participation in
the group of group leaders every second week over a period of 18 months, clinical
narratives presented by participants in the same group, and eight qualitative inter-
views of members of the reection group.
Findings. The core concept in acknowledging communication, mutuality, was
described as inter-subjective sharing of feelings and beliefs in a respectful way.
Participants presented their process of development as a movement from knowing
what was best for the patient (acknowledging patients as competent persons, a
milieu-therapy culture based on conformity), to appreciating diversity and stubborn
talk, to reective wondering questions. Misunderstanding of acknowledgement
occurred, for instance, in the form of always being supportive and afrmative
towards patients.
Conclusion. The concrete approaches in acknowledging communication presented
in this article could be a fruitful basis for educating in and developing milieu
therapy, both for nursing and in a multi-professional approach in clinical practice
and educational institutions. Future research should focus on broader development
of various areas of acknowledging communication in practice, and should also
include patients experiences of such approaches.
Keywords: acknowledging communication, mental health, milieu therapy, nursing,
participatory action research, relational understanding
ORI GI NAL RESEARCH
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690 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
Introduction
In the international literature, it seems to be accepted that a
therapeutic milieu is an important phenomenon in mental
health nursing (Peplau 1952, Gunderson 1978, Geanellos
2000). Gundersons (1978) ve therapeutic processes
structure, containment, support, involvement and validation
have become commonly used in many countries and in a
broad range of clinical contexts, independent of size, patients
length of stay, stafng and philosophy (Lawson 1998,
Thomas et al. 2002, Norton & Bloom 2004, Thorgaard &
Haga 2006). However, there appears to be little published
research evaluating the impact of these approaches in this
area of practice (Geanellos 2000). Some studies conrm that
containment and structure are practised in nursing; this is
also the case, to some extent, with support and involvement
(Thomas et al. 2002). The myth of a positive effect of
structure seems to have dominated the discussion, placing
emphasis on the physical milieu and rules for interaction
between patients and therapist and between therapists
(Norton & Bloom 2004, Vatne & Fagermoen 2007). The
fth process, validation, appears to need a more concrete
development for use in the clinical area (Thomas et al. 2002,
Vatne & Fagermoen 2007). Validation, as described by
Gunderson, is the afrmation of and respect for a patients
individuality through interaction with staff.
The purpose of the work presented in this paper was to
give more substance to the concept of validation in clinical
work. Schibbyes (2002) theory of intersubjective relational
understanding was the theoretical foundation for the
study.
Theoretical framework
Therapeutic relationship in challenging encounters
The reason for the strong emphasis on a therapeutic
relationship in milieu therapy is that the patients often have
relational traumas that make it difcult for them to form
positive relationships with other people (Peplau 1952).
Trauma-related symptoms can be understood as manifesta-
tions of the anxious, avoidant, aggressive and disorganized
feelings, often expressed by disruptive behaviour that chal-
lenges interaction in daily relationships with other people
(Lawson 1998).
A search in CINAHL, PsycInfo and MEDLINE, using the
keywords difcult and manipulative behaviour combined
with mental health care yielded a large number of studies.
They generally showed that patients characterized as chal-
lenging are those who do not stay within traditional
boundaries in society (Hepworth 1993, Breeze & Repper
1998, Lowry 1998, Bowers 2003a,b, Hayward et al. 2005).
Often they were described by the staff as non-compliant,
manipulatingsplitting, cantankerous, attention getting
and so on. Patients with aggressive, acting out and self-
harming behaviour belonged to the same category (Vatne &
Fagermoen 2007). They challenged professionals feelings,
for example, of powerlessness, shame, fear and anger. They
were also experienced as a threat to nurses competence and
feelings of control (Breeze & Repper 1998).
Use of milieu therapy is suggested to meet the treatment
needs of people who are recovering from traumatic experi-
ences by offering opportunities to develop more constructive
thoughts and behaviour in managing their distress and
vulnerability (Norton & Bloom 2004). However, we found
little concrete evidence in the research literature that might
help guide milieu therapists during challenging encounters
while also meeting the therapeutic need of traumatized
patients. The interventions suggested were rm limit-setting
and non-judicial approaches (Hepworth 1993, Breeze &
Repper 1998, Mason 2000, Laskowski 2001, Bowers
2003a,b), which often are contradictory demands (Vatne &
Holmes 2006, Vatne & Fagermoen 2007).
