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Being in love is one of the most profound experiences we can have, one that can powerfully move us and irrevocably change the way we see ourselves, one another, and even the wider world. Literature and film often explore romantic love’s capacity to move us and radically alter our world (think of Romeo and Juliet, for instance), but this experience is not limited to romantic love: parents sometimes speak of experiencing overwhelming love at the first sight of their children, for example.

On the face of it, this powerful experience has little to do with morality. For many thinkers influenced by Immanuel Kant, there is no place for luck in morality, and accordingly little place for the emotions. Morality seems to have to do with helping others, regardless of who they are and whether we like or are emotionally connected to them or not. Morality, on this way of thinking, is about duties we have towards others, or demands that they can make of us. Love, on the other hand (whether romantic, familial, or love of friends) seems unpredictable, idiosyncratic and unique. We can love others for all sorts of reasons – Romeo and Juliet fall in love at first sight – and it is not something that anyone could demand of us, because it is not wholly under our control. As William Godwin memorably put it in 1793: ‘What magic is there in the pronoun “my”, that should justify us in overturning the decisions of impartial truth?’ I might especially love and care for my friends, my family and so on – but this might seem to have little to do with morality.

As a result, love (whimsical, unpredictable, unique) is often thought to be a rather separate matter from ethics (a matter of duties we hold towards all equally). At worst, the partiality that seems central to love can seem to conflict with the impartiality that seems to characterise ethics. And, at best, it may seem irrelevant to ethics. Few contemporary ethicists, in fact, give love a central role.

The philosopher and novelist Iris Murdoch, however, insists that love is not only morally relevant, but absolutely central to morality. She begins two of her most famous essays with assertions of the significance of love in ethics, claiming in ‘The Idea of Perfection’ (1962) that ‘love is a central concept in morals’, and in ‘On “God” and “Good”’ (1969) that ‘we need a moral philosophy in which the concept of love, so rarely mentioned now by philosophers, can once again be made central.’ Specifically, she suggests that, though our actual experiences of love may often fall short of it, attentive love is fundamental to morality.

But why does she think that love is so central? And is this an idea worth taking seriously today?

To see how Murdoch ends up thinking that love is central to morality, it is first worth asking a broader question: what is morality? Murdoch’s answer is that at the core of our moral life is the way we see the world, our ‘vision’ of it. We are always looking at something, in some manner, and in doing so we either build up a fairer, more just, more adequate picture of it, or we distort our vision of it. This is a continuous part of our lives.

Our vision, she thinks, largely determines how we go on to act: if I see you as my enemy, there will be no surprise when I start treating you like my enemy. If I had instead seen you as a potential friend, then I would naturally treat you with warmth and care. Acting rightly matters, she thinks, but how we act depends on how we see, principally on how we see other people.

Correspondingly, she sees the key moral activity not as choice but as attention – an idea she gets from the activist, mystic and philosopher Simone Weil. On Murdoch’s picture, our most basic moral activities are activities of attending to particular things in particular ways, since this is the activity that shapes our vision of the world.

Thinking about others in a hostile way is morally significant even if it never eventuates in outward action

To see why this is, Murdoch asks us to imagine a fraught relationship between a mother and a daughter-in-law, ‘M’ and ‘D’. M, she imagines, cannot bear D: she sees her as common, unpolished, and ‘lacking in dignity and refinement’. D’s accent and the way she dresses grate against M’s sense of decorum, and, again and again, M finds herself annoyed at D’s tiresome childishness. M, however, is a very ‘proper’ person who would never dream of acting improperly. Does her unfair assessment of D morally matter here?

It seems very intuitive here to think that M is doing something morally bad in conceiving of D as juvenile and vulgar. It is a snobbish and unfair way to think about D, and it is shaped by class and gender prejudices in concerning ways. But M is stipulated to have behaved beautifully to D despite this; she doesn’t overtly express her disdain for D or act contemptuously towards her. Still, we might think that how M sees D matters in and of itself. Thinking about others in a hostile and condescending way is morally significant even if it never eventuates in outward action. Murdoch thus suggests that vision is itself morally significant.

For Murdoch, this little vignette is representative of our moral lives as a whole. We are always building up pictures of the world. And those pictures can either be enlightening and illuminating, or unfair, distorting and misleading, like M’s vision of D. On Murdoch’s picture, to distort one’s conception of reality and fail to do justice to another person in one’s vision of them is a key kind of moral failing. Ultimately, she’ll suggest that love is what enables us to grasp important truths about others. Love, on her picture, both enables and constitutes treating others rightly.

Why would M have such an unfair image of D? More generally, why is it that we all tend to distort things, and view them in ways that fail to do justice to them? Why do we find it so hard to see one another truthfully? Murdoch argues that the key problem here is the ego. The ego, she suggests, prevents us from seeing truly because it leads us to self-deceive or fantasise. These fantasies prevent us from seeing others as they really are, a process that is shaped by both social convention and (what she calls) ‘neurosis’.

