Family Communication in Long-Term Care: Why Recognition Beats Presence Alone

So many human wounds stem from a simple yet profound absence: the expectation of a relationship that truly meets us. Even when one is surrounded by other people—living within a care-home, attended by caregivers, participating in scheduled activities—the deeper longing for connection can persist unfulfilled. This tension was laid bare during the COVID-19 pandemic: many long-term-care facilities imposed sweeping visitor restrictions to protect older residents. In doing so they arguably safeguarded physical health, but at the same time heightened relational isolation for residents and their families.

In England alone, between the week ending 20 March 2020 and the week ending 21 January 2022, 16.7 % of all care-home resident deaths were attributed to COVID-19. Visitor policies during this time were radically altered. A qualitative study of six care homes found that distancing, isolation and other restrictions not only affected residents’ physical health but also deprived them of physical touch, non-verbal cues and familiar rhythms of family life. Another relevant review found that among older patients, effective communication with caregivers improved satisfaction, emotional well-being and other patient-centred outcomes — yet these opportunities were severely constrained during lockdown. 

This reveals a striking paradox: A resident of a nursing home may receive attentive care, share space with fellow residents and benefit from rich programmes of animation, and yet still remain in waiting… waiting for the familiar voice of their child, the handshake of a grand-child, the comfortable unspoken communication that only family can bring. Institutional presence does not always satisfy relational expectation. The human relational model goes beyond mere supervision: it calls for familiarity, shared history, recognition, emotional reciprocity. When that dimension of “belonging, seen-by-family” is weakened—by distance, by policy, by digital substitution—the gap remains. And that gap carries measurable consequences.

Isolation and loss of familial contact have been shown to correlate with increased loneliness, depression, cognitive decline and even elevated mortality among older adults. For example, a systematic review found loneliness significantly accelerates the transition into long-term residential care by a median of nine months for those with the highest needs. In this light, communication between families, residents and care facilities is not simply a convenience or “nice-to-have” but a core component of quality of life. Yet too often in the digital transformation of aged care, relational strategy is treated as an afterthought.

This is why today addressing the subject of “family communication in long-term residential care” is not a luxury but a necessity. It is time to explore how family expectations — around information, inclusion, link, voice — shape the resident’s perception of their living environment; how those expectations influence relational satisfaction, staff-family trust, and ultimately the legitimacy of digital or organisational initiatives to modernise care. Technology, digital platforms, structured activity programmes—they all matter. But if they are not integrated into a culture of communication that honours family ties and relational depth, the relational vacuum remains.

We must begin to treat family-resident relationships not as an optional extension of care, but as a pillar of the communication strategy of any residential care institution. Because at the end of the day, what residents seek is not just to be “seen” or “taken care of” — they want to be connected, recognized, included in the relational whole: to their history, to their loved ones, to a sense of belonging. And it is this often silent but potent expectation that institutions must learn to respect and integrate.

Communication as a Pillar of Psycho-Emotional Well-Being

Communication is never just the transfer of information. At its core, it is the exchange of presence. Human beings need to feel recognized in what they experience emotionally — not only heard, but understood. This is why communication is both verbal and affective: words carry meaning, but tone, gesture, silence and attention carry belonging.

Psychologists describe this as an intrinsic expectation of connection. From infancy, we are shaped by how others respond to our emotions. Before we speak, we communicate through looks, smiles, cries, and proximity. Caregiver responsiveness is the foundation of psychological security, as emphasized by attachment theorists such as Bowlby and Winnicott. Throughout life, this expectation persists: we long for someone who sees how we feel, not only what we say.

Authentic communication — one that integrates words and emotions — becomes a source of stability. It allows individuals to express needs, fears and hopes without fear of rejection. In older adulthood, this relational security takes on an even stronger significance. With aging can come loss: of mobility, of autonomy, of familiar reference points. Communication is then one of the last channels through which identity is affirmed: I still matter, and someone cares to know me.

