TRANSMURAL FAMILY GUIDANCE what is the difference with open dialogue?

1. TRANSMURALFAMILY GUIDANCEwhat is the difference with open dialogue? 2nd International Conference on Dialogical Practices Margreet de Pater Truus van den Brink Leuven, 8-3-2013

2. 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

3. 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

5. 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

6. 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

7. The case manager is a fellow traveler • All parties are helping each otherand 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

8. 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)

9. 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

10. The nature of the family workThe 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

11. 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

12. Differences with open dialogue Open dialogue 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 • 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

13. Similarities Open dialogue Transmuralfamily 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 • Staying with the family • No family member is allowed to terrorize others • Speaking about themes of family/psychosis • In context of needadapted treatment

16. Qualitative research 46 patients and family members (37 TMG). What is the process was only one of the questions

17. 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

18. 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

19. Vignet 2 Young guy was psychoticaftercaraccident Butbefore that the light in hiseyesdisappeared Was verysuicidalduringpsychosis Tellshisparentshe was sexualabusedbyolderwomen

20. It would be very interesting to compare this two ways of family work

21. Howeverthe biggest problem in the Netherlands is the complex system of care promoted by a thick layer of managers

22. “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

23. 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.

24. 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?

25. And there are more new opportunities! Everywhere in the country are mobile first psychosis teams

26. But they have not discovered family work yet So there is work to do!

27. Suggestions ? Why is familywork, which is evidencebased, notusedeverywhere? How toimplementfamilyworkwith open/transmuraldialoguein more teams? Whatshould we do in Amersfoort?

28. Thank you for your attention