To start at the beginning, Murdoch suggests that the ego makes it difficult to properly attend to one another. We often fail to see others adequately because the ego gets in the way and obstructs or distorts such vision. On Murdoch’s very loosely Freudian picture of the human psyche, the ego is anxious and utterly self-centred, utterly absorbed in itself and focused on protecting itself at all costs. It therefore ignores or distorts anything not directly relevant to the self or inconvenient to it, even at the cost of losing one’s grasp of reality. In ‘The Sovereignty of Good Over Other Concepts’ (1970), she writes:

We are anxiety-ridden animals. Our minds are continually active, fabricating an anxious, usually self-preoccupied, often falsifying veil which partially conceals the world.

The ego, on this picture, is resolutely inward-looking: it pulls us into ourselves and our own concerns, and, in doing so, obscures everything else. As such, it distorts our attention and vision, inducing us not to look at things that in fact matter, or encouraging us to distort what we should (and could) in fact see. It can therefore prevent us from truly seeing or understanding reality, and, most importantly, it can prevent us from understanding other people.

Think of the way in which resentment towards someone who irritates you can colour your vision of them

On Murdoch’s picture, the self-centredness of the ego therefore pushes us to fantasise, to protect the ego by seeing only what we wish to see, or what concerns us – whether by ignoring certain other things altogether, or by horribly distorting them. Such fantasies present us with a world reflecting our own concerns, not a world as it truly is. She writes: 

The chief enemy of excellence in morality (and also in art) is personal fantasy: the tissue of self-aggrandising and consoling wishes and dreams which prevents one from seeing what is there outside one.

The ego is dangerous, Murdoch suggests, because it so strongly incentivises us to fantasise. Fantasy prevents us from engaging with reality, prevents us even from recognising that reality.

There are some particularly stark examples of fantasising: things like belief in arcane conspiracy theories, or belief in ungrounded prejudicial stereotypes. These can plausibly feed a person’s ego in different ways, such as by making them feel privy to some kind of elite knowledge, or reinforcing their complacency in their own social standing. But Murdoch’s thought is that much of our ordinary vision is like this, too. Think, for example, about the way in which resentment towards someone who irritates you can colour your vision of them. This is a much more everyday case of fantasising that might also importantly distort your grasp of who that person really is.

Murdoch’s suggestion is that what M was doing when thinking about D was fantasising. She wasn’t really responsive to how D is, or considering the fairest way to think about her. Her ego got in the way of really seeing D. M’s caricature of D depended both on unjust social conventions, and on more individual or personally specific concerns M had (her ‘neuroses’). For instance, in seeing D as ‘vulgar’ and lacking in refinement, M’s vision made use of problematic class stereotypes that picked up on D’s lower-class status. But there was also a more personal element to M’s vision of D: her caricature was also shaped by fear and jealousy at the thought that D has displaced her from the centre of her son’s life.

These social and personal elements (convention and neurosis) can combine, Murdoch suggests in ‘The Sublime and the Good’ (1959), to create images that have great power over us. Since they speak so strongly to our egos, we are resistant to amending or displacing them. Instead, it is easier for us to retain our self-serving fantasies – and so we often do.

This picture of being caught up within our egos and unable to really see others sounds rather bleak. What would enable us to overcome the ego, and see one another rightly? How is it, according to Murdoch, that we might stop fantasising? She insists that what is needed for moral progress to occur is ultimately a reorientation of love.

For Murdoch, what is needed to counteract our tendency to draw our attention inward, towards self-centred concerns, is something that draws us outwards, towards the reality of others. What can draw us outwards in this way? Loving attention: a kind of just, patient, generous attention to others. This, she thinks, is what will improve the moral quality of our vision and put us in touch with reality as it truly is. Loving attention, she insists, is central to morality, and that is because it draws us out of ourselves towards the object of love, overcoming our habitual tendency to turn inward. She writes: 

It is in the capacity to love, that is to see, that the liberation of the soul from fantasy consists.

In lovingly attending to others, we attend to them as sources of interest and value in their own right, not as things we care about merely in relation to our own concerns. We come to care about such things, as it’s often put, ‘for their own sake’. This, she suggests, frees us from the grip of our fantasies. Love draws us out of ourselves and our concerns towards the world, and especially towards other people. Such loving attention therefore enables us to get to the truth in a way that our ordinary looking – distorted as it often is by the ego’s fantasies – does not. Loving attention is a kind of discerning attention that allows us to see things as they really are.

