Enabling Fuzziness: Autopsy of the Impact of Enabling Situations on Mental ‘Illness’

Abstract

People’s stories about recovery include interactions with professionals. What happened in these situations? Seven situations were analysed using an abductive approach. Enabling situations seem to be characterised by their fuzziness regarding the place they occur, the time spent, the role of doings and the reciprocal interaction between the participants, resulting in a loss of balance, challenging their sense of self, professional settings and knowledge. A dominant view is that mental illnesses are caused by deviations from the body’s normal functioning. Illnesses should be treated accordingly through biochemical interventions. Unexpected fuzzing situations are presented as central in a person’s recovery process.

Preamble

We are four researchers who have conducted various studies, sometimes together, sometimes with other colleagues or by ourselves, but with the common ground of trying to understand how we can contribute to the knowledge that could help people challenged by mental health and/or drug problems.

Our professional backgrounds vary and include careers in nursing, social work, psychology and sociology. We have published books and articles in scientific reviews in which we have analysed and presented our understanding of helpful situations.

Thus, each of us has been studying recovery processes from different starting points for some years. The starting point of the writing process was a common dissatisfaction with the way we, separately and/or together, had analysed with different methodologies (grounded theory, thematic analysis, content analysis and discourse analysis) our interviews with people with their own experience.

After reading Brinkmann’s (2014) article ‘Doing Without Data’, we discussed whether this work could open a way to manage our dissatisfaction. Brinkmann writes about the importance of being able to sometimes lose one’s balance without quickly regaining it. This allows one to appreciate those situations when one encounters something that does not fit and cannot (or should not) be avoided, neglected or denied. Thus, this article’s background is the recognition of a shared state of unbalance that we came to recognise when confronted with people’s stories about what helped them when diagnosed with different ‘mental illnesses’.

Here, we need to make a comment about the words we use in this article. Language, the words we use, is loaded with meaning we sometimes are blind to. This might be especially actual on the psy-field, where different paradigms fight for hegemony and define the very essence of its object. Therefore, we would like to make a clarification.

When we use medical expressions like ‘illness’, ‘mad’ and ‘malady’, we put them between apostrophe, as they are not properly quoted, but we want to distance ourselves from them. However, we use them because they are part of the dominating paradigm and our study, and an important part of recovery research, has to position itself in relation to it, even if only to challenge it.

There is a plethora of alternative words and expressions, and we have chosen to use mental health problems and sufferance.

Brinkmann’s work became a catalyst for our work with this study, as we found his metaphor for staying unbalanced without immediately trying to regain balance adequate for describing our state of mind and pointing out how we could use our dissatisfaction in a way that could give new perspectives to our data and to enabling situations.

Out of our unbalance, we formulated three related questions: What happened in the situations the interviewees described as enabling? How can interactive situations influence the course of ‘mental illness’? Finally, what consequences does this have for our understanding of ‘mental illnesses’?

Enabling Situations

In this article, when referring to stories told by people diagnosed with mental health problems recounting situations that contributed to their recovery process, we call these ‘enabling situations’. Enabling situations is a development of Duff’s concept of ‘enabling places’ (2012). In the present text, ‘enabling’ means ‘opening possibilities’; possibilities to reflect on, think about, feel, act and regard oneself, others and the situations in which one is involved, in different ways.

The units of analysis are situations, not relationships. This does not dismiss the significance of relationships; rather, relationships are seen as secondary. The situations in question ‘may mark and enact various kinds of personal relationships. They are reminders of how people stand toward each other, with what degree of friendship (i.e., solidarity), intimacy, or respect’ (Collins, 2005, p. 18).

Relationships, especially asymmetrical ones, are important as they contribute to the definitions of situations and to the participants’ comprehension of them. Goffman (1982) claims that common ceremonial work is necessary to complete a picture of ourselves. In a ceremonial interaction situation, even small talk and no talk have great intensity and power as rituals because they communicate identities. Following Goffman, Berger and Luckmann (1966/1991) claim that identities are shaped, developed and maintained by social processes, and when we say something about identities, we also say something about how we perceive reality. Identities must be seen in connection with the context in which the people are situated. Jenkins (2003, p. 2) notes that our identities are established (or not) in everyday situations in a way that is not always trivial: ‘it can shake the foundations of our life’. This clearly indicates the power of everyday situations regarding recovery (or, on the contrary, experiencing problems usually defined as a loss of health).

Background

‘Severe mental illnesses’ are often considered to be lifelong diseases; ‘Schizophrenia is a chronic psychiatric disorder with a heterogeneous genetic and neurobiological background that influences early brain development . . .’ (Kahn et al., 2015). Even other diagnoses, such as depression and neuropsychiatric diagnoses, are considered chronic illnesses. However, despite extensive investments, no biomarkers have been found (Johnstone et al., 2018).

Thomas Insel, former director of the American National Institute for Mental Health, stated:

I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that, I realise that while I think I succeeded in getting lots of really cool papers published by cool scientists at a fairly large cost – I think $20 billion – I don’t think we moved the needle in reducing suicide, reducing hospitalisations, improving recovery for the tens of millions of people who have mental illness. (Quoted in Scull, 2022, p. 358)

Independent of these shortcomings, ‘mental illnesses’ and ‘troubles’ are still presented as consequences of malfunctions in the brain and are believed to be curable through medical treatments in some uncertain future.

This dark image of mental health problems remains independent of several long-term follow-up studies showing that many people in fact do recover from ‘severe mental illnesses’, and that these recoveries cannot be connected to specific professional interventions (Harding et al., 1987; Warner, 1985/2004).

This paradoxical situation should be a cause of imbalance within the mental health field, but independently of recurring controversies, it continues to be defined as a medical field.

Avoiding Unbalance?

Today, we have access to a significant number of studies based on narratives from people diagnosed with ‘mental illnesses’ collected in industrialised countries about their recovery processes (Borg & Kristiansen, 2004; Laugharne et al., 2012; Ljungberg et al., 2015; Ness et al., 2014; Ribner & Knei-Paz, 2002; Sandhu et al., 2015; Topor, 2001; Ware et al., 2004). We also have access to several stories written by people based on their own experiences of mental health problems and mental health care and institutions (Deegan, 1996; Romme et al., 2009). In the most used definition of recovery, it has been described ‘as a deeply personal, unique process’ (Anthony, 1993).