Psychotherapy research over the past decades has identied
the therapist-client relationship, especially therapeutic
alliance as of the greatest importance, along with thera-
peutic techniques. There is evidence for the positive benets
of conditions such as giving support, attention to patients
experiences, reection and exploration and facilitation of
affects (Roth & Fonagy 2005). Basing their claim on reviews
of controlled studies, Asay and Lambert (1999) propose that
so- called common factors have the clearest implications for
psychotherapeutic practice, i.e. equality, acceptance, empa-
thy, warmth and understanding, perceived trustworthiness,
condence and investment in the relationship. Therapists
perceived to be rigid, uncertain, critical and uninvolved are
more likely to be valued as less effective therapists (Roth &
Fonagy 2005). It is reasonable to assume that such common
factors also are a fundamental premise of milieu therapy. In a
qualitative interview study with patients support was
reported for a good and helping relationship characterized
by treating the patient as a valued person, displaying warmth
and empathy, and carrying on normal conversations that
enable the patient to have some meaningful control over the
situation (Breeze & Repper 1998). According to Gunderson
(1978), validation has to be carried out through respect for
patients individuality and acceptance of their symptoms as
meaningful expressions; for example, hallucination may be
understood as an expression of some unclear but important
aspects of the patients self. We suggest that common factors
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and Gundersons concept of validation can be combined
through the theory of acknowledging communication.
Acknowledging communication
Although the importance of being acknowledged is recog-
nized as a contributing factor in helping people who suffer
from mental illness (Stern 1985, Schibbye 2002), acknowl-
edging communication is a concept not previously used in the
international mental health literature. Communication that
focuses on acknowledgement comprises an attitude, but also
concrete approaches that emphasize the subjective, experien-
tial aspect of what is shared by staff and patients during
communication. Inter-subjectivity is the sharing of common
experiences, for example being open to the subjective
opinions or feelings of someone else. When patients experi-
ence that their feelings are being regarded as important and
valid, they may also experience that they become subjects in
their own lives. By being acknowledged as thinking and
feeling individuals, they can regain their ability to engage in
self-reection and self-delimitation (Schibbye 2002). To-
gether, those theoretical concepts draw on concrete strategies
which could provide an important supplement to Gunder-
sons concept of validation.
Self-delimitation and self-reection
Schibbye (2002) describes self-delimitation as the ability to
sort out and distinguish between ones own opinions,
feelings, values and assessments and those of others; this
ability is fundamental in acknowledging oneself and others.
It is concerns maintaining boundaries when engaging in
dialogue with others (Schibbye 2002, p. 78). She describes
self-reection as a specic human quality whereby one is
able to relate to oneself by observing oneself from an
outside position. Self-reection is our ability to have
thoughts about our thoughts and to be aware of our
feelings, i.e. the fact that we can have a relationship with or
access to processes within our selves (Schibbye 2002, p. 77)
concurs with how Gunderson (1978) describes the concept
of introspection.
In a clinical context, self-delimitation requires that both
therapist and patient develop clear boundaries in the treat-
ment relationship; the therapist does not control the patient.
Engaging in reective processes means to wonder together
about what is happening in concrete situations. In turn,
wondering questions can be helpful in increasing self-reec-
tivity. Additionally, it involves emotional empathy by being
emotionally present, i.e. tuning in on the other persons
feelings.
The study
Aim
The aim of the study was to develop milieu therapists
acknowledging communication in their relationships with
patients. The following research question was asked: What
changes occurred in the milieu therapists clinical work
during participating in the process of developing acknowl-
edging communication?
Design
The project presented was an empirical study carried out at
the Nordmre and Romsdal Health Trust, Norway, a
medium-sized public Norwegian psychiatric hospital. The
rationale for this project was to offer patients a better process
of self-development by building staffs ability to behave in
more acknowledging ways.
The project was based on a participatory action research
design founded in critical theory (Holter & Schwartz-Barcott
1993, Hart & Bond 1996, Polit & Beck 2004), and the
assumption that development of practical knowledge in a
professional community calls for an inquiry that fosters
enlightened self-knowledge which involves self-reection in
dialogues (Polit & Beck 2004).
The setting
The study unit, which has a total of 17 young patients, is
divided into two wards with approximately 50 staff
members. The unit provides treatment for young people
between the ages of 16 and 30 who suffer from various
mental disorders: some have self-control problems, often
related to trauma and abuse, and some have developed
symptoms that are consistent with a diagnosis of schizo-
phrenia. The length of stay varies from 6 to 30 months.