This is an exercise in loving attention – in setting the ego aside and grasping the reality of another

Murdoch thus embraces the forceful aspect of love, its ability to overcome us. Love needs to be a powerful force, she suggests, in order to overcome the strong pull that fantasising has for us. We are strongly motivated to fantasise because doing so speaks to our deep egocentric needs and wishes. But love is a powerful-enough force that is able to overcome this, able to draw us out of ourselves and towards reality. In thus reorienting us, it can allow us to see and respond to others as they really are – and this, she thinks, is at the core of morality.

So, Murdoch continues the story about M and D by imagining that M really does want to do the right thing, so she takes herself to task. She reflects on herself and her relations to D, and realises that she’s snobbish, old-fashioned, and perhaps even jealous of D. M then attends carefully, patiently and generously to D, and the way M thinks about D gradually changes. Rather than seeing her as vulgar, she instead comes to see her as refreshingly simple. Rather than seeing her as undignified, she comes to appreciate her spontaneity. Rather than seeing her as irritatingly childish, she sees her as pleasantly youthful, and so on.

In Murdoch’s terms, what M does when she reflects further on D is lovingly attend to her. She’s trying to be fair to her, trying to do justice to her, trying to see her as she really is. In short, M is trying to understand D properly, and this is an exercise in loving attention – in setting the ego aside and really coming to grasp the reality of another individual. Lovingly attending in this way is a way of coming to grasp D, a way of being responsive to her as she really is, and Murdoch thinks of this as something that is morally significant in and of itself.

This might seem to capture some kinds of love, but we might wonder whether it captures them all. Can’t love be dangerous and misleading? Murdoch allows that it can. At the start of Romeo and Juliet, after all, Romeo is speaking of his love for Rosaline – a love that is instantly forgotten on meeting Juliet. Ordinary human love can lead us astray, and is sometimes blind and selfish. But, she insists, when love leads us astray, this is because something that properly aims at a real person has instead taken as its object an illusion, something that falls short of its own true aim. Love that is morally misleading is (though perhaps common) itself a defective, or at least imperfect, form of love. Attentive love, by contrast, represents the ideal of love.

Imagine, for example, that D’s husband in Murdoch’s example does not really know or understand her. Instead, he projects a mixture of feminine stereotypes onto her and responds positively to D as a result of this fantasy. Although this is much more positive than M’s hostile fantasies, it would still count as an at-best defective form of love – a love that has failed to meet its own standards. For Murdoch, real love is a way of actually engaging with another, not merely with an illusion. A love that fails to attend to the other is a failure of love.

Love, then, is central to morality for Murdoch because it can enable us to overcome our temptation to fantasise, and instead see and respond to others. And although the claim that love is central to morality might sound strange to contemporary ears, it is an idea that has been, for millennia, at the heart of many religious and cultural traditions such as Judaism, Christianity and Buddhism. In this light, Romeo and Juliet’s ill-fated love might be understood as more than the expression of personal whim. Rather, it might be a rare moment of undistorted blinding insight into the infinite and irreplaceable value of others.

What might this mean for us today, and how might we come to practise attentive love? Unfortunately, there are, Murdoch suggests, no quick fixes here enabling us to do so instantaneously. Nevertheless, the practice of attentive love is something that we can gradually cultivate and strengthen; the ego’s hold on us is not fixed, and we can lessen its grip bit by bit.

The way to do so is via attention to others. Though it is often difficult to do so, we can consciously devote our time and energies to focusing away from the busy throng of our own tasks and towards others. Simply dragging ourselves away from our own concerns and paying patient attention to another person helps. For example, attending to a frustratingly arrogant acquaintance may allow me to realise that their arrogance is in fact a symptom of social insecurity, and thus provide me with an opportunity to respond to them with greater insight and compassion.

Even our everyday engagement with art, skill and craft can be a starting point for learning to attend to others

Very often, we may be prompted to attend to others by our dim awareness that we are judging others harshly or failing to do justice to them. This, of course, is what happens to M. M is tacitly aware of her own snobbery and classism, though recognising it is probably still painful to her. This kind of inchoate recognition of our failures regarding others is common, and we can respond to it in different ways. The ego would have us look away and avoid the painful recognition of shortcoming. But recognising it can prompt us to look outwards, at those we are judging unjustly, and rethink our understanding of them. Significant creative imagination may then be required of us to come to grasp them more truthfully.

Finally, Murdoch makes the intriguing suggestion that even our everyday engagement with art, skill and craft can be a starting point for learning to attend to others. In learning skills and crafts or engaging with art, we learn to focus on something outside of ourselves, something we seek to gradually deepen our grasp of. The beginner, in this context, needs to exercise humility, to recognise that their initial impressions may need to be rethought and that their grasp is partial and inadequate. Thus, Murdoch suggests, though the person who took things no further would clearly be morally lacking, arts, skills and crafts are an excellent introduction to moral life and the kind of attentive love required of us there.

