TRANSMURALFAMILY GUIDANCEwhat is the difference with

OPEN DIALOGUE?

2nd International Conference on Dialogical

PracticesMargreet de Pater

Truus van den BrinkLeuven, 8-3-2013

The changing mental health system in the

Netherlandsin 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 conferencescontinuity of care [1993]

• 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 psychiatrist

Throughout 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 open dialogue, every voice is heard•An outreaching team•The possibility to add intensive home treatment by the 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 dialogue

Open dialogue• Mindful be with the

family• Listening carefully• The theme of the

psychosis refers to the nature of the family difficulty

• The dialogue flows• When family can

speak of the theme of psychosis then there is a better prognosis

Trans mural family guidance• Assist family to set

limits• Educational• More on family

structure• Promoting clear

communication• Open conflicts without

good or bad• When family

hierarchy is restored we expect better prognosis

Similarities

Open dialogue• Staying with the

family• No family member is

allowed to terrorize others

• Speaking about themes of family/psychosis

• In context of needadapted treatment

Transmural family guidance• Staying with the

family• Patient is not allowed

to terrorize• Family is open about

family life during process

• In context of continuity of 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 very interesting to

compare this two ways of family work

Howeverthe biggest

problem in the Netherlands is the complex 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 not discovered 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 dialoguein more teams?

• What should we do in Amersfoort?

Thank you for your attention