Transcript Trialogue – experiences and perspectives

The Trialogue Experience
Explications and Implications
Contribution to deconstruction
Toronto 05.06.08
Prof. Dr. Thomas Bock
University Hospital of Hamburg
What´s Trialogue
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A vision, idea (rather powerful in Germany)
A realistic event (about 100 trilogue-forums at same time)
with theoretical Meaning (anthropological aspects)
Influencing daily practice
(f.e. Treatment contract, Family meeting with first episode
patients)
• Implications on several levels
(e.g. antistigma campaign, EXperienced Involvement)
Two cultures
Evidence based medicine
Culture of trialogue
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Investigating
Collecting knowledge
Claiming objectivity
Constructing order
Telling stories
Looking for sense
Exchanging subjectivity
Accepting chaos
What´s the Meaning of
Trialogue-Forum
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Meeting as experts (on equal terms)
Mutual education (not only in one direction)
Cultivating Common language (no prof. power to define)
Sharing subjective perspectives
Supporting individual strategies (instead of „standards“)
Trying to open understanding
(anthropological instead of pathological point of view)
• Practice of dialogue for daily work
(and for education, research, health-politics, antistigma-work
Trialogue - Individual effects
for the “experienced”, relatives, professionals, students
• Telling your story in a good context
Psychotherapy without intention
• Learning with distance / without dependence
Family therapy without family
• Reflecting your point of view
Triple supervision without payment
• Avoiding simplifications (in education)
to be confused at the right time
Comparison
Trialogue-Seminar Psychoeducation
Members: • Trialogue
Contents: • Telling stories
subject. perspect.
Aim: • Empowerment
Learning: • mutual
Themes: • agreed
Roles: • open
Language: • Every day
Anonymity: • possible
Participation: • independent
• Only patients
• Common
knowledge
• Compliance
• one-sided
• defined
• traditional
• clinical
• unusual
• By Indication
How to start a Psychosis-Seminar
(Conditions for a trialogue forum)
It is very simple! You only need:
• Participation of experienced experts, relatives,
professionals (and students)
• Joint invitation, Joint program
• A public and neutral room
• Time-structure (e.g. 8 meetings, 2 hours each, with a break)
• Middle size groups (20-60 persons; not too large, not too small)
• Chair person (chair can rotate to represent the three groups)
Levels of Trialogue
• Psychosis-seminars
and now starting Trialogue-forums for borderline / bipolar disorder
• Trialogue cooperation of the 3 Associations
of Survivors/Experienced, relatives/families, professionals
• Antistigma-Campaigns
• Trialogue in Daily work
f.e. Treatment contract, Family meeting with first episode patients
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Health politics, Planing, Complaint-Agencies and
Education-programs, conferences, newspapers
Science and Research Empowerment, recovery
EXperienced-INvolvement-project
The Anthropological Point of View
Implications of trialogue - Deconstruction of schizophrenia
“Human beings, in contrast to all other living
creatures, have to struggle to achieve a knowledge
of themselves. We have the possibility of doubting
ourselves - and of despairing in this way, to think
beyond ourselves and loose ourselves in the process.
....If such a experience prevail for some time, we call
this (affective and cognitive) psychosis. Consequently,
whoever becomes psychotic, isn´t an “alien from
another planet”, but deep human....”
Trialogue brochure “It´s normal to be different”
Further Anthropological Aspects
• Every psychotic experience is special:
Standards don´t help; treat individual, not diagnosis
• Psychosis like a „dream without protection of sleep“:
Look for symbols of fear and wishes
• Similar to the perceptions of a child:
Which reasons for regression?
• Existential life crisis of a thin-skinned human being:
Not easy to be avoided; or you avoid life and cause depression.
• Subjective meaning: a desperate attempt of balance
About 80% of patients emphasis subjective meaning of
psychosis.
Deinstitutionalization
doesn´t only concern buildings
• If you want to reduce force-treatment, you have to build up
confidential relationships.
• If you want to have a process of Deinstitutionalization you
have to start in your mind.
• If you want to reduce stigmatization, start with mutual
prejudices between Experienced, professionals, relatives
• Than start common work against public prejudices
• If you want to work in trialogue, you have to practice same
language and to respect subjective perspective
Bottom-up Antistigma-Campaign
1st Example for trialogue on several level
From working with mutual prejudices to common
fight against public prejudices:
• Authentic informations to journalists
• Meeting-/information-/prevention-Projects at
schools, university, companies, churches
• Education to teacher, health services, police ....