The staff varies in professional background (psychiatrists,
psychologists, nurses, mental health nurse specialists, social
workers, occupational therapists, nursing assistants) and
age (2565 years).
Methods
The researcher in this study interacted in reection arenas
with the study participants. The reection was based on
analyses of taken-for-granted assumptions in concrete clinical
narratives from the unit presented by the staff, and transla-
tion of the theories of acknowledging communication into
concrete actions related to those narratives.
S. Vatne and E. Hoem
692 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
Staff in the unit (about 50) were divided into a total of
eight multi-disciplinary groups, named reection groups,
with two of the staff as group leaders. Additionally, the two
group leaders in each reection group participated in a
leader support group 16 group leaders in total. This group
was led by an internal experienced professional and an
external researcher (the rst author). A total of 27 meetings,
15 hours each, were held in the reection groups and the
group leaders group; the meetings were held every second
week over a period of 18 months. Reection also took part at
project seminars (eight in total), in which the theory of
acknowledging communication was presented and discussed.
Data collection methods in action research can vary, but
follow the action taking place. Figure 1 gives an overview of
the data collection methods related to the different arenas of
reection, and shows that data were collected in form of
researchers (rst authors) process notes (reections and
narratives) written during participation in the leader support
group and project seminars. Because of transfer of informa-
tion by the leaders between the reection and leader support
groups, this became a main data source. In the leader support
group, data were collected over an 18-month period in 2004
2005. Using qualitative interviews (lasting 2 hours each),
data about experiences of participating in various arenas and
the whole project were collected (tape-recorded and tran-
scribed verbatim). A strategic sample comprising eight
members, one from each reection group, was recruited to
take part in the interviews. To achieve broadness and
variation in the data, participants with different professional
backgrounds and length of experience were selected. The
interviews were carried out after the conclusion of the project
(JanuaryFebruary 2006), by a researcher who had not taken
part in the group reections but was familiar with the
projects theoretical foundation. They were based on a semi-
structured interview guide that dealt with staff members
experiences of the action process, opinions about the essence
of an acknowledging approach, and possible changes in
themselves and in the unit during the process.
Ethical considerations
The project was approved by the Norwegian Regional
Committee for Medical Research Ethics and the Norwegian
Data Inspectorate. Participants were each given information
sheets about the study, were informed that they could
withdraw from the study at any time without explanation,
and were reassured that their contributions in groups and in-
depth interviews would be treated condentially.
Data analysis
The interviews were analysed using Kvales (1996) theory on
qualitative thematic content analysis. Each case was carefully
analysed and interpreted by both authors to identify units of
meaning. The method involved systematic structuring,
detailed analysis and coding of the text data from all
interviews by creating themes and subthemes that reected
the essential meaning in the text, and reecting distinctions
Project seminars (8)
All participants
Documents in researchers process note
8 Reflection groups, 16 meetings
6-8 participants, 2 group leaders
Interviews
8 Informants
1 from each
reflection group
Leader support group
2 group leaders form each reflection group
Researchers and supervisors
Researchers process notes
Narratives
Figure 1 Data-collection methods (in bold)
related to reection arenas.
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2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd 693
and contradictions inherent in the data. In a nal analysis,
data from all participants were analysed together and in
conjunction with the researchers process notes and narra-
tives from the group of group-leaders. Through this process,
an inclusive and reduced text was created to facilitate further
theoretical analysis related to the theory of acknowledging
communication.
Rigour
In action research, rigour is related to use of learning cycles
and focus is placed on factors that are signicant and useful
for the organization (Coghlan & Brannick 2005). This
studys specic strength was the assembling and analysing
of data from different reection and teaching arenas over a
relatively long period (15 years). This made it possible to
include interviews of participants from the reection groups
together with the researchers process notes from the leader
support group so that experiences and knowledge developed
in both arenas of reection were represented. The reliability
of the study was ensured by tape recordings the interviews
and by the research journal containing systematic notes taken
during the leader support groups.
Findings
Participants
The eight participants in the interviews represented different
professional backgrounds: four mental health nurse special-
ists, two whom were leaders of the unit; two occupational
therapists; two nursing assistants. The interviewees ranged in
age from 35 to 55 years. The members of the group of group
leaders (16) were mental health nurse specialists (7), nursing
assistants (2), occupational therapists (2), psychiatrists (2)
and psychologists (2), physiotherapist (1). They ranged in age
from 35 to 60.
Three major themes emerged from the data: core condi-
tions for acknowledging communication, the process of
change in staff practice, and misunderstanding of acknowl-
edgement in practice.