Most knowledge about the central themes in recovery literature was summarised already in 2011 in the CHIME model (Leamy et al., 2011), comprising connectedness, hope and optimism about the future, identity, meaning in life and empowerment. This model has since then been widely used, with over 2000 citations (Hare-Duke et al., 2023). Its components can be found in many studies based on service users’ experiences with some variations (Farrelly & Lester, 2014; Sandhu et al., 2015). Most notably, research has pointed out the lack of structural aspects in CHIME, such as socio-economic and structural factors (Karadzhov, 2021; Topor et al., 2022). Research has also touched upon the content of the relation with professionals, for example, in meeting places (De Ruysscher et al., 2022). Recently, Klevan et al. (2021) proposed a meta-analysis exploring the nature and characteristics of the experiences of recovery. Five meta-themes were developed: (a) being normal, (b) respecting and accepting oneself, (c) being in control, (d) recovery as intentional and (e) recovery as material and social.

In summary, we might argue that the results of recovery studies show that it seems important for service users to be treated as human beings. This might cause important improvements in clinical praxis, as the dominant narrative has described persons with a diagnosis of schizophrenia as ‘empty shells’ (Andreassen, 1984) and ‘a person without a person; a world without world’ (Ey, 1977), probably as the result of ‘a tragic decline in intellectual and social function’ (Frith & Johnstone, 2003). In short, as nonhuman.

Recently, research has focused not only on the individual level but also on contextual aspects (Beeker et al., 2021; Larsen et al., 2021), such as ‘relational recovery’ (Price-Robertson et al., 2016; Wyder et al., 2022), stressing the contributions of peers (Bøe et al., 2014; Davidson et al., 2006) and professionals (Lindvig et al., 2019; Ljungberg et al., 2015; Wilken, 2010). Other studies have focused on the material conditions of everyday life, such as the person’s economic situation (Mills, 2015; Topor et al., 2014), housing conditions (Piat et al., 2017; Tanzman, 1993), spirituality (Fallot, 2007; Ho et al., 2016), relation to the labour market (Burns et al., 2009; Priebe et al., 1998), materiality (Larsen et al., 2020) and enabling places, both public and institutional (Duff, 2012; Larsen et al., 2021). These studies acknowledge that recovery processes should be understood in a socio-material, relational and cultural framework to fully account for their complexity.

Looking at the enabling situations, that people report, some studies have pointed out the importance of ‘trivial actions’, ‘the commonplace’, ‘everydayness’, ‘small moments’ and ‘small things’ in recovering from mental health problems (Davidson et al., 2010; Davidson & Johnson, 2013; Skatvedt, 2017; Skatvedt & Schou, 2010; von Greiff et al., 2018). Most focused on ‘identity (re-)construction’ (Rowe, 2008; Skatvedt, 2017) or ‘recovery of a sense of self’ (Davidson et al., 2010).

Thus, a common feature of many stories about enabling situations is that they are not about something special – at least not that would be judged as important in a psychiatric context. Rather, in such contexts, they are part of the unseen, ‘the nothing’ (Bøe et al., 2019). At least nothing that could function as an acceptable explanation of how people diagnosed with ‘severe mental illnesses’ could get better. They are not only unseen but also made invisible as they contradict and transgress the dominant discourse about illnesses. Even more so, the individuals telling these stories were or had been in contact with different mental health services, but when they talked about their recovery, medical or psychological interventions were seldom mentioned.

In our search for help from our unbalanced situation, we noted a lack of studies about how the diverse mentioned themes fused to become parts of a recovery process. We also notice in studies about ‘trivial actions’ the lack of how these actions could possibly influence ‘mental illnesses’ and be important parts of people’s recovery processes. Furthermore, both individual and contextual studies have difficulty clarifying how the factors and themes they formulate might influence the course of a supposed chronic medical state. Social conditions, relationships, mundane situations and each person’s own efforts to deal with the challenges of lifelong illnesses might ameliorate their situation but not cure ‘the malady’. But the narrators told those stories to make us understand how these situations were important contributions to their recovery, in the cure from their ‘malady’.

As the stories we presented were collected in the framework of studies about what helped people in their recovery processes, we can expect that the narrators have chosen to tell these stories to help the researchers understand something about what helped them. This is where we want to start our exploration. And we do this armed with stories told by ‘mad’ (wo)men who claim they have recovered from what is traditionally considered as chronic illnesses. To challenge the dominant narrative, we might also need a more complex understanding of the stories we present.

Type of Method

In ‘Working without data’, Brinkmann (2014) problematised the very concept of data in its etymological sense of ‘givens’. Given that we should accept them as pieces of an objectively existing world and not as products and creations in a specific situation during the encounter between the teller and the researcher, ‘Givens’ are selected by the researcher for further distillation – as ‘takens’.

We have followed the steps described by Brinkmann (2014): choosing a topic, collecting material, consulting the literature, continuing to collect material, conducting analytical writing and finally creating a text that might be published. An exception was that we were specifically oriented towards the literature from the beginning, as our inquiry started with a dissatisfaction with this literature to which we have contributed.

Starting with Brinkmann’s reasoning around abduction, we chose situations from earlier publications, making us ‘stumble’, becoming ‘unbalanced’ and leading to a process that could be called a ‘breakdown’ (Brinkmann, 2014) when we heard, tried to interpret, analyse and classify them into themes.

We decided that each of us would bring three stories, which are analysed earlier with well-known qualitative methods. We searched for stories that kept us in an unbalanced state and where we had not been able to bring to light their complex richness in our previous articles. We sent these stories to each other and met to talk about what made us unsatisfied with our previous treatment of them. After this discussion, the first author chose seven of the stories we would work further on. We gathered several times to discuss the chosen stories and started to formulate common factors. Working this way, we followed Brinkmann’s (2012) description of the six steps of an analytic process (p. 147).

