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

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transmural family guidance what is the difference with open dialogue

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

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 conferences continuity of care 1993
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
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
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 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
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
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 t ransmural family guidance
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

s ources
  • 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
Differences with open dialogue

Open dialogue

Trans mural family guidance

Assist family to set limits


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

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
qualitative research
Qualitative research

46 patients and family members (37 TMG).

What is the process was only one of the questions

  • 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
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
Vignet 2

Young guy was psychoticaftercaraccident

Butbefore that the light in hiseyesdisappeared

Was verysuicidalduringpsychosis

Tellshisparentshe was sexualabusedbyolderwomen

however the biggest problem in the netherlands is the complex system of care

Howeverthe biggest problem in the Netherlands is the complex system of care

promoted by

a thick layer of managers

new developments
“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
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
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

And there are more new opportunities!

Everywhere in the country

are mobile first psychosis teams

Suggestions ?

Why is familywork, which is evidencebased, notusedeverywhere?

How toimplementfamilyworkwith open/transmuraldialoguein more teams?

Whatshould we do in Amersfoort?