transmural family guidance open dialogue? transmural family guidance what is the difference with...
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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
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?
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?