On Murdoch’s picture, attentive love is therefore a possibility for us all, and with practice anyone can exercise it. What it requires is for us to take the time to wrench ourselves away from the insatiable ego and orient ourselves towards the difficult reality of other people.

Introduction

Neurodegenerative diseases, such as Alzheimer’s disease (AD), lead to a progressive decline in cognitive abilities, behavioral disturbances, and loss of autonomy.^1–3 Currently, these diseases affect more than 55 million people worldwide. In France, approximately 1.3 million individuals are affected, and 11% of people aged 30 and over have a sick or dependent relative or spouse. The majority of these individuals are “family caregivers” (FC), who support their ailing loved ones. Their challenging situation has been recognized as a significant public health concern.⁴

As the disease progresses, the continued care of loved ones at home places an increasing burden on FC which can result in the placement of the affected individual in an institution.^5,6 This transition represents a highly emotional challenge for FC, who experience mixed feelings of guilt, sadness, and failure, but also, at times, relief.^7–11 While institutionalization may provide some respite for FC, it does not necessarily alleviate their emotional distress, depression, or sense of burden.^12,13 Anxiety related to institutional care,^14–16 difficulties in relationships with professional teams,^17,18 and feelings of exclusion from their loved one’s life are common daily concerns.¹⁹ These challenges compound the emotional strain caused by disease progression and the loss of meaningful interactions.²⁰

From a therapeutic point of view, various authors have proposed different types of psychoeducational interventions for caregivers which aim to strengthen coping strategies,²¹ change perception of the situation, increase self-efficacy,²² and self-confidence through information reinforcement, and provide comprehensive support to the individual, taking into account their emotions, knowledge, and environment.¹² The impacts of these programs on family caregivers are heterogeneous, yielding positive outcomes in some domains (improvements in feelings of guilt, psychological distress, and caregiver burden following institutional placement) but no effect in others (reducing depression or improved satisfaction with care.^23,24 The observed heterogeneity in program outcomes can be attributed to the wide range of caregiving situations and caregiver characteristics (eg, family environment, available local resources, stage of the illness, caregiver’s personality, etc) that influence how interventions are received and applied.^13,24

In the context of developing a novel psychoeducational program to support FCs during the transition of their relatives with dementia from home to a nursing home, we initiated a first pilot implementation designed to identify primary impact trajectories across diverse FCs profiles. Although the program will subsequently be evaluated in a larger trial using both quantitative and qualitative measures, this preliminary study adopts a clinical case approach to generate in‐depth qualitative insights into initial effects, which can later be cross‐validated with objective and standardized clinical assessments. Through qualitative analysis of these cases, we aim to address the heterogeneity of caregiver responses, thereby refining the program content and guiding the design of future implementations.

Methods

Participants

The study sample was recruited from the initial pilot implementation of the psychoeducational program in nursing homes located in the Paris region, in which twelve family caregivers participated. Participants in the psychoeducational program were selected based on the following criteria: being the primary caregiver of a loved one with neurocognitive disorders, having a loved one institutionalized for less than six months, committing to attendance of at least five of the seven group intervention sessions to ensure sufficient engagement, being 18 years or older, and providing informed consent after receiving all necessary study-related information.

Exclusion criteria included being a professional caregiver, being a family caregiver (FC) for an individual who still resides at home, absence of depression and/or anxiety, having a diagnosed but untreated psychiatric disorder, presence of cognitive impairments, or already benefiting from another caregiver assistance program.

Clinical Case Selection

Three cases were selected from among the twelve observed for the case series based on their relevance to the study objectives, the diversity of their care experiences, and their representativeness of the overall population of family carers. They were also included based on how their difficulties evolved after the program—what we refer to as their trajectory. Indeed, the program had a positive impact on some family caregivers (FCs) but proved ineffective for others. The three cases presented in this article illustrate these main trajectories of program impact identified in that pilot study. Additionally, selection was guided by the richness and depth of participants’ narratives, particularly their capacity to express and reflect upon their emotional experiences. Table 1 presents the demographic characteristics of the selected clinical cases.

Table 1 Sociodemographic Characteristics of Clinical Cases and Duration of Care

Psychoeducational Program

The intervention is a structured therapeutic and educational program designed to support FC during the critical transition phase of institutionalizing their loved ones. The program consisted of nine sessions including two individual interviews, each lasting approximately one hour, conducted before and after the seven group sessions and seven group sessions.

Inspired by Lazarus’s transactional model of stress and coping,²⁵ this intervention was designed to support family caregivers (FCs) in regulating distressing emotions such as guilt and anxiety, thereby enhancing their capacity to manage the challenges associated with institutionalization. The program offered tools to reduce stress, strengthen caregiving competencies and knowledge, improve communication with healthcare professionals, and facilitate caregivers’ adjustment to their evolving role.