Core conditions for acknowledging communication
Known but still unknown
Theoretically, the participants were familiar with the basic
philosophy of acknowledgment. Mental health nurse spe-
cialists described acknowledgement as a basic attitude in their
professional education, e.g. to acknowledge the patient as a
valuable person. However, it was not an philosophy that was
consciously settled in the units everyday practice. How to
practise acknowledgement was an unknown area of compe-
tence. All participants said that they found the theory difcult
to put into practice in their actual encounters with patients.
One said, It feels like my tongue gets tied. Before exploring
more thoroughly the ndings, these are rst illustrated with
an abridged narrative. The story was discussed rst in the
reection group and then in the leader support group.
A story about and not about acknowledging
communication
Lisa, a 19-year-old, is on leave of absence during a discharge
process from the ward where she has been an inpatient the
last 2 years; she is living in her own apartment in the com-
munity, attending high school. Her main care professional
network in the community is a local medical practitioner and
a mental health community nurse.
This story starts when Lisa makes contact with the
community mental health nurse because she feels an urge to
cut herself. To verbalize her feelings instead of cutting herself
is a strategy learned in the ward. The nurse immediately calls
the medical practitioner. Together they decide to send Lisa to
the hospital in an ambulance, in spite of the fact that Lisa tells
them that she wants to stay at home.
Arriving at the ward, staff asks Lisa why she is returning
and what the problem is. Lisa whispers that she wants to go
home and withdraws to her room. When staff members
speak to her, she remains silent. Since they nd it difcult to
get her version of the situation, they are not happy about
letting her go. Lisas former primary nurse, having a good
relationship with Lisa, knocks on her door and waits for an
answer; but Lisa is still silent. She knocks once more, at
the same time saying that she is entering the room. Lisa is in
the bed covered by the sheets. The nurse asks if it is OK if
she sits on her bed, and Lisa nods. Both keep silent, but
after a while Lisa rises to a sitting position. The nurse gives
Lisa a slight hug while she says that she thinks it must have
been awful and dramatic for Lisa to be transported in an
ambulance. Lisa nods. The nurse continues by saying that
she feels it is difcult to know what to believe about Lisas
opinions, since she says that she wants to go home but non-
verbal signals say, Leave me alone. She therefore asks Lisa
to help her, because she thinks that Lisa must be the one
who knows what her need is at this time.
The nurse then suggests taking a walk. During the walk
Lisas voice is clear and her posture is straight. She speaks
plainly about her admission, which she felt was unnecessary,
and how the transport in the ambulance was horrifying. She
wants to go home and be with her friend. The same afternoon
she goes home alone by bus.
S. Vatne and E. Hoem
694 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
In the rst part of the story, the professionals in the
community acted based on their own point of view. Later,
the story illustrates how a nurse takes the patients perspec-
tive and makes it visible to the patient by sharing her feelings
about the situation. Study participants named such an
approach creating a mutual relationship.
Mutuality: a core theme in acknowledging patients
The participants presented mutuality as the essence in
acknowledging communication; they described it as an inter-
subjective sharing of good and bad feelings and beliefs in a
respectful way. Through mutuality, both patients and pro-
fessionals were allowed to appear as distinct persons. In
various fashions they stated inter-subjectivity to be an
important aspect of a therapeutic relationship:
Trying to understand the stories patients tell us, and their
subjective reality, is necessary to attain a therapeutic change.
In a collaborating relationship I have to respect the
patients point of view.
It is about sharing good and bad experiences.
The participants thought this manner of mutual sharing
could make a change in both parties of the relationship.
The process of change in staff
From knowing best to acknowledging patients as competent
Participants explained that one consequence of respecting
patients subjective points of view were that therapists have
to take the patients expressions seriously and to accept and
dare to show diversity in behaviour and opinions among
patients and colleagues. For the participants this change in-
volved a role-shift away from what they called a traditional
role of a professional expert, i.e. the role in which the pro-
fessional always knows what is best for the patients like
the professionals in the start of the story of Lisa. The expert
role was described as involving behaviour like stubborn talk
and assertive manners, for example dening the patients by
ascribing negative attributes to them, and performing a role
of disciplining the patients. If staff relate deviation only to
the persons negative qualities, this is a diagnostic approach
(Lchen 1971, Vatne & Holmes 2006) which can prevent
staff from understanding the situation and their own contri-
bution to it, for example the way they interact (Breeze &
Repper 1998, Vatne & Fagermoen 2007). According to
Schibbye (2002), disciplinary interactions can easily occur
during clinical activities and are characterized by therapists
dening patients behaviour, problems, experiences and
solutions. Often such attitudes can contribute to deadlock in
the treatment relationship. When staff nd themselves in
challenging encounters, it is recommended that they try to
view the situation from the patients perspectives (Wright
1999) and examine their own behaviours and responses
(Harris & Morison 1995). Our participants described such a
change in their perspective and actions during the project, but
the new approaches were yet not totally integrated, either in
themselves or in the practice of the unit: Such dramatic
changes in communicating with the patients takes time.
