Ethical considerations
Ethical approval was obtained from the Institutional Re- search Ethics boards of Altrecht Mental Health Care and Symfora Mental Health Care. In the study, written informed consent was obtained from each participant at the beginning of the initial interview after they were given information about the study and informed that they could withdraw at any time. With permission, inter- views were recorded using a digital recorder and later transcribed in full. Confidentiality regarding the col- lected data was assured.
Results
The MHNs acknowledge the importance of family rela- tionships, “nobody can do without a family”, but nonethe- less, their caregiver support varies considerably. Based on the extent to which the MHNs believe that the informal caregiver plays a necessary role in the client’s support sys- tem, and that caregiver wellbeing is important, three MHN prototypes can be distinguished. At one end of the spectrum, we have the MHN who sees the caregiver and the care recipient as inextricably connected with each other. In these cases the MHN directs her/his intervention towards both the informal caregiver and the care recipi- ent. We call these the concerners. At the other end of the spectrum we see an MHN who is basically only concerned with the wellbeing of the care recipient and considers the caregiver to be a potential obstacle in reaching the client’s goals. We call these the tolerators. In the middle position are MHNs who realize that caregivers are important agents in attaining the client’s goals, and consider prevent- ing them from becoming overburdened as the main goal of their support. We call these the preventers.
Notwithstanding the distinction of three prototypes, in practice pure prototypes are rarely seen. Instead, the MHNs may also exhibit features of an adjoining proto- type, depending on the specific situation. For reasons of clarity we describe only the three pure prototypes. Each prototype description begins with a presentation of the MHNs’ essential understanding of caregiver support. Based on this essential understanding, we describe their interpretation of their role and responsibilities and the manner in which the MHNs perceive the MHN- caregiver relationship Table 2. Finally, the MHNs’ as- sessment of caregiver needs and the nature of the inter- ventions that fit their respective role conception are described.
The three prototypes
The tolerator (for illustrative quotes see Table 3)
The tolerator focuses almost exclusively on reaching the treatment goals set for the client. A tolerator does not pay serious attention to the caregiver because the caregiver is seen as a potential obstacle to providing care
for the client. Tolerators also assume that because of the severity and long-lasting character of the mental illness, the caregiver may lose interest in the situation and may no longer wish to be involved. They consider this loss of contact between client and caregiver and friends an irre- versible fact. In the eyes of the tolerator, the caregiver lacks the skills and/or understanding to cope with the client’s condition and behaviour. The tolerator also be- lieves that standard provision of caregiver support is ex- perienced as unwelcome by clients.
As a consequence, the tolerator builds a relationship with the client only. The attention given to the caregiver is meant only to obtain the caregiver’s “trust and confi- dence” in order to gain and maintain free access to the client and to the necessary information.
Interpretation of role and responsibilities
As the tolerators hold themselves responsible only for the treatment of the client’s mental illness they feel re- sponsible for organizing the appropriate treatment envir- onment. Tolerators assume they are improving the treatment environment by demonstrating professional interaction with the client that the caregiver can imitate. The MHN believes that the caregiver can benefit from this modelling. The tolerators mention several reasons why they solely focus on client goals. First they refer to a work culture in which caregiver support is not consid- ered an important professional activity and second, in their opinion, caregiver support adds to the already existing demanding work situation. The time spent on the caregiver is not considered justified, and if a need for help is detected, the caregiver is referred to other profes- sionals such as a psychologist.
Acknowledgement of the relationship with the caregiver
As the interaction between client and caregiver is con- sidered a possible threat to achieving the client’s goals, the tolerator avoids engaging with the caregiver. The tol- erator’s contacts with the caregivers are meant to gain the trust of the caregiver in order to obtain access to the client. Besides gaining trust, the tolerator also wants to receive additional information from the caregiver about the client’s illness and treatment. Even in problematic client-caregiver interaction, the tolerator always chooses the side of the client. They never intervene in the rela- tionship between the client and caregiver.
Defining caregiver needs
The tolerator does not focus on the needs of the care- giver. Although the main focus is on the client’s needs the tolerator does listen to the caregiver’s story but then hears and interprets this story from the perspective of