The educational program was led by a rotating multidisciplinary team of experts, including a geriatrician, a facility director, a healthcare manager and a psychologist serving as the consistent facilitator across all sessions These four facilitators received the same initial training and participated in the entire psychoeducational program.

Each session was centered on a designated theme (Table 2) and included a presentation, followed by an opportunity for participants to engage in discussions with the facilitators and other caregivers. Each session integrated focused theoretical input, peer discussions for shared support, practical exercises for real-life application, and multimedia resources to reinforce and extend learning.

Table 2 Titles, Content, and Objectives of the Caregiver Program Sessions in Nursing Homes

The intervention was implemented under the same conditions for all family caregivers in the core sample from which the clinical cases were drawn.

The program included the following elements:

1. The pre-program interview aimed to assess the relationship between the family caregiver (FC) and the care recipient, identify the caregiver’s needs, sources of dissatisfaction, stressors, goals, and motivation for participating in the program. This initial meeting also addressed crisis situations and adaptation challenges, providing an opportunity to offer personalized guidance.
2. Participant Introductions: Each person introduces themselves and their situation, creating a compassionate and supportive group atmosphere.
3. Neurodegenerative Disease Overview: A clear summary of common diseases, behavioral challenges, and how institutions typically handle them.
4. Nutrition in Institutional Care: A practical look at identifying malnutrition and implementing effective prevention measures within care settings.
5. Institutional Structure & Governance: An explanation of how the institution is organized, including roles, responsibilities, and rights of all parties.
6. Psychological Impact on Caregivers: Discussing the emotional effects for family caregivers when a loved one enters institutional care and strategies to adapt.
7. End-of-Life Laws & Support: A concise overview of relevant legal frameworks, ethical considerations, and available emotional and medical support.
8. Workshop Recap: Bringing together key points from all sessions, inviting questions, and mapping out next steps.
9. The post-program interview was designed to review the program with the caregiver, reinforce their knowledge, evaluate changes in dysfunctional patterns, and, if necessary, revisit topics not covered in the group sessions or explore new issues that may have emerged since the end of the workshops.

Clinical Case Presentation

Case 1

Mrs. K. was a retired teacher and had been the primary caregiver for her 91-year-old mother, who had advanced Alzheimer’s disease, for seven years. She struggled to balance her caregiving responsibilities with her own well-being and experienced deep guilt over the decision to institutionalize her mother, despite recognizing that her mother’s declining health made in-home care unsustainable.

During the interview, Mrs. K. expressed significant psychological distress, fluctuating between feelings of guilt and powerlessness. She acknowledged that continuing home care had become unbearable but blamed herself for placing her mother in a nursing home against her will:

I felt completely lost. she didn’t want to talk about the institution, and it weighed on me.

She was also troubled by the difficulty of distinguishing her mother’s disease-related behavioral disturbances from her pre-existing personality traits.

Case 2

Mr. B. was a retired engineer who cared for his 75-year-old wife, who had mixed dementia (Alzheimer’s and vascular disorders).

The decision to place his wife in an institution was largely imposed by the medical team, leaving him with a deep sense of powerlessness. He also struggled to establish a meaningful connection with the nursing home staff.

Mr. B. explained that managing his wife’s illness at home had become overwhelming due to the increasing demands of caregiving:

It was very difficult because it took more and more time, and I couldn’t manage it anymore.

Although he acknowledged that the nursing home provided appropriate care for his wife’s needs, he expressed frustration over the lack of transparency regarding its operations and the roles of the professionals involved. This uncertainty fueled his dissatisfaction with the facility.

Case 3

Mrs. O. was the caregiver for her 80-year-old partner, who had dementia. She shared caregiving responsibilities with her partner’s son, with whom she had a strained relationship. Disagreements over care decisions, particularly the choice to institutionalize her partner—ultimately made by an external guardian—exacerbated her stress and sense of isolation.

She described the daily challenges of managing her partner’s deteriorating condition, compounded by conflicts with his son. Additionally, she was deeply dissatisfied with the chosen facility, which was located far from her home. She criticized both the quality of care provided and the poor communication with the institution’s staff:

I have a two-hour journey to see him, [.] I have asked several times to see the doctor, and it’s impossible [.] I always leave with a knot in my stomach.

Mrs. O. expressed profound psychological distress, feeling unsupported and unheard in the care process.

Qualitative Assessment

The pre and post program interviews were used for the trajectories analysis and they aimed to explore caregivers’ personal experiences, emotional responses, and sources of stress, as well as to assess their expectations and perceived changes before and after the intervention. All interviews were audio-recorded and transcribed into verbatim. Transcripts were independently coded by two researchers (HL and ASR) and analyzed following Braun and Clarke’s thematic analysis approach.²⁶

Ethical Approval and Informed Consent

This study received approval from the National Ethical Committee (Comité de Protection des Personnes Est II, Ref. No. SI: 22.00264.000072 / National No.: 2021-A00553-38). The national clinical trial number is ID: NCT05651555. Institutional approval was not required to publish the case details. Participants read and signed the consent form for the study and for the publication of their case descriptions. They were informed that the descriptions would remain anonymous.