The seven stories were gathered from seven different studies. They have previously been published in different publications. A common feature of the different studies might be formulated as a focus on the participants’ experiences of helping professionals. All the situations described occurred either in Norway or Sweden, two Nordic welfare countries that have undergone a deinstitutionalisation process and developed public and voluntary social and psychiatric interventions in the community. The situations the participants depict occurred in connection with contacts with either specialised psychiatric care or with social services. Several occurred when the narrator was admitted to an institution, some when the person was discharged and received support in the community. Four of the narrators were men; three were women. Three of the professionals mentioned in the stories were men, and three were women. In one case, the story refers to a group with both professionals and users of both genders. All storytellers were living in the community when they were interviewed and could be considered in recovery or even having recovered.

Repeatedly, people who have been asked about what helped them in their recovery process would answer ‘to be seen’ and ‘to be heard’. Some of the enabling situations we quote came after questioning what ‘been seen and heard’ meant for them.

In the following section, we present the situations chosen for this article:

• 1.

  I had mobilised all my strength to go to social services. However, when I got home, the social worker called and said that I had forgotten to sign my application for benefits. I had to go back. ‘Without a signature, I couldn’t get my money’, she said. But the anxiety hadn’t gone away, and I said that I couldn’t handle the bus ride again . . .

• A little later, the doorbell rang. I checked who it was and jumped. It was the social worker. Why did she come to me? I opened the door carefully . . . An hour later, when she left, I was filled with gratitude. Imagine that she had come to my home during her lunch break, so that I could sign the application. She had done it for me, so that I wouldn’t be left without money. Never had anyone gone so far for my sake. (Michalsen & Bachke, 2020, n.p.)

• 2.

  He wanted to come fishing with me! On his day off! He came with me to my place, and the way he was at home with me and . . . I asked him in for some hot dogs and coffee and things like that, and he was there; it was . . . like . . . he behaved . . . It was so okay! [Martin laughs as he tells me] . . . He wasn’t there with a strict face on . . . like . . . ‘Here is a staff member’ . . . you know? He was just, ‘Hey, shall we eat soon, or what?’ . . . He was so very okay – it was just like being with a pal . . . I thought it was so good that . . . I noticed I was different that day, there when we were together. (Skatvedt, 2017, p. 405)

• 3.

  Here [at the meeting place], you get treatment and help in a different way. When you attend an appointment at a professional place, you know where to sit at the table. These are my experiences. Looking at these professional meetings, nobody gives a pat on the shoulder. Most people who are visiting this place here, they do not recognise who is employed or not. This feeling, I believe, is the big difference between those places. . . . It is about an equal status. (Friesinger et al., 2024, p. 274)

• 4.

  She (an occupational therapist) didn’t have a room of her own, but . . . She had a space in the corridor . . . those long corridors. It was a space at one end of the corridor where they had some handicraft stuff on a couple of shelves, and twice a week she sat there. Was available . . . So, she had a whole different way of getting in touch with the patients than what the nurses had. She had a lot more time. That was important, you know. Just the fact that she chose to devote several hours at a time twice a week and just be there. . . . So, it was up to folks to come and sit down, talk and have a cup of tea, or you could do something else.

• So, she was a person who was available?

• Yes, the nurses were always too busy. . . . They did the rounds and . . . They made up these agreements that were such a bother, and so you were supposed to ‘cough up’ something about something or other; that’s what it felt like anyway. If I asked to talk to a nurse, then it had to be about something. So, what was really nice about her . . . that she . . . that it was a bit more fun being around her. (Topor, 2001, p. 229–230)

• 5.

  Yeah . . . that was a difficult question (asked to look back and reflect upon the most important parts of the program) . . . I think that . . . some sort of, it may seem a bit banal, but some sort of love, then . . . a care that makes you fancy.

• How come?

• She seems to enjoy chatting with me . . . ‘Come here! Now, we’re going to have a fag’, she says. She apparently enjoys chatting with me . . . so nice, eh? From a staff member, you know! (Skatvedt, 2017, p. 403)

• 6.

  I had had a bad night and was belted down, so he came in that morning and was supposed to keep watch over me, as they say. But he untied me. I was feeling calm, and we went for coffee. We sat and talked, and I felt that we really got close to one another. He sat there and drank coffee with me. He wasn’t in a hurry; he didn’t have to go off somewhere. He had time to listen. I needed that, then. There was no rush. And when I was finished, after we had eaten and I had taken my tray back, he was still sitting there when I came back to the table. And we talked a little bit more.

• That’s my kind of person. That’s how I want people to be. It was so cozy. We were honest with one another. I asked if I could have his phone number and if he would like to be my contact person. He thought I meant my contact person at the hospital, and so he was, but afterwards I asked if he could continue with me. I didn’t know how he would get paid, but it’s worked now for 11 years. He’s paid by the municipality. (Topor, 2001, p. 294)

• 7.

  A boy enthusiastically described the practitioner who helped him as ‘the world’s best psychologist’. Nevertheless, when he was asked what made this psychologist so good, he started out energetically, as if it would be easy to find words.

• He is . . . he is like . . . sometimes I have said that he is . . . he is like . . . he is quirky, actually [laughs loudly]. It’s hard to say how he is. . . . He is weird. He is a real . . . I would recommend him to anyone. . . . So, he is . . . he must be . . . No, he is simply the world’s greatest . . . psychologist. He is just insanely good. Well, it is . . . the way he . . . just to look . . . just to look at him, you know [smiles and twists his body]. Just to see him, like, the way he looks . . . He is . . . he is quirky, simply . . . Unfortunately, I cannot describe him with any other words than that. (Bøe et al., 2019, p. 5)

The stories quoted above are fragments from longer interviews, dialogues and fieldwork notes. Rereading and discussing these interview extracts, ‘fuzziness’ emerges as what Blumer (1954) would call a sensitising concept; ‘. . . it gives the user a general sense of reference and guidance in approaching empirical instances. Whereas definitive concepts provide prescriptions of what to see, sensitizing concepts merely suggest directions along which to look’ (p. 7). Brinkmann (2012) also mention the usefulness of such concepts ‘that we use to help us to look in fruitful directions and helpful ways’ (p. 4).