• Culture-projects, website, radio-spot ....
• Support to other initiatives
EXperienced-INvolvement Project
2nd Example for trialogue on several level
6-country-project of European Union:
Qualification-progrann of „Experienced Experts“
to work as a:
• supporter in mental health services or
• recovery-assistant or peer-adviser
• trainer for mental health professionals
• „Life-teacher“ in schools
Summary: General Implications
Against main-stream simplification
• Schizophrenia is not only a shortage of transmitter but a
existential crisis of a thin-skinned human being
• Deconstruction of schizophrenia means not to deny
suffering, but to remember anthropological aspects.
• “Insight of illness” is not a pre-requirement of the patient,
but professionals’ responsibility!
• “Compliance” means cooperation not subordination!
• Being self-willed / stubborn is not a symptom of illness,
but a challenge.
• Trialogue has to influence daily work: “Treatment
contract”, “Family meeting with first episode patients”
Vision
• Natural Communication on equal terms
• Same language between the 3 groups
• Cooperation regarding education, science and
research
• More acceptance to self-willing patients
• More Tolerance to others, more sensibility to
yourself
perspective
From evidence based medicine to
Experienced based Work
„Wo aber Gefahr ist,
wächst das Rettende auch“
„But where is danger,
There also graws salvation“
(Hölderlin)
Thank you for your attention
The Trialogue Experience
Consequences for the Illness Concept
and Daily Practice
Workshop 6
June 5th, 3:00 - 4:30 pm
Trialogue - Overview
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Some Details of Trialogue-Forum
Meaning of Anthropological Aspects
Antistigma-Campaign and Ex-In-Project
Details of Trialogue in Practice
Critical Reflections of German Psychiatry
(1) What´s an Trialogue-Forum?
• Meeting on same level
• Dialogue as Experts: „experienced experts,
relatives and professional experts
• Mutual education
• Developing a common language
• Interested in subjective Exerience
• Effort on open understanding
• Practice equal rights
Basis for transfer to daily work, antistigma campaign,
EXperienced-INvolvement, psychiatry-planning, ....
Develompent of Trialogue
in Germany
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First Trialogue-Seminar in Hamburg (1989)
Founding of user organization (1990)
First Trialogue- books „Stimmenreich“, „Im Strom der Ideen“, ...
World Congress of soc.psychiatry (1994) „Beyond Babel“
More than 100 Seminars (1998) in German speaking countries
Trialogue in daily work (treatment contracts, first episode patients)
Brochure: „It´s normal to be different“ (in german + english)
„Antistigma campaign from below (“Irre menschlich Hamburg”)
Experienced-Involvement-Movement
Basics of a Trialogue-Forum
Conditions for a psychosis-seminar
It´s very simple. You only need:
• Participation of experienced experts, relatives,
professionals (and students)
• Common invitation, common program
• A neutral room
• Time-structure (e.g. 8 meetings, 2 hours each, with a break)
• middle size (20-60 persons; not too large and not too small)
• chair person (chair can rotate to represent the three groups)
The job of the moderator
• To moderate
• To recognize, if one group is quiet
• To encourage the three groups to ask direct
questions
Regulations better happen between and
inside the groups
The very first psychosisseminar
• A normal socialpsychiatric seminar: students
made interviews with several therapists, how they
handle the content of psychosis
• Dorothea Buck, elder president of user
organisations wants to be interviewed too
• All were impressed of the comparison
• The seminar was opened the next semester:
80 persons came in exactly three parts - a
great need
Implications:
Trialogue on Several Levels
The idea of Trialogue starts to influence psychiatry
profoundly on several levels
• Theory: anthropological aspects, deconstruction
• Daily psychiatric work: f.e. treatment contract, trialogue
meetings with first episode patients
• Antistigma-campaigns
• Health-politics, quality control,
• Research: empowerment, recovery ....
• Education-programms, conferences
(2) Anthropological aspects
• Every psychotic experience is special: don´t treat a
diagnosis
• Everybody is able to become psychotic: remain modest
• Psychosis is a „dream without proection of sleep“:
symbols of fear and wishes
• Similar to Child-like perceptions: reasons for regression?
• Existential life crisis of thin-skinned human being: not
easy to be avoided
• Human themes in psychosis: try to reduce stigmatization
• Vulnerability in both directions: see „real danger of life“
• The body as mirror of soul: no one way determination
• Psychosis as active response: basis for dialogue
Deconstruction of schizophrenia
• May not remain theoretical.
