TRANSMURAL FAMILY GUIDANCEwhat is the difference with OPEN DIALOGUE?2nd International Conference on Dialogical Practices Margreet de Pater Truus van den Brink Leuven, 8-3-2013
The changing mental health system in the Netherlands in 1993!! There has been many contradictory changes since then!!• The government wanted multifunctional units, where continuity of care during hospitalization was possible• The managers wanted large facilities• The government subsidized new forms of care and discouraged old ones• Family movement was strong• Some workers in the mental health system also wanted change
Conclusions conferences continuity of care • Rehabilitation has to start early in treatment• More possibilities than hospitalization or outpatient clinic alone, there must be a range of facilities• Help must start early• Must be an answer to what a patient and family and friends ask• Must also be practical• The process of dialogue was the most important
Writing a program of care• 1996 Somewhere in the organization we in Zeist were told to write a program• We involved patients, colleagues, families, referring colleagues through conferences• We finished it in 1997• Then we had to do it again together with a whole bunch of people from al kind of parties• The finishing touch was gender friendly• The board of directors approved in 2001
The essentials of the program• There must be a stable team of – The patient – The family – A case manager – A psychiatristThroughout the mental health system
• The case manager is a fellow traveler• All parties are helping each other and have a dialogue – Systemic crisis intervention – Family work – Crisis plan• When this is not enough patient is not referred but help from other facilities is added• When there is enough safety patient can – Take part in a group where information is given and experience shared – Learn to cope in a Lieberman group – Learn to cope with his experiences in cognitive behavior therapy – Rehabilitate himself
So this multi functional unit offering Transmural Family Guidance resembles the Finnish model•Need-adapted treatment given by the same team•Working with families from the very first start in opendialogue, every voice is heard•An outreaching team•The possibility to add intensive home treatment bythe IHT-team, visits twice a day were possible•Care conferences (not within 24 hours)
What were the differences with the Finnish circumstances?• We had to work in the shadow of a large university facility• Which was biologically oriented• Had a high status• Nearly all patients with a first psychosis started there• Longer admissions
The nature of the family work The Transmural Family Guidance• Theory: there is a circular relationship between psychosis, development of the person and family reactions• Labeled as possibly adolescent development crisis• Organization: starts from the very first crisis• Content: starts as family psycho-education.• Setting limits to overwhelming psychotic behavior• Then problem solving and promoting autonomy of the psychotic person• No intensive family story taking• Family talks about their problems during this process
Sources• Jay Haley, leaving home• Family crisis intervention from Frank Pittmann III [RCT in the sixties!!! Controls: hospital admissions]: helping family and patient to do the right thing [flooding]. Please don’t act crazy, it does confuse me, you may only act crazy in your own bedroom• Family psycho-education of Julian Leff: teaching and doing, instead of interviewing
Differences with open dialogueOpen dialogue Trans mural family guidance• Mindful be with the family • Assist family to set limits• Listening carefully • Educational• The theme of the psychosis • More on family structure refers to the nature of the • Promoting clear family difficulty communication• The dialogue flows • Open conflicts without good• When family can speak of the or bad theme of psychosis then • When family hierarchy is there is a better prognosis restored we expect better prognosis
SimilaritiesOpen dialogue Transmural family guidance• Staying with the family • Staying with the family• No family member is allowed • Patient is not allowed to to terrorize others terrorize• Speaking about themes of • Family is open about family family/psychosis life during process• In context of needadapted • In context of continuity of treatment care of MFE
Qualitative research• 46 patients and family members (37 TMG).• What is the process was only one of the questions
Outcome• There was a balance between wishes of the patient and the families• Sometimes more distance but to our surprise often more closeness• Patients took more responsibility [accepting their vulnerability] and parents accepted this• Family contact only in crisis• Sometimes patients could talk about the theme of psychosis• However, cognitive deficits remained
Vignet 1• Moroccan guy: thinks he is possessed by Jesus and Maria• Family was strict Islamic, but school was Christian, father tried to convince schoolleader about praying but didn’t succeed• After family intervention he can tell his father that he missed his influence very much in school
Vignet 2• Young guy was psychotic after caraccident• But before that the light in his eyes disappeared• Was very suicidal during psychosis• Tells his parents he was sexual abused by older women
It would be veryinteresting to comparethis two ways of family work
Howeverthe biggest problem in the Netherlands is thecomplex system of care promoted by a thick layer of managers
“New” developments• RIAGG Amersfoort & Omstreken, Regional Institute for Community Mental Health• No (day)clinic, ambulatory care only, outpatient clinic or outreachend, crisis intervention team, treatment teams• November 2012: Intensieve Home Treatment• 2013: Care program psychotic and bipolar disorders to be written and implemented
Intensive Home Treatment• Goal: prevent hospital admission or facilitate early discharge from an acute ward.• IHT means (twice) daily home visits by a multi- disciplinary team of mental health professionals.• Treatment consists of medication, counseling, practical help and support for relatives.• Family involvement is an absolute condition: dialogue!• The team is available 24 hours a day, during a limited period of 6 weeks.• IHT continues until the crisis has resolved and the patient is transferred to further care.
Care Program Psychotic and Bipolar Disorders• Though different syndromes, shared needs of care• First episodes and long lasting treatment• Open dialogues with patients and their families: we have the same goal, different knowledge and responsibilities• Should we choose the Open Dialogue or Transmural Family Guidance? The Finnish or Zeister approach?
And there are more new opportunities! Everywhere in the country are mobile first psychosis teams
But they have notdiscovered family work yet So there is work to do!
Suggestions ?• Why is familywork, which is evidence based, not used everywhere?• How to implement familywork with open/transmural dialogue in more teams?• What should we do in Amersfoort?