Fuzzy refers to something that is not clear, distinct or sharply defined and to concepts or situations that are vague, ambiguous and lacking precision. In the frame of our study, the fuzziness is created in relation to the established definition of professionality as stated by Parsons (1951) as a combination of scientific knowledge, distance to the patient and objectivity. In modern terminology, this could be summarised as the use of evidence-based manualised methods.

Studying the fuzziness in our collected situations, the aim of our study became to get a more precise knowledge about these situations without necessarily fixing fuzziness in an all too precise and simplistic formulation and thus losing important aspects of it.

Hopefully, the final text reflects part of this exciting and pleasurable work in all its unstructured ways, as the central concept of unbalance had to be reflected in the work and not result in a new state of certainty.

We do not believe that it is possible to empty stories of all their meanings, and that readers might also create their own analyses and understandings of the presented situations. Thus, other answers to our questions are possible, even within the framework created by the stories. We see this as a reflection of their potential richness and not as contradicting our efforts, summarised in the ‘Fuzzy Findings’. As Brinkmann (2014) writes, ‘Abduction is a never-ending process, something that goes on as long as humans are alive’ (p. 722).

Bias

Our main entry to the encounters with the persons we talked to was our interest in recovery, well-being and helpful relations and situations. This constituted a bias in the construction of our collected stories, as in most of the conversations we had, we were also told about problematic, negative situations that destroyed hope and self-confidence (Ljungberg et al., 2016; Skatvedt & Schou, 2008; Topor et al., 2021).

The importance of users’ experience-based knowledge has begun to be recognised and forms an important ground for our understanding of mental health problems and of the impact of different institutions on peoples’ sense of self (Grim et al., 2022).

However, as with all knowledge, it is not without problems. One problem is the existence of master narratives that tend to influence an individual’s stories (Bøe et al, 2021; Llewellyn-Beardsley, 2020). In the mental health field, one aspect of the current master narratives is that contextual factors are seldom mentioned. We received detailed stories of a situation, but not of the context in which each occurred. What were the person’s living conditions, their ‘recovery capital’ (Tew, 2013) and the different interventions at their disposal to help and support them? Another problem common to life stories is that the teller tends to rationalise the chaos of life events into a consistent narrative in which one event causes another (Bourdieu, 1986/1994). The same efforts to rationalise are present in recovery stories. Our presentation should be read against this critical background.

Fuzzy Findings

The situations we present are chosen fragments, both regarding which situations we have chosen for this article and where they start and end. We will now look closely at these situations. The concept of fuzziness was chosen to underline the uncertain, unplanned, unclear and not goal-directed aspects of the enabling situations. Aspects that cannot be standardised and reproduced, neither in a research context nor in practice.

Fuzzy Places

A common feature for the narrators is that they all have been diagnosed with a ‘mental illness’ and treated accordingly in different institutions. Thus, enabling situations occurred within formal contact with mental health and social services. However, it was possible to see that most of the situations occurred in specific places that we could characterise as differing from the usual professional places.

The enabling situations included the social worker coming to the user’s home but also the professional who went fishing, left their professional places and went to the users’ home ground or public places. The meeting place is characterised by its uncertainty, as it is open to everyone, and once inside, you cannot distinguish between employees with or without experience of mental health problems and care. Even the occupational therapist’s place in the middle of a hospital ward was odd. It seemed to be a deserted place that no one uses. Still, it was transformed by her presence in the eyes of the person mentioning it into ‘an oasis’ surrounded by the busy and unavailable nurses, a bit like the breakfast situation in another ward.

The places themselves seemed to generate a space for enabling situations when the professionals transformed their clinical places into something else, when they created a social space outside the clinical places, or when they left the clinical places to go out to mundane places such as the user’s home, a fishing boat or just outside the institution to smoke together.

It could be argued that a common feature of these places was that they were ‘fuzzy’ and not susceptible to being defined undimensionally. A person’s home was transformed by the presence of a representative of an authority, but was not experienced as invaded and institutionalised. On the contrary, it became a place for spontaneous social exchanges, pleasures and gratitude.

The institutional places mentioned were also characterised in contradictory ways as inside an institution, but in contrast to an institution’s characteristics, such as containing planned and goal-directed activities, organised, time-limited encounters and a clear division of roles. They even became spaces for pleasure. As the interviewee reported about the occupational therapist sitting in the wards’ corridor, ‘it was a bit more fun being around her’. And even the possibility of getting ‘a pat on the shoulder’ was not only about consolation and support but also about bodies touching each other.

Fuzzing Situations

Fuzzy situations are fuzzing, that is, they offer possibilities to do things differently compared to traditional encounters, talk in a different way about different things and be different in the eyes of the other and, thus, in one’s own eyes. It seemed that the unclear conditions (place, doing and talking) of the fuzzy situations widened the protagonists’ ways of being/acting and their experiences of each other and of themselves. Possibly, this broke the one-dimensional role division and created a space for fuzzy and fuzzing knowledges and ways of being. What then happened with this way of ‘being different’ in the future, it is not possible to presuppose. However, the fact that people chose to tell us these stories implies that these situations meant something to them.

The stories were told coherently, and at the same time, we noticed difficulties in transforming the experience into words. This is clearly present in the description of ‘the world’s best psychologist’, but also of the fishing professional: ‘And he was there, it was . . . like . . . he behaved . . . It was so okay!’ Another way to express these experiences was by contrasting them with ‘treatment as usual’: ‘So she had a whole different way of getting in touch with the patients than what the nurses had’. ‘He wasn’t there with a strict face on . . . like . . . “Here is a staff member”.’ ‘Here [at the meeting place] you get treatment and help in a different way’. ‘She apparently enjoys chatting with me . . . so nice, eh? From a staff member, you know!’ Places, people and their interactions were not like they were supposed to be, but how could one talk about them, if not in a fuzzy way? One possible way was to observe that the professional in the actual situation did not act as professionals should act. The difference is the central moment in a fuzzy and fuzzing situation as it opens to the unknown.