Results

The three FC attended all seven sessions and were evaluated one week after the seventh session.

Qualitative Results: Post-Intervention Interviews

Case 1

After the intervention, Mrs. K. reported significant emotional relief:

Now, I feel like I’ve made progress. I’ve put myself more in her shoes, and I feel a little less… helpless.

She came to understand that institutionalization was inevitable, a realization made easier by a greater understanding and acceptance of the illness:

This acceptance of her fragility […] makes entering an institution more acceptable—yes, inevitable.

Her previously strained relationship with her mother had improved:

We walk together, there’s interaction. […] You can feel it.

Shared moments became more meaningful, even in small gestures like observing the sky together:

I took a photo, showed it to her, […] she was happy, and so was I.

Regarding emotional regulation, Mrs. K. learned to adjust her approach:

Patients are like sponges […] I think my voice is softer now.

She became more focused on the present, acknowledged her mother’s remaining abilities, and placed greater value on their time together:

We’re not going to focus on what’s lost; we’re going to focus on what remains.

Her sense of isolation also diminished through collective support. Conversations with other caregivers helped her feel less alone and gain perspective:

The discussions helped me feel less isolated.

Through the intervention, Mrs. K. was able to alleviate her psychological distress, strengthen her bond with her mother, and develop a more peaceful and constructive outlook on the situation.

Ms. K’s emotional relief allowed her to change her perspective on her mother’s reality (acceptance of the progression of the disease and its consequences on her autonomy). This made institutionalization the most appropriate solution for their situation and resulted in a decrease in depression scores.

Case 2

After the intervention, Mr. B.’s perspective and attitude evolved with each session. He highlighted his growing acceptance of a partnership between himself, the institution, and his wife:

I’m increasingly able to convince myself of what you said—that before, it was just the two of us, but now it’s three: her, me, and the institution.

He learned to temper his expectations and adopt a more balanced perspective, recognizing that care may not always be perfect:

The problem is that I’m the one making demands… I think I should tone them down.

Mr. B. found comfort in his regular visits to the institution, a routine that brought him peace, despite recommendations from others to take more distance:

I’m happy to be here; it does me good.

He believed that this new arrangement created a calmer environment for both himself and his wife:

Thanks to the institution, everything is much calmer for everyone.

Through the intervention, he learned to appreciate the joyful moments he shared with his wife, particularly realizing that her laughter had become her primary way of communicating:

She laughs all the time. Let’s enjoy these moments; they’re good moments.

Discussions with other caregivers also helped him understand that he was not alone in facing these challenges:

The fact that there were several of us in the program made me realize this is a somewhat common issue.

One session, focused on end-of-life considerations, had a profound impact on Mr. B., prompting him to reflect on advance directives—a topic he had long avoided:

Before, it made me laugh. Now, I realize my partner hasn’t formulated any advance directives.

This realization encouraged him to approach these discussions more proactively.

The intervention helped him gain a deeper understanding of the institutionalization process, strengthen his relationship with his wife, and develop a more balanced approach toward the institution’s staff. By adjusting his expectations and focusing on the present, he found a new sense of harmony in an otherwise difficult reality.

Case 3

After the intervention, Mrs. O. showed only slight improvement in her psychological state. However, her dissatisfaction with the quality of care provided by professionals remained unchanged. Suggestions from the team or other family caregivers during the sessions were consistently dismissed, and any attempt at negotiation proved impossible. For her, expressing her suffering remained the only way to demonstrate her unwavering commitment to her partner.

Faced with this impasse, the psychologist (SD) asked her what could bring her relief, to which she responded:

Who told you I wanted relief?

Mrs. O. acknowledged that her approach to caregiving was not the most peaceful, but she attributed it to her unique situation, her age, and her small family network.

While she recognized the value of the program, she ultimately felt that it did not fully address her specific circumstances.

Discussion

The value of the psychoeducational program in this study lay in its dual structure: individual interviews tailored to address each caregiver’s specific needs and concerns, and group workshops designed to provide knowledge, coping strategies, and emotional support. In addition, the opportunity to interact not only with professionals but also with peers fostered a safe space for open expression, which proved beneficial for family caregivers.¹⁹ The three clinical cases highlighted common challenges, including a lack of understanding of the illness, feelings of guilt, difficulties in delegating and adapting, and communication issues.^{14,17,18,20,27} The intervention addressed these factors by promoting a better understanding of the illness, facilitating acceptance of institutionalization, and improving relational dynamics, ultimately influencing each FC’s response. After completing the program, the three participants experienced distinct trajectories, as discussed in the following sections.