Family relationships play a central role in this. A family is more than a group of people: it is a shared system of interpretation. Each family develops its own micro-language — small cues, routines, meanings that outsiders often miss. A raised eyebrow, a short “I’m fine”, a half-smile can reveal far more to a loved one than a full medical report. When families communicate, they are not only exchanging information; they are maintaining a shared history.

Culture also shapes how individuals expect to be treated and acknowledged. In some societies, older adults are seen as custodians of memory and social harmony. In others, independence and productivity are primary values, so dependency may be experienced as a threat to dignity. The same act — moving into a nursing home — does not carry the same emotional meaning across cultural contexts. This influences how communication with families should be designed: what comfort looks like, what transparency means, what “being included” requires.

Even in residential care, psychological needs remain active and powerful: the need for reassurance, recognition, closeness, and emotional reciprocity. Activities and good care practices can support well-being, but they cannot replace the familiar relational signs built over decades inside the family circle. Without them, a resident may be physically well yet emotionally unrooted.

To communicate with an older adult, then, is to honour not only the person as an individual, but also the relationships that define who they are. Effective communication in aged care does not merely “keep families informed” — it preserves identity, belonging, and dignity. It reassures residents that they remain part of a living relational story: you still belong with us — and we still see who you are.

The Paradox of Residential Care: Presence Without Recognition

Residential aged-care facilities are designed to protect, support, and care for vulnerable individuals. Professionals in these environments often believe — sincerely and with dedication — that by offering safety, medical attention, and structured activities, they are fully responding to residents’ essential needs. Yet 34% of adults aged 50 to 80 report feeling isolated “sometimes or often” despite living among others. Being surrounded by people does not guarantee being seen.

Healthcare culture can fall into what might be called professional benevolence — the assumption that goodwill and clinical competence are enough to sustain emotional well-being. However, research shows that social isolation increases the risk of premature death by 29% and dementia by 40%. Even care environments with regular human contact can leave emotional needs unmet when the connection lacks personal recognition.

Older adults need more than assistance and company: they need an individualizing gaze, the lived sense that “I matter to someone, as a unique subject.” Lacan reminds us that the subject cannot see itself merely through thought; it becomes visible through the gaze of the Other. Edith Stein similarly argues that the self only fully emerges when it is received by another consciousness. When this relational mirror is missing — even in communities — the sense of self erodes.

Globally, the World Health Organization estimates that one in six people experience significant social isolation or loneliness. Among older adults, loneliness is a driving factor in transitions to long-term care — accelerating dependency and institutionalization by up to nine months. These numbers underscore a crucial truth: without authentic relational communication, collective care can become a collective solitude.

To care well, then, is not merely to provide services but to enter into an ongoing dialogue between subjects — a reciprocal recognition where each resident feels encountered rather than simply managed.

The Paradox of Long-Term Care: Surrounded, Yet Unseen

Long-term care facilities are designed to protect and support vulnerable older adults. Many professionals — sincerely and with dedication — believe that by ensuring safety, medical care and structured social life, they are fulfilling residents’ essential human needs. But the data reveal a striking paradox: being surrounded by people does not guarantee being recognized as a person. In the United States, 34% of adults aged 50–80 report feeling isolated “sometimes or often”, despite living in sociable environments. In North America, researchers have identified the highest global prevalence of loneliness (≈ 30.5%), and this emotional burden peaks among institutionalized older individuals (≈ 50.7%). In Europe, loneliness affects roughly one in four seniors (≈ 27%), while nearly 20% of people aged 65+ live alone — already a major driver of vulnerability when entering residential care.

Inside nursing homes, this emotional reality becomes even clearer: around 40% of residents report feeling lonely, and more than one in five experience high loneliness, directly harming their quality of life. And although many residents in France still receive visits from family, the subjective feeling of being emotionally overlooked persists — a reminder that physical presence is not enough.