The Pleasures of Doing Togetherness

As mentioned, a recurring puzzling experience in recovery research occurs when people say that an important experience is ‘being seen and being heard’. What can this possibly mean? In most encounters, professionals look at users (see them) and listen to them (hear them).

One possible way to understand this is that, in traditional encounters, professionals not only look at and listen to the person but also transform what they see and hear into diagnostic criteria, symptoms of an ‘illness’, as a basis for an evidence-based intervention. They try not to see and hear aspects of the person that would make their search for specific signs fuzzy.

However, it could also mean that in traditional situations in mental health services, people feel seen, listened to and heard when met with a diagnostic agenda. Somebody is interested in what they say and asks questions to understand it even better. A story is created. A story that gives balance, ‘a red line’ (Bury, 1982) to the user who now disposes of a new language and understanding about their suffering, who they are and what they must do to get better. It also provides a steady ground for the professional, who now knows what to do about the user’s ‘illness’. Many people say that they are pleased to get a diagnosis. The diagnosis becomes an instrument to give meaning to experiences in one’s life.

However, it could be argued that in a medical context, the price to pay for being seen and heard is the risk of a transformation of the person into a diagnosis in the eyes of others and in one’s own eyes, as in Hacking’s (1995) ‘looping effect’.

In this context, fuzziness refers to a situation in which the governing script for an encounter between the service user and the professional is nonobvious. Something has changed in the conditions that usually direct it. The usual roles and ranges of action are open to improvisation, and ‘anything’ can happen. A professional ‘. . . enjoy chatting with me and invites me to smoke together’. A fuzzy situation thus fuzzes the actions of the persons involved and, ultimately, their perceptions of themselves and each other.

Doings in Fuzzy Time

An aspect of enabling situations that often remains unnoticed is that they are about ‘doings’ and not essentially about talking. That is, doing together and not having a goal-directed conversation to get the patient to do, to reflect on or to understand something hitherto unknown to them and to change their way of thinking. Rather, doings seem instead to take place as a language that might be easier to hear, understand and trust than words.

The occupational therapist was there, waiting when the nurses rushed to their duties, and you would need a good reason to interrupt them. The social worker used her lunch break to come to the client’s home. The professional took his day off to go fishing with you and then eat sausages at your place. At the meeting place, you work and spend time together. The psychologist ‘is just insanely good. Well, it is . . . the way he . . . just to look . . . just to look at him, you know’. The ‘unskilled nurse’ waited for you after breakfast.

Such enabling situations may consist of existential conversations without words. Maybe just the fact that somebody, a professional, ‘has gone so far’ not only leads to gratitude but also questions: ‘Who am I, if a professional goes so far for my sake?’ Maybe the fact that the occupational therapist sat there at my disposal without any expectation that I had to produce any reason good enough why I sat beside her could be seen as an invitation for me to take power in the encounter, or not?

The young man describing the world’s best psychologist missed words but still expressed something: ‘He is . . . he must be . . .’. ‘He was just . . .’ said the person who ate a sausage with the professional. ‘Some sort of love’, said another person, exemplifying it by smoking a cigarette together with a staff member. ‘Some sort’ is as near as it seems possible to get when influenced by the dominant representation of effective, scientific and emotion-free interventions and trying to tell somebody about what helped.

Doings involve bodies in movement, people moving together in the same direction or moving towards each other. Again, the social worker moved from her office to the person’s home and then stayed there for an hour. The occupational therapist sat quietly, waiting. The colleague gave a pat and touched their own body. The staff member’s face did not reflect professional distance, and they ate together before going fishing. Even when looking at these aspects of the stories, we see them contrasted with the usual distanced bodies that represent professionalism.

Movements take time, and time seems to be important in many fuzzing situations. In this context, time has three transgressive qualities. One such quality is the amount, the quantity of time. In our examples, many enabling situations take longer than is usually given for professional encounters. The second is the quality of the time. The professional’s attention is directed at the encounter. Another aspect of the quality of time is that the time of the encounter is sometimes taken from the professional’s private time. This transgression of the division between work and private time did not seem to pose a problem for the professional, as it is based on a decision taken by them, and not as a routine.

Time might also be about constancy. Just one experience of fuzzing relationships and doings at a fuzzing place can be of great importance, but might not always be enough to support a change in a person’s perception of their possibilities and capacities. One condition for a change in one’s life and sense of self might be to have the possibility of repeatedly exposing oneself to fuzzing experiences. The meeting place seemed to offer such constancy – the repeated experience that persons with mental health problems could not be discerned from others without such a background.

Usually, pleasures, ‘mental illness’ and professionals’ interventions are not connected with each other. Their simultaneous presence in the enabling situations might be a result of the creation of an unbalance and of a craving for a new definition of what is happening and who we are as protagonists in these fuzzed and fuzzing situations.

The aid nurse untied the person, even if she had the mission to monitor when strapped to the hospital bed. However, after this liberation, he went on and shared breakfast with her, sitting and waiting for her to come back to the table. He then stayed with her after breakfast and was still present in her social network years later. It seems to be about the presence of the other, taking initiatives to get together, answering to the person’s initiatives and apparently taking pleasure in the shared presence, doing mundane things like smoking a cigarette together. Having pleasure and experiencing oneself as able to take mutual pleasure in ordinary doings with another person, especially one representing normality, might challenge both one’s image of professional interventions and of one’s capacity to be attractive in the eyes of someone else.

This fuzziness was also reflected in the division of power in doings described in the enabling situations. The professional who rang the doorbell of a user in the hope of being admitted. A psychologist acting so that he could be described as ‘weird’ and ‘quirky’. Another professional asking for food or a third sitting in an open space, waiting for somebody who would take the initiative to accept her invitation and sit with her.

This could be understood as creating an unbalance because when you are not treated like you expect to be treated, as you know that in a certain type of relation/situation you should be treated as, something unpredictable opens. Who am I, if not what I usually am in this kind of situation? Who could I be?