The Cases of Mrs. K and Mr. B: Evidence of Positive Outcomes Following the Psychoeducational Intervention

Mrs. K reported a positive impact from the program. Gaining a deeper understanding of the illness helped her recognize that her mother’s behaviors were caused by the disease rather than personal intent. This shift reduced her resentment, increased her empathy, and ultimately facilitated acceptance of institutionalization while strengthening their relationship. Similarly, Mr. B gained a better understanding of the institution’s functioning and came to see the staff as caregiving partners.⁸ This perspective reduced his stress and helped him accept the transition to institutional care.

For these two cases – Mrs. K and Mr B –, the psychoeducational program initiated a progressive process for FC, leading to several key benefits:

1. Reducing Psychological Distress: The intervention’s most immediate benefit was alleviating psychological distress among FCs. A better understanding of the illness allowed caregivers to take a step back, accept cognitive decline, and recognize behavioral symptoms as part of the disease rather than personal failings.^20,26–29 This shift helped them break free from a cycle of guilt and suffering, initiating emotional healing—a crucial first step toward more effective coping.
2. Accepting Institutionalization: With a clearer understanding of the illness, caregivers were better able to accept institutionalization, no longer seeing it as a failure but rather as a necessary and appropriate solution. This acceptance fostered a more collaborative and harmonious relationship with healthcare professionals.^15,30
3. Improving Caregiver-Patient Relationships: Reduced psychological distress led to more empathetic and harmonious interactions, ultimately improving the quality of life for both caregivers and their loved ones.²⁷
4. Valuing Positive Moments: As FC progressed through the program, they learned to transform daily interactions with their loved ones into meaningful experiences.³¹ Mrs. K, for instance, began appreciating simple moments with her mother that she had previously perceived as insignificant or frustrating. Similarly, Mr. B redefined his visits to the institution as opportunities for comfort and connection. This ability to recognize and cherish shared moments strengthened their emotional resilience.³²

The Case of Mrs. O: Revealing the Limits of the Psychoeducational Intervention

The case of Mrs. O. highlights the limitations of psychoeducational interventions. For some caregivers, such programs are insufficient to address deeply entrenched relational dynamics marked by pain and conflict. Mrs. O., for instance, appeared trapped in a cycle of suffering, in which her role as a home-based caregiver had become a core component of her identity. Several factors might have contributed to this, including overwhelming guilt, anticipatory grief, and a rigid perception of her caregiving role. The psychological vulnerability of spouses—particularly wives—whose partners have been institutionalized has been well documented in the literature.^20,26,29 Furthermore, the absence of familial support has been recognized as an additional source of stress for caregivers.²⁶

Mrs. O.’s experience illustrates that some caregivers require a complementary approach—one that considers the deep emotional dynamics and the specific nature of the caregiver–care recipient relationship. A combined approach, integrating psychoeducation with one-to-one counselling or family therapy, might have supported Mrs. O. in developing greater psychological flexibility.³³

This clinical case also underscores the importance of the initial assessment interview. To enhance the effectiveness of future psychoeducational programs, initial evaluations should include an in-depth analysis not only of caregivers’ diverse needs—shaped by their personal circumstances and relationship with the care recipient—but also of their psychological distress and readiness for change.³⁴ A preliminary psychological assessment could help tailor interventions more effectively, particularly by identifying those caregivers who would benefit from individualized support, including therapy sessions adapted to their specific needs.

A key strength of this in-depth analysis of the evolving challenges faced by three family caregivers—each representing a distinct trajectory during the pilot implementation of the psychoeducational program—was its potential to inform improvements in caregiver support. In particular, it highlighted the importance of the initial psychological interview, which could help identify caregivers with heightened psychological vulnerability and offer them additional psychological support.

Limitations

The findings of this case study are subject to several limitations. The small sample size of three clinical cases limits the generalizability of the results and does not fully capture the diverse needs of caregivers. Additionally, cultural factors influencing caregiving perceptions were not explored. Other limitations are the lack of long-term evaluation to assess the sustainability of the intervention’s impact over time and the reliance on self-reported outcomes. These limitations highlight the need for a larger trial using both quantitative and qualitative measures – which is currently ongoing– to validate the intervention’s effectiveness.