• Means throwing off disturbing ballast
• without denying illness or suffering, but looking
at the anthropological aspects
This is what I´ve learnt in trialogue: to broaden my
perception and calmness
Trialogue on other level:
(3a) Antistigma-Campaign from below
From working with mutual prejudices to common
fight against public prejudices:
• Authentic informations to journalists
• Meeting-/information-/prevention-Projects at
schools, university, companies, churches
• Education to teacher, health services, police ....
• Culture-projects, website, radio-spot ....
• Support to other initiatives
Offer to Schools
„Irre menschlich Hamburg“
• Advising Teachers
• Authentic material: child books, movies ....
• Meeting of experienced people and students:
Psychosis, Depression and Mania, self- mutilation, eating disorders,
drug addiction, Personality disorder
• Radio-spot, Website
• Special „Open Day“ for pupils at the clinic for
psychiatry and psychotherapy
Goals of School-projects
For pupils
• reducing prejudice
• Increasing tolerance (for others) and selfawareness
• improve dealing with own crisis
For the experienced person, the „life-teacher“
• Empowerment, integration
• More self-confidence
Trialogue on other level:
(3b) EXperienced-INvolvement Project
6-country-project of European Union:
Qualification-progrann of „Experienced Experts“
to work as a:
• supporter in mental health services or
• recovery-assistant or peer-adviser
• trainer for mental health professionals
• „Life-teacher“ in schools
Goals of EX-IN-project
• Empowerment: find your own power, your
individual abilities, your own portfolio
• Working as recovery-assistant or peer-adviser,
with stubborn patients, in Hometreatment and so
on .....
• Hope, Empowerment, Sense/Meaning
Look at brochure „Erfahrungsschatz“
(wealth of experience!)
Trialogue in Practice:
(4a) „Treatment Contract“
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Trialogue agreement with long time patients
Agreement about crisis intervention
Created by the Trialogue-Seminar
Reduces force-treatment (Zwangsmaßnahmen)
Increases confidence and continuity
Empowerment
Trialogue in Practice:
(4b) Initial Family Conference
with First Episode Patients (ALAANEN et al)
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Common agreement as basis for treatment
Involves the whole family from the beginning
Systemic point of view
Refer to daily conflicts
Integration of psychotic symptoms
Careful diagnosis and medication
Home treatment
The earlier, the more careful
Critical reflections to German
psychiatry
• There is still a trend of reductionism and not
enough respect for subjective perspective
• We continue organizating breaks of therapeutical
relationships instead of continuity
• Too much money is fixed in clinics, out door
services are too weak and not mobile enough
• The sicker you are, the lesser support you get
„Dogs of hell“ in front of psychiatry
• If you want to come in, you have to feed „insight
of illnes“ and „compliance“. or you come with force
• They prefer the „good“ patients. - So called
„heavy user“ are outside, often without any help
• There is a big change: The more ill patients are
outside, the less ill patients inside psychiatry
contradictionary concepts
Realization of illness
Compliance
Patient thinks like doctor
Patient acts like doctor wants
• Pre-requirement of patient? • A kind of subordination?
• Our Duty! We have to take • Result of dialogue! We
insight!
have to cooperate!
Noncompliance
• Not as sign of illness, but ther. challenge
• Fighting for identity, duty task for ps. p.
• Correlates with life quality! (Roessler 1999)
Noncompliance as a resource
• Noncompliance isn´t sign of illness, but a special
challenge, a special offer of relationship
• Fighting for identity, duty task for psychotics.
• Life quality correlates with „idiosyncratic illnessconcept“ (Roessler 1999)
Because of this:
• If patients always follow your orders, be careful –
something is wrong
• If patients keep their own opinion, you are right
and they have a better prognose
A special out-patient-service
what I´ve tried to learn from trialogue
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Low-level offers
Flexible individual support
incl.Home-treatment
Social support and group therapy
Creative methods
Family orientated help
Anthropological understanding
Learning from trialogue
and from stubborn patients
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See what happended before treatment
Avoide relapses not at any prize
Prepare „ecological conditions“
Offer individual treatment, not „standard“
Stop organizating breaks of therap. relationship
Give attention to individual + familar ressources
The earlier, the more cautious
Psychoeducation has to be removed by dialogue
Make your service mobile, flexible, dialogue-orientated
Change the financial system of psychiatry
(don´t reward beds, but therapeutical continuity)
Thank you for your attention