These emotional ruptures have measurable health consequences. Social isolation significantly increases the risk of premature mortality and cognitive decline, including dementia. Even more critically, loneliness has been shown to accelerate admission into residential care by approximately nine months among the most isolated older adults. In other words: the lack of relational recognition does not only affect well-being — it shapes the entire trajectory of aging.

This gap reveals what could be called a form of professional benevolence illusion: the belief that kindness and efficiency alone can fulfil the resident’s emotional world. Yet, as Lacan argues, the subject cannot see themselves through thought alone; they become visible through the gaze of the Other. And as Edith Stein affirms, the self only fully exists when it is received by another consciousness. Without this personal confirmation — without someone who says, even silently, “you matter to me” — collective care risks turning into collective solitude.

Thus, older adults do not demand attention out of caprice. They seek a reciprocal dialogue between subjects — a presence that withstands frailty and affirms identity. True care is not only assistance, but recognition: an encounter where every resident is treated not merely as someone to look after, but as someone worth looking at.

From Function to Fragility: How Dependent Identity Becomes Socially Isolated

Human beings are not merely isolated subjects; they are embedded in webs of relation, role, and mutual expectation. From early childhood onward, individuals develop not only competencies but social roles—child, student, professional, spouse—through which they confirm their value. Social psychologists and developmental theorists such as Jean Piaget show that our cognitive and relational schemas are formed via assimilation and accommodation: we adapt to the world and at the same time transform our templates through interaction. Over a lifetime, this relational scaffolding supports a sense of dignity and belonging.

Yet when age, illness or dependency erodes the capacity to contribute, that scaffolding falters. The German philosopher Axel Honneth argues in The Struggle for Recognition that identity is sustained through three interrelated spheres of recognition: love (emotional affection), rights (legal respect) and achievement (social esteem). When a person moves into a setting where their function as family member, worker or contributor is diminished, the third sphere—esteem—weakens. Their story of “who I am in relation to others” shifts, often toward passive reception: I am cared for rather than I care, I am assisted rather than I assist.

Honneth emphasizes that recognition is “a social requirement of self-confidence, self-respect and self-esteem”. In the context of long-term care, this means that when a resident perceives that their voice matters less, their choices are fewer, and their historical role is no longer referenced, the self-relation suffers. The literature shows that among older adults entering residential care, a sense of usefulness plummets and the risk of emotional decline rises. While specific datasets differ, one survey in the US found that 71% of older adults stated they were unlikely to live in a nursing home—a statistic that reflects not only preference but fear of identity loss.

In losing their social role, individuals encounter what the anthropologist Marcel Mauss described as the “exchange of selves”—that in giving we maintain our place in the world. When someone is no longer expected to give, no longer counted on, they confront the existential question: Who am I still? The transformation from actor to object is more than semantic; it is ontological. As Honneth argues, social pathologies such as reification or disrespect are fundamentally about the way subjects are treated as objects, as “things” rather than persons.

This shift marks the beginning of social isolation, not merely physical but relational. It is not about having fewer visitors or activities; it is about the absence of being needed, of being awaited. Studies suggest that residents in institutional care suffer loneliness at rates up to two or three times higher than community-dwelling older adults. This elevated loneliness, in turn, is strongly associated with depression, cognitive decline, and even premature mortality.

If we accept Honneth’s insight that recognition is a necessary condition for the good life, then institutional care models must not only provide safety or activity but preserve and rebuild social esteem. They must ask: how is this person still contributing, still seen, still valued? Without that question, we risk substituting care for relationship, presence for participation. And in that substitution, dignity fades.

In short: to prevent the slide from valued actor to invisible object, long-term care must move from management of dependency to cultivation of recognition. The challenge is not simply medical or organizational—but deeply human: to ensure that each resident continues to stand in a world where others desire them, expect them, and recognise them.