According to participants, respecting the patients view
implied that they had to undress from a distanced profes-
sional role, and stand out as independent persons having
their own opinions about patients and treatment. It also
involved reecting about the language used and speaking to
them in a way that opens up, giving the patients a possibility
to reect upon themselves, and their relationships with
others.
From a culture of conformity to appreciating diversity
To show diversity was perceived by participants as a big
step from the units former philosophy to act identical and
conform, in accordance with the units informal rules. By
practising self-disclosure, the professionals were allowed to
develop a closer relationship to the patient, being a profes-
sional acting self-delimitated through self-reection, and
more like a friend. The statement about being both a pro-
fessional and a friend is worth examining. For example, in a
study by Hem and Heggen (2003), nurses described being
professional and being human as contradictory demands
that produced difcult role conicts.
Self-delimitation and self-reection in practice
Our participants talked about self-delimitation and self-
reection as concepts that had to be translated into concrete
actions in clinical encounters. They described self-delimita-
tion as consciousness about their own thoughts and feel-
ings, and regarded their previous lack of consciousness as
being a possible background for serious conict with pa-
tients. In order to behave differently, they felt it was
important to distinguish verbally between the therapists
and patients experiences of the situation. To behave in a
self-delimited way assumed that they practised self-reec-
tion, explained in terms such as reecting about our own
feelings in the concrete situation and what we think might
be the individual patients feelings. Practising self-reection
in groups through discussion and role-playing clinical situ-
ations became the arena for developing ways of verbalizing
self-reection and self-delimitation. When practising self-
reection, one participant said that he came to see himself
from another perspective. Others reported that they found
it important to investigate experiences together with the
patients.
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When we reected on the researchers narrative in the
group and role-played the interaction, she suddenly saw
herself in a new light and realized that it was her own shame
she had placed upon the patient. This shows that it is
important for nurses to look into their selves and we are not
used to doing this. It is important to investigate our
experiences and beliefs with patients and to ask them about
their feelings and thoughts because our interpretations of
what is happening inside patients from an outside position
can be wrong.
Similar to our ndings, other researchers have demon-
strated that critical reection through dialogues, combined
with narratives helped to transform nursing practice by
bridging the gap between theoretical ideals and the realities of
daily care-giving practice (Kim 1999, Forneris & Peden-
McAlpine 2007).
According to Gunderson (1978), staff working with
validation should be able to combine introspection with
involvement with patients (Gunderson 1978, p 331).
Validation depends on professionals empathic skills and
sensitivity, and also on the ability to tolerate uncertainty.
Looking at the narrative about Lisa, it is obvious that the
nurse is practising empathic skills and emotional presence
when she verbalizes the dramatic feeling for Lisa caused by
being transported in an ambulance. The nurse shows self-
delimitation when she verbalizes what she sees from her
own position, saying that it is difcult to know what to
believe about Lisas experiences from what Lisa expresses
verbally and non-verbally. When she asks Lisa about help,
she is acknowledging Lisa as a competent person who
knows what is best for her. Additionally, she shows her
own limitations of understanding, which is self-delimita-
tion. When she claries her uncertainty she demonstrates
self-reection and disclosure of her own feelings. Partici-
pants proposed these processes as possible and important
actions in their daily work: When I reect, I help the
patients to reect about themselves, then the patients can
be more distinct for themselves.
Norton and Bloom (2004) also describe the main form of
validation to be validating clients negative experiences and
providing a framework to start viewing themselves as parties
who can participate actively in recovering, rather than as
sick, bad or disruptive individuals. Validation supports
individuality and differentiation of self, characterized by the
ability to separate thinking and feeling. By sharing feelings
with patients in a self-reective and self-delimitating manner,
our participants described their behaviour as professional,
with a closer relationship to the patient and sometimes also
becoming a friend. MacGillivary and Nelson (1998) found
that mutual trust and respect, sustained by self-disclosure,
friendships and relationships, emerged strongly as a core
value of partnership, which seems to be a more professional
concept than friendship.