Coping With Unbalance

People in unbalancing situations can probably react by rejecting the questioning of who they are and avoiding the fuzzing professionals and the situations they propose. A second possibility could be to behave even more according to one’s diagnosis, to challenge the uncertainty created by the fuzzy professional’s way of acting. Unbalance is a threatening experience when one might have found a kind of stability and security in a certain way of being perceived and perceiving oneself. After all, things can always get worse. In such situations, many of us would stick to the well-known with its established definitions and rituals.

A third possibility would be to be curious about, or even to let yourself be seduced by, what the unbalance could lead to, from threatening to questioning and possibly to go beyond the established certainties. What might happen after one has lost balance? Does one fall to the ground and hurt oneself? Fall beyond the ground and into what abysses? Establish a new balance?

Keeping our focus on the individual, this calls into question their own definitions of themselves. Our participants were all diagnosed and used to be in contact with the mental health system. Even if they resisted this labelling process, they were accustomed to it. Still, when resisting such a labelling, it might have repercussions on their own perception of themselves.

Double Unbalance

Parsons (1951) wrote about role division between a help-seeking patient and a professional anchored in objectivity, scientificity, neutrality, fairness and the importance of avoiding the patient’s seductive tentative to establish reciprocity in the relationship. In today’s language, professionals should confine themselves to scheduled, evidence-based interventions according to the user’s diagnosis. These are hardly the characteristics of the described enabling situations, neither of the professionals’ nor of the patients’ roles. Here, we are far from Parsons’s role division.

A central aspect seems to be that when not acting as a professional is expected to act, the professionals address themselves not to the patient, but to a more complex being. Someone more than a diagnosis – a person. The social worker acted in relation to a person who would have problems because of a lack of money. The occupational therapist waited for the patient’s initiative to sit with her, and then they might just drink a cup of tea as ordinary people do. It was not about negating the problems of the person but about meeting a person with problems.

The enabling situations involved professionals, as official representatives of normality, knowledge and power, but a core aspect of the situations was the participation of a professional not acting as a professional usually should.

Thus, the unbalance could be seen as double-sided. It is not only the users who might lose their balance, but even the professionals have left their role expectations that they shared with colleagues and their organisations. Most initiatives for the enabling situation were taken by the professional, thus putting themselves in an unbalanced situation if/when the person accepted the invitation to take part in the puzzling situation. ‘Come here! Now we’re going to have a fag.’

Spontaneity and even emotional sympathy seemed to be present in enabling situations and seemed to hinder one from behaving according to prefabricated plans in the context in which the user and professional met. What are you doing when you are not doing what you know you should be doing? Have you been seduced into reciprocity? How can you explain and define what you are doing so that you can adapt your actions to the local administration’s activity registration forms and to your colleagues’ expectations? Should the experience be silenced? Who are you if a service user ‘only’ sees you as ‘a person’ and defines you not by your formal competence but says: ‘That’s my kind of person. That’s how I want people to be’, and you give her your phone number? Who are you if what you do is considered to be unprofessional, if you cannot even be distinguished from service users and you are thus silenced and transformed into a ‘nothing’?

Triple Unbalance

One possibility could be that the unbalance created in us as researchers might be understood as a reflection of the unbalance present in the situations people choose to tell us.

Unbalance is not the only way to understand the situations we have presented, and it is not the only way to understand all the situations that people describe as enabling. However, a dual unbalance might be part of the professionals’ contribution to the recovery puzzle. It points to different aspects that could be present in other situations, such as the place where things happen, the social interaction between two parts, both affected by the situation, and accepting to be affected and stay ‘unbalanced for a moment longer than what is comfortable, for this is where we may learn something new’ (Brinkmann, 2014, p. 724).

Inconclusive Reflections

Maybe the fuzzing practice described is the red thread that could help us understand the high probability of recovering from ‘mental illnesses’ found in several studies (Harding, 2005, 2024). Some general reflections could be formulated.

Final Fuzziness?

Our perception of professional encounters in the mental health field is about a professional and a patient/client/user, in which the setting and scenario are given. The encounter happens in a special space, the professional’s home ground, at scheduled times. It has a defined goal and milestones that will be reached through interventions initiated by professionals according to the golden rules of evidence-based best practices. Most professional practices involve words that are expected to have a therapeutic, or at least calming, effect. Even in medical practice, building an alliance is seen as important in an instrumental way, resulting in compliance so that the service user will act according to the doctor’s decisions.

Fuzziness can arise in relation to all these aspects. The division of roles, place, time, therapeutic goal, best-practice interventions, words and gestures can be affected. Even if not necessary, it seems that fuzziness contaminates all or most of these aspects to generate enabling situations.

Dominant (in terms of official acceptance, cultural dissemination and economic resources) mental health research and knowledge-based practices are based on a simple and attractive representation of what it is all about. It is about different ‘illnesses’. These ‘illnesses’ are grounded in the body, the brain, the genes or eventually in the ‘mind’. Research looks for the actual deviation from normality in the body of the individual. Treatment interventions are directed towards these deviations to (re)establish normal functionality. Large amounts of money and time are devoted to research to study the different parts of the model and to develop effective interventions to (re)establish health.

In this context, asking individuals with delusions or whose connection to reality and capacity to reason about what has helped them might at least be considered inappropriate. To argue that this knowledge could be important to understand the symptoms and ‘malady’ they are said to be dealing with, and what could be effective help, might be considered as bordering on insanity.

Living within this dominant paradigm and in the academic mental health field, we are part of this culture. Nevertheless, we have collected people’s stories about what has helped them. Reading and listening to stories about enabling situations might make you lose your balance if you don’t immediately dismiss them. Thus, like many colleagues, we have stumbled and written scientific publications about the importance of seeing the service user ‘as a person’ and ‘as a human being’. Doing so has helped us recover our balance, and it has become part of a discussion about humanising the conditions in different institutions. This can also be transformed into ‘person-centred care’, ‘user involvement’ and ‘shared decision making’, all of which are wonderful words but are often integrated as harmless predetermined procedures inside the bio-medical practice with strongly delimited choice possibilities, both for the service user and the professional (Eriksson, 2013).

