HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals


  • Jochen SchweitzerProfessor, University of Heidelberg and Helm Stierlin Training Institute, Heidelberg

Transcription editing: Jochen Schweitzer

Ευχαριστώ πάρα πολύ, συνάδελφοι, καλημέρα, I am happy to be here and I must tell you that although being a German, I am one of the many German who are not content with the fiscal and European policy of their own  government. And I think there are many people in Germany, not the majority, but many people who have very strong sympathy with the Greek people, at this point in time, and I just want to let you know that we also feel very helpless about our own situation.

My talk will be about a family systems approach in adult psychiatry, particular in hospital settings and also to some degree in community settings. And this is what I could speak about this morning, but I must not speak about it all. I would like to give you three brief introductions upon the history and current situation of psychiatry in Germany, and briefly about the actual situation of systemic therapy in Germany. Then, I would like to tell you a little bit about how systemic thinking in psychiatry developed in the German-speaking countries over the last 40 years and talk very briefly about some neighbouring ideas that have influenced us very much. So this is –and I hope to give you some ideas here about the context in which SYMPA has been based.

SYMPA is a project that brings many ideas together on the level of one hospital in an area and its collaborating agencies, and my talking about SYMPA will be my major part and maybe we’ll finish there, but if you are interested, I could talk a little bit about the traditions that have developed in outpatient psychiatry, in community settings where we did another project in Germany, in the 90s, which resulted in this about chronic and de-chronicying psychotic developments. And if anybody’s interested, I could tell you a little bit about outcome research, about how useful is systemic therapy with psychiatric problems. With colleagues, we’ve done an overview over several years and we are conducting studies right now and we are developing some measurements that are particularly fitting to changes in social