From Social Role to Dependence: The Hidden Erosion of Identity in Aged Care

Human beings are not merely isolated individuals; they are embedded in networks of relationships, roles and mutual expectations. From early childhood onward, people acquire not only skills but social positions — child, student, worker, caregiver — each of which contributes to their sense of being someone in the world. We receive our identity through our participation in the family, community and society, and in return we are recognized by others as actors in a shared reality.

As age advance­s, illness deepens or dependency increases, the roles that once anchored identity begin to fade. The German social philosopher Axel Honneth argues in The Struggle for Recognition that individuals need three forms of recognition to sustain self-confidence, self-respect and social esteem: emotional affirmation, legal respect, and social achievement. When older adults enter care settings and find that their capacity for social contribution diminishes, the sphere of esteem weakens and with it the storyline of “who I am in relation to others”. Recognition no longer comes through what they do, but increasingly through what they receive. This shift from agent to object, from contributor to beneficiary, often marks the beginning of a slow slide toward social isolation. Surveys show that as much as 71 % of older adults in the United States express reluctance or fear at the idea of moving into a nursing home — a figure which speaks not only to practical concerns, but to the dread of losing social identity.

The anthropologist Marcel Mauss once described the person as constituted by the “exchange of selves”—that is, by what we give and receive in relationships. When someone is no longer expected to give — no longer needed by others in meaningful ways — it is not merely their utility but their very personhood that falters. Compounding this, the psychologist Jean Piaget explained how individuals build schemas to interpret reality: assimilation allows the world to enter our pre-existing categories, and accommodation allows those categories to adapt when the world resists. But dependency resists the schema of the independent social actor, and for many older individuals the accommodation is painful—or fails altogether.

In professional care settings, a further dimension arises: many practitioners arrive with profound personal histories of family neglect or abuse. Studies indicate that as many as 68 % of health-care workers report adverse childhood experiences (ACEs) such as abuse or neglect before the age of 13. Among them, psychological distress is significantly higher. The psychoanalytic concept of transference, introduced by Sigmund Freud, explains how emotions or desires rooted in early life are displaced onto current relationships. A caregiver who once sought recognition from absent or unreliable parents may now look to a resident to receive what was never given. The care relationship becomes both a professional commitment and an unconscious effort at personal repair.

These intertwined dynamics produce what might be called relational absence: the older resident may be physically among others, but existentially alone. Data show residents in long-term care report loneliness at rates up to 40 % or higher, and isolation is associated with accelerated cognitive decline, depression and higher mortality. Without reconstruction of social roles and relational significance, institutional care can, paradoxically, become a place of solitude. To prevent this, organizations must shift from managing dependency to cultivating recognition—ensuring that older adults remain subjects of relationship, not mere objects of care.

Transference and the Non-Encounter of the Other

As long as our relationships are structured by transference, the possibility of truly encountering the other in their ontological reality remains blocked. For Lacan, the subject is constituted not by direct self-possession, but through the “gaze of the Other” — a gaze which the subject can never fully master, for it reveals the subject as object. When one interacts with another person not as a fellow subject, but as a projection of one’s own unresolved desires, the other becomes a screen, a mirror for the prior self-experience and not a self-existing I-thou relation. In such a dynamic, the older adult may be physically surrounded, yet existentially solitary: they are treated not as a “subject who is loved for themselves,” but as an object of the other’s psychic economy.

Edith Stein helps clarify this from a phenomenological standpoint: she writes that empathy is the mode by which one perceives another as “in a state” — an experience of the other’s subjectivity — rather than simply attributing mental states to them. Without this empathic recognition — without the other truly receiving me in my being — the relational field becomes impoverished. The person in care experiences a non-recognition: not so much the lack of social contact, but the lack of being seen as a subject in one’s own right.

And the statistics reflect this silent wound: a recent meta-analysis estimated that in nursing homes, approximately 61% of residents experience moderate loneliness and about 35% suffer from severe loneliness. This is significantly higher than community populations, indicating that mere proximity, even professional care, does not compensate for the absence of subject-to-subject recognition. The subject in care is thus trapped: still present in body yet relationally absent in being.

