1. 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

2. 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

3. Conclusions conferences
continuity 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 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

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 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

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
• 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

13. Similarities
Open 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

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 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

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

21. However
the 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 evidence
based, not used everywhere?
• How to implement familywork with
open/transmural dialogue
in more teams?
• What should we do in Amersfoort?

28. Thank you for your attention