In the present study, we accepted Brinkmann’s invitation to remain unbalanced just a little bit longer than comfortable. However, afterward, we found company in our unbalanced fuzzy findings. Brinkmann is far from being the only one challenging ‘simplistic and mechanistic approaches to qualitative inquiry (. . .) to produce knowledge devoid of critical reflection and contextual considerations . . .’ (Koro-Ljungberg & Mazzei, 2012, p. 728).

In the same perspective, Law (2004, quoted in Koro-Ljungberg & Mazzei, 2012) stated: ‘If the world is complex and messy. Then at least some of the time we’re going to have to give up on simplicities’ (p. 728). Here we can see parallels between our ‘fuzzy’ concept and Law’s ‘messy’. These parallels strengthened us in our aim to get a more precise knowledge about these situations, without necessarily fixing fuzziness in an all too precise and simplistic formulation, and thus losing important aspects of it.

Epilogue

We initiated our search for a new temporary balance by formulating three related questions: What happened in the situations the interviewees described as enabling? How can interactive situations influence the course of ‘mental illnesses’? Finally, what consequences does this have for our understanding of ‘mental illness’?

Fuzzing Common Factor

What Happened in the Situations the Interviewees Described as Enabling?

Spontaneity seems to be a core moment in enabling situations. Spontaneity creates surprise as part of the unbalancing process. The unexpected is part of the situation.

This can be strengthened by the fact that the situation also includes the professional as someone who is unbalanced, going beyond and even breaking the rules and routines commonly accepted as signs of a professional approach (Borg & Kristiansen, 2004; Laugharne et al., 2012).

Thus, based on our inquiry and even if spontaneity seems to be of central importance, it might be possible to identify some common factors that characterise fuzzy enabling situations:

Movements

Change is about accepting that what seems to be given is given only in a delimited moment of time and under certain circumstances. Movement involves one’s body and mind and includes movement in new chapters in one’s biography. Leaving one’s home ground or creating new public scenes for encounters involves movements. Also, to imagine, be tempted by and create situations other than the routinised, centrally decided, preprogrammed, scheduled immobility. In many of the presented stories, we see professionals leaving their institutions to meet at the user’s home or in public places. The meeting place with its shop is a new kind of institution and brings about movement for ‘service users’, now being ‘service providers’; ‘professionals’ who cannot be distinguished from mental health professionals at the shop and from clients looking for something to buy and bringing even more confusion about who is who.

Places

Where the encounter happens influences the protagonists’ range of action, their interactions and reciprocal knowledge, but also their knowledge about themselves and, thus, their sense of self. Having access to an enabling landscape with different kinds of spaces opens a different range of actions, relations and facets of one’s personality. It strengthens aspects of one’s recovery capital, such as material, social and personal resources. Mentioning ‘movements’, we pointed at professionals in the homes of service users and public places. But even inside the traditional institutions, it sometimes seems possible to transform their character. The occupational therapist, without an own office, created a public place inside the institution. Eating breakfast with a patient, at the same table, transforms the ward for a moment into something else.

Improvisations

Leaving clinical settings or transforming them creates fuzzy conditions for the encounter’s possible content, course of events and consequences. Without a map, one must invent trajectories in the created landscape. Improvisation means accepting uncertainty and being conscious that things can end in many ways. What can happen when you get to the service user’s home? Will they open their door? What do you say if they invite you for a hot dog?

Doings

Where the meeting takes place enables different venues for action. Taking a walk or a car trip, eating together, sharing a cup of tea or coffee, receiving a visit during the professional’s lunch break, or just being silent together. Doing can be doing things together, but also doing things for the sake of the other. All these actions might be perceived as languages carrying messages in contradiction to the traditional messages about illness and diagnosis as identity. Unbalancing actions unbalancing one’s sense of self. The social worker stayed at the service user’s home for far longer than needed just to make him sign his application. Could she have some pleasure staying and talking with him? And the professional accepting a hot dog at the service user’s home before going out to fish together. What messages were transmitted in those situations? Professionals taking pleasure in being together with users; succumbing to the seduction into reciprocity, as Parsons would put it?

Time

Enabling situations, having the time to improvise, and remaining unbalanced take time. The power over time might be seen as a core contradiction between administratively-driven mental health interventions and fuzzy enabling situations. The quantity of time might be one aspect, but also quality aspects might be important. Giving a hug or taking a fag together takes no time. Going fishing on a day off or sitting for a shared breakfast and then accepting being a social contact person requires more time.

Dual Recovery

Recovery is a process involving the service user, but also the services, the professionals, their methods, knowledges and routines. This might be done openly or as a ‘street-level’ practice made invisible by the guardian of the traditional order and their control over what should happen between service users and professionals (Lipsky, 1980). But describing the professional as quirky and weird, getting the impression that the professional enjoys chatting with you, or recognising that both you and the professional were different in this special situation, beyond the expected interventions scheduled frame point out to reciprocal changes.

Unfairness

The situations that we studied are unfair. As fuzzy situations cannot be transposed into a method, we are back to the common factors found for helpful psychotherapies (Frank & Frank, 1991). These are based on and strengthened by a reciprocal emotional bond between the person and the professional. It is a relational aspect that cannot be commanded or planned for groups of individuals based on diagnosis, gender, socio-economic status and so on. To force social workers to go home during their lunch break to their clients or to give a hug to service users would empty these situations of their emotional charge, meaning and impact. People are unique and appreciate and are appreciated by different people, so resonance is and can only be unpredictable (Rosa, 2020).

Paradoxically, the praxis we met in enabling situations could be interpreted as a recognition of social and mental health workers’ participation in informal, mundane interaction with ‘service users’. However, the ongoing proletarisation of their work conditions, when a growing part of their job is directed by centrally decided schedules and placed under ever-growing scrutiny, could be seen as ways to take from the professionals their experience-based knowledge and their capacity to adapt to the concrete person they meet (Standing, 2023). It is also part of a simplification and even a destruction of the original intention for evidence-based practice, in which the results from different studies would be merged with the preferences and experience-based knowledge of the service user and of the professional (Sackett et al., 2000). The fuzzing praxis is absolutely based on users’ experiences; it has been the focus of several studies with similar results and has also been confirmed by professionals and studies of professionals’ praxis (von Greiff et al., 2018).

