The Trialogue Experience Explications and ImplicationsContribution to deconstruction

Toronto 05.06.08

Prof. Dr. Thomas Bock

University Hospital of Hamburg

What´s Trialogue

• 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• Investigating• Collecting knowledge• Claiming objectivity• Constructing order

Culture of trialogue• Telling stories

• Looking for sense

• Exchanging subjectivity

• Accepting chaos

What´s the Meaning of Trialogue-Forum

• 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 effectsfor the “experienced”, relatives, professionals, students

• Telling your story in a good contextPsychotherapy without intention

• Learning with distance / without dependenceFamily therapy without family

• Reflecting your point of viewTriple supervision without payment

• Avoiding simplifications (in education)to be confused at the right time

Comparison Trialogue-Seminar Psychoeducation

Members:Contents:

Aim:Learning:

Themes:Roles:

Language:Anonymity:

Participation:

• Only patients• Common

knowledge• Compliance• one-sided• defined• traditional• clinical• unusual• By Indication

• Trialogue• Telling stories

subject. perspect.• Empowerment• mutual• agreed• open• Every day• possible• independent

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

• 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 livingcreatures, have to struggle to achieve a knowledgeof themselves. We have the possibility of doubtingourselves - and of despairing in this way, to thinkbeyond ourselves and loose ourselves in the process. ....If such a experience prevail for some time, we callthis (affective and cognitive) psychosis. Consequently,whoever becomes psychotic, isn´t an “alien fromanother 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 commonfight 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 ExperienceConsequences for the Illness Concept

and Daily Practice

Workshop 6

June 5th, 3:00 - 4:30 pm

Trialogue - Overview

• 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 Trialoguein Germany

• 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-ForumConditions 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 commonfight 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 self-

awareness • 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“

• 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)

• 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 illnessPatient thinks like doctor

• Pre-requirement of patient?

• Our Duty! We have to take insight!

Compliance Patient acts like doctor wants

• A kind of subordination?

• Result of dialogue! We 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 illness-

concept“ (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-servicewhat I´ve tried to learn from trialogue

• 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

• 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