The Essential Role of Reflective Practice Groups: Beyond Transference to True Recognition

In care professions, the relationship is rarely neutral. Caregivers often bring their own histories into the encounter, and unconscious dynamics — particularly transference — can distort the way a resident is perceived. Sigmund Freud described transference as the displacement of emotions, desires or fears from past relationships into present ones, blurring the boundary between who the other truly is and what they symbolically represent.

To ensure that older adults are recognized as subjects, and not as projections, reflective practice groups offer a fundamental safeguard. These multidisciplinary spaces provide professionals from social care, nursing, psychology and management with an opportunity to step outside the invisible logic of transference, examine their emotions, and reinterpret the relationship with the resident from multiple viewpoints.

Recent findings show the urgency of such structures. Studies demonstrate that as many as 68% of healthcare professionals report having experienced abuse, neglect or violence before the age of 13 — a history strongly associated with increased psychological distress in their work with vulnerable populations. When unexamined, these wounds can silently shape their caregiving behaviour, leading them to seek repair through the resident rather than responding to the resident’s actual needs.

Reflective practice groups counteract this drift by creating a shared interpretive frame, where the meaning of the resident’s behaviour — and of the caregiver’s reactions — can be explored critically and ethically. Multidisciplinary reflection functions as a de-transferential process: instead of responding to a symbolic parent or child from the caregiver’s past, the team collaboratively re-anchors the resident within their true ontological identity.

The psychological stakes are high. In long-term care, loneliness affects up to 61% of residents and severe loneliness 35%, despite living surrounded by others. Part of this paradox comes from the fact that presence without recognition creates ontological isolation — being seen physically, but not acknowledged as a person with a story, agency, and inner life.

Reflective practice groups help prevent this by strengthening the ethical and clinical quality of the encounter. They support caregivers in:

• Becoming aware of their own vulnerabilities

• Tolerating the resident’s difference and otherness

• Listening to the real person, not the projected one

Beyond safety and competence, these groups work toward recognition, in the sense formulated by Axel Honneth: enabling each individual — staff and residents alike — to remain a subject within a community of subjects, not an object in the system.

Through such interdisciplinary reflection, long-term care moves from managing dependency to honouring personhood.

Conclusion — Preserving the Ontological Freedom of the Person

Ultimately, the well-being of residents in long-term care does not emerge solely from the protection and services provided around them, but from the tacit preservation of their freedoms — the freedom to see their family when they need them, to move at their own rhythm rather than the institution’s, to practice faith or attend Mass, to remain involved in community life or an association. These seemingly simple liberties sustain what could be called the resident’s ontological dynamic: their ongoing experience of being a living subject, with desires, roots, and a place in the world.

When institutions decide “what is best” on behalf of the resident, even with benevolent intentions, they risk replacing the person with a category — the dependent, the patient, the cared-for. The more decisions are taken for them, the more the resident becomes an object of care rather than a subject in relation. Yet human dignity is grounded in agency: the ability to choose, to initiate, to remain a participant in one’s own life.

A care environment that wishes to protect the person must also protect the continuity of their story. Freedom of movement, freedom of ritual, freedom of interpersonal ties — these are not optional elements or “quality of life extras”. They are the foundations of identity and the conditions of a true encounter between caregivers and residents. To care well is to ensure that the collective environment does not erase the individual horizon, that the rhythms of the institution do not silence the unique tempo of each life.

The mission of aged care is therefore not only to keep people alive, but to keep them living. A resident who can still choose, still contribute, still be recognized as someone — not merely someone cared for — remains a subject among subjects, present in their own existence and present for others. That is where well-being begins and where dignity endures.

This article is part of a broader reflection on dignity, time and engagement in long-term care settings. I support organisations in translating scientific and ethical insights into clear, responsible CSR and institutional content, adapted to highly regulated environments.