Thus, enabling situations seem to occur in most institutions. Foucault (1982) wrote that liberation and freedom cannot be created through architecture. They can arise only through people’s practices. Sadly enough, losing one’s balance cannot be transformed into a structured method that could be tested in randomised controlled studies (RCT), because social life is not an experiment where you can control all the variables. It is probable that many similar situations that could have become enabling occurred earlier in the lives of the people we interviewed or talked to in our fieldwork. Situations that, for different reasons, didn’t become enabling. It seems that losing one’s balance and what happens then might be facilitated or aggravated by certain conditions, such as the place it happens, actual living conditions and when, in the person’s life history, it happens.

However, let us not forget that most of these situations have an end. Both participants will often return to a different quotidian reality, with clear delimitations between diagnosed service users and evidence-based practitioners. Later, it will be possible to tell a researcher that this situation was the beginning of one’s recovery process, that one has met ‘the world’s best psychologist’, or that the relationship has continued for years outside the institution. Others will find other places where new fuzzing situations might emerge, where they will experiment with their perceptions of themselves (Duff, 2012; Hope et al., 2023). Still others will never be part of fuzzy situations or forget about them, as we forget about moments of our lives when change seemed possible but never happened.

Losing one’s balance is hardly a new method. Paradoxically, such enabling situations seem not to be rare in professionals’ practices.

Breaking With the Sense of Oneself

How Can Interactive Situations Influence the Course of ‘Mental Illnesses’?

If we understand people’s mental suffering as not caused by biogenetic reasons but by past and present disabling situations, mundane enabling situations in which the professional initiates mutual exchanges with the ‘patient’ might create a ‘crack’ in expectations about how they should be encountered. These cracks and the fuzziness they create might, in turn, lead to an unbalance in and a challenge to the patient’s (and the professional’s) sense of self as ‘ill’, deviant and in need of treatment, opening the way to a transformation of it into a person’s sense of self (Barham & Hayward, 1991).

This possibility has already been explored by different professionals, researchers (Collectif International, 1977; Basaglia, 1987; Beeker et al., 2021; Johnstone., et al., 2018; Priebe et al., 2013) and service users (Romme et al., 2009; Recovery in the Bin, 2025).

In this context, the enabling situations are fuzzing, as they break with this view of oneself as ‘patient’ or ‘professional’ and the modes of behaving that one has adopted. Skatvedt (2017) has presented this kind of situation as a way of ‘being human together’. It refers to situations where the actors become just two human beings, in two bodies, in more or less wordless communion. Despite these situations’ apparent emptiness, they illustrate everyday rituals loaded with emotional energy (Collins, 2005; Goffman, 1982). Further, they provide powerful signs of inclusion in a common humanity in which identities as equal and worthy are established, and self-feeling is developed (Skatvedt, 2017). Our main issue has been to point out interaction situations of significance for clients/patients. It is important to note that being human together seems vital, also for professionals. In line with Frank (2004, p. 5), it may help professionals to ‘be the people they want to be’.

Recovery might be understood as a questioning and dismantling of a sense of self built up through sociocultural interactions, material conditions and power relations that diminish and confirm the person as profoundly different and unworthy; as a collection of symptoms and disturbances inside of oneself. Fuzzy situations might be enabling, as they contradict this sense of self but also propose another way to be through being with others in a different way. This concrete questioning of the abstract person/patient also opens the possibility of experiencing who one can be if one dares to leave behind the security of an abstract life as a living diagnosis.

Illnesses or Problems

Finally, What Consequences Do This Have for our Understanding of ‘Mental Illness’?

If recovery is possible through experiences of reciprocal fuzzy doings, then it is not possible to think of such changes related to biologically caused illnesses. Instead, it becomes possible to think about mental health problems as the result of disturbing experiences in disabling situations (Topor et al., 2021). Earlier and/or present situations and interactions in a sociocultural context form the person’s understanding of themselves; their sense of self (Davidson & Strauss, 1992) and their possible range of action. Strange behaviours and ways of thinking might not be the sign of an illness, but ways of dealing with an oppressive reality and actual or past threatening situations and interactions. Although strange behaviours might have been adequate and even successful in coping with threatening situations, they might become inadequate in others (Johnstone et al., 2018; Watzlawick et al., 1974).

This should be considered as a provisional state of the situation as long as no discovery of biological marks has been made and tested, opening the possibility for new diagnostic systems and treatments. Until then, it should be time to leave the present dead-end street of the one-sided biomedical model.

A Firm Ground?

Have we finally found a firm ground for how enabling situations can be understood and the consequences of this understanding? Certainly not, but it could be possible that reading our reasoning based on some experiences told by people in recovery from mental health problems could create an echo in the reader’s own experiences, unbalance them and stimulate them to go further with new understandings.

We could apply Brinkmann’s description of abductive reasoning to the result of our own unbalance:

Abduction is a form of reasoning employed in situations of uncertainty; when we ‘stumble’ and need an understanding or explanation of something that happens. It can be formalised as follows: (1) We observe X, (2) X is unexpected and breaks with our normal understanding, (3) but if Y is the case, then X makes sense, (4) therefore we are allowed to claim Y, at least provisionally. (Brinkmann 2012, p. 4)

As provisionally concluding remarks we have used Brinkmann’s description related to our findings:

1. We observe people recovering from ‘mental illnesses’ and not connecting their recovery to medicine or specific psychotherapeutic interventions.

2. This is unexpected and breaks with our normal understanding, as ‘mental illnesses’ are expected to be cured through medication and eventually specific psychotherapeutic techniques,

3. But if ‘mental illnesses’ are not ‘illnesses’, then the possibility that people may recover in connection with social enabling situations makes sense,

4. Therefore, we are allowed to claim that ‘mental illnesses’ are not ‘illnesses’ but socially situated expressions of experiences in people’s life history, at least provisionally.