From authoritarian talk to wondering reective questions
Our participants explained their changes in communication
with patients as a shift from authoritarian messages to using
wondering reective questions, based on emotional listening
to patients expressions, as was demonstrated by Lisas nurse.
It also involved a change in approach from walking ahead of
the patient, trying to drag him from behind, to pushing to-
gether in collaboration. In contrast, they pointed out that
their previous focus was on reality of facts, and motivating
patients to change opinions and behaviour in accordance
with the professionals view. Often such advice from staff
could end in closing up the talk. When shifting to
acknowledging approaches, participants described their work
as more meaningful but also as more difcult and uncertain:
It is tough to put focus on our self and strenuous to be
conscious of oneself all the time.
Misunderstanding of acknowledgement in practice
Some participants claimed that misunderstood acknowledge-
ment could take place in practice; for example, It is easy to
think that you always have to agree with the patients. An
example of misunderstood acknowledgement is illustrated
below.
A story about misunderstood acknowledgment
Martin, a 26-year-old inpatient, has symptoms consistent
with schizophrenia. On his own initiative he has acted to
arrange for a rafting tour combined with a weekend slee-
pover. It is also known that Martin is extremely careful with
his money. One afternoon he tells one of the nurses that he
does not want to participate, because the cost of the tour is 50
dollars. The following conversation takes place:
Nurse: Why dont you want to participate, Martin?
Martin: It is too expensive.
Nurse: But what do you want to spend your money on then?
Martin: I want to save money to buy furniture and appliances for my
new apartment. I have thought a lot about it the past few days, and it
has been a big problem to make a decision.
Nurse: I understand - you take very good care of your money. You
are the one to decide what to do, not me.
Martin decided not to participate on the rafting trip, but when he
walked away he did not look very happy. The nurse said that she felt
disappointed about the outcome of the talk and that the situation
ended puzzled.
S. Vatne and E. Hoem
696 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
The story illustrates that a process of shifting perspective
from being authoritarian and rule-governed can move in the
opposite direction, to thinking that one has to be kind and
supportive to everything the patient says. The consequence of
such a passive approach could be that the professionals
become vague and indistinct. In the story, the nurse gives no
correctives that can help the patient to appear as a distinctive
person for himself. The following solutions to this problem
were introduced in the leader support group: If the nurse,
instead of letting Martin take the decision, says, It seems to
me that you want me to agree with you, she can possibly
match the feeling Martin has by getting the nurse to take his
side. The nurse can also reect the conict she thinks Martin
experiences by saying, I am really surprised; I thought you
wanted to participate. The nurse can also continue: Now, I
am a little uncertain. How do you think we can nd a
solution? The last sentence opens up the possibility for
Martin to suggest a solution that he probably already has in
his mind.
From the discussion of the story, a difference between
afrmation and acknowledging, which is not clear in Gun-
dersons conceptualization, became visible: afrmation of
patients can take place, without acknowledging, when the
mutual sharing of distinct opinions is not done. Afrmation
itself can, according to Schibbye (2002), be one-sided when a
professional afrms the patient in accordance with what they
think the patient needs. In contrast, respectful sharing of
opinions contributes to challenging the patients point of
view, which is important in therapy (Peplau 1952).
Study limitations
As the data have been drawn from only one study site, the
study has limited transferability. It is also a weakness that no
data on patients experiences of changes in collaboration with
the staff were collected. Patients were invited to participate in
interviews but they declined.
It is a challenge for leaders in mental health care to arrange
for processes which foster awareness of the therapeutic
outcomes of nursepatient relationships and which build a
caring culture of acknowledgment. Our experiences are that
the many education programmes do not involve students in
concrete training in therapeutic communication. We believe
that the concrete approaches to acknowledging communica-
tion and reection presented in this paper can be a fruitful basis
for educating staff in and developing milieu therapy both for
nursing and in a multi-professional approach in clinical
practice and educational institutions. Future research should
focus on more in-depth and broader development of various
areas of acknowledging communication in practice, and
should also include patients experiences of such approaches.
Author contributions
SV and EH were responsible for the study conception and
design and SV was responsible for the drafting of the
manuscript. EH performed the data collection and SV and
EH performed the data analysis. EH obtained funding and
provided administrative support. EH made critical revisions
to the paper.
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