Conclusion

In this pilot implementation study, we introduced a novel psycho-educational intervention for family caregivers (FCs) of persons with dementia during the transition from home to long-term care. Three illustrative cases were analysed to delineate the principal impact trajectories. Two FCs—Mrs K and Mr B—exhibited marked benefits, including reduced self-reported psychological distress, greater cognitive and emotional acceptance of institutionalisation, adoption of more adaptive interaction strategies, and reinforcement of affective bonds with the institutionalised relative. These findings indicate that the intervention can facilitate emotional adjustment and help caregivers recalibrate relational dynamics during placement. By contrast, the third FC—Mrs O—showed limited gains, highlighting the programme’s constraints when confronted with complex pre-existing family tensions. This case underscores the need for a more flexible, individualised framework—such as optional one-to-one counselling or family therapy modules—to adequately address heterogeneous caregiver needs.

Acknowledgments

We extend our gratitude to the family caregivers, the professional participants of the nursing home program, and the healthcare professionals of the nursing homes who contributed to this work.

Funding

This work received funding from the French National Old-Age Insurance Fund (Caisse nationale d’assurance vieillesse, CNAV) and the Île-de-France Regional Health Agency (Agence régionale de santé Île-de-France, ARS IDF).

Disclosure

The authors report no conflicts of interest in this work.

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This musical comedy about billionaire tech gurus Steve Jobs (Kane Oliver Parry) and Bill Gates (Dan Buckley) is, in all likelihood, not going to enlighten you about the making of these Silicon Valley founders.

A young Gates (of Microsoft) meets Jobs (of Apple and iPhones) at a Homebrew Computer Club competition in the 1970s. Jobs wins it and from hereon the rivalry is on – or that is how this production spins it.

Capturing the vaguest approximation of the relationship between the men, there is little fidelity to fact, or nuance, or penetrating psychological unpicking. But it is a highly entertaining, well put together parody all the same, however cartoonish in its portrayal of the two central players. It takes swipes at technology (from old-school cameras to printers and the limited life of Apple products) and the nerdy megalomania of tech culture itself.

Under the direction of Nick Winston, characters resemble the geeks from TV series The IT Crowd. To a lesser degree, it is about self-acceptance from those deemed oddballs by their school bullies, mainly through the character of Gates. Jobs is, by contrast, a visionary hippy and self-serving ladies’ man whose charisma Gates envies. Both are ridiculed and brilliantly performed.

Writer-lyricists Jordan Allen-Dutton and Erik Weiner give the show a high school style makeover while Hal Goldberg’s score brings easy, fun tunes. There are romances for the men in Sally (Elise Zavou), a Xerox researcher with a social conscience, and fellow nerd Myrtle (Teleri Hughes) for Gates. Their real-life love lives, and wives, are nowhere to be found.

Real life is ignored or smoothed over on the whole: there is a legal battle, which follows some facts around Apple’s suing of Microsoft in 1988, and it ends in an out-of-court settlement, but without really telling us how or why. But it includes a thoroughly amusing rap battle between Gates and Jobs – a highlight of the show – which leads to the sudden transformation of Gates from an insecure tyrant into a fairy godfather of sorts. He steps away from Microsoft willingly here and devotes himself to his charitable foundation. Jobs’ death from cancer is ignored, too, although there is a – very funny – song in which he writes an email to God (with lots of ccs) because he thinks he is dying.

While it fails in its factual history, this is a compelling parody of the tech age, then and now, with heaps of the fun factor.

At Cowbarn at Underbelly, Bristo Square, Edinburgh, until 25 August

Expectations are raised high, but not satisfyingly met, in this initially intriguing and certainly atmospheric Scandi thriller that ranges from Sweden to Poland and Exmoor in England; it teases hints of Gone Girl and Patricia Highsmith. Screenwriter-producer Michèle Marshall has adapted 2014 novel The Living and the Dead in Winsford by veteran Swedish crime writer Håkan Nesser, and Caroline Ingvarsson makes her feature directing debut.

The scene is the stylish home of a Swedish power couple. Maria (Mirja Turestedt) is the presenter of an popular TV talkshow, and she is married to the older Magnus (Thomas W Gabrielsson), a star academic with a drinking problem and a seedy reputation for infidelity. Maria is a former student of Magnus and has, in fact, surpassed him intellectually, now faintly despising herself for her middlebrow job as well as for editing and almost secretly co-writing papers for Magnus, who grumpily relies on her help. But Maria despises herself still more for standing by Magnus despite a rape charge against him. With an ugly, boorish defiance, Magnus intends to brazen it out legally and claim consent; in her heart, Maria does not believe him.

Things come to a crisis when the couple are driving through Poland after visiting an old friend of his, quarrelling constantly. They stop to look at an abandoned military bunker and things take a terrible turn. A series of flashbacks and a final, tense conversation with a police inspector are to disclose most (but, bafflingly, not quite all) of what is supposed to have happened. The audience are perhaps entitled to ask what precisely went on in the bunker, given that a final moment-by-moment revelation does seem to be implicitly promised; there are odd plot points that have been telescoped and garbled, possibly lost in the edit. Disappointing overall, but a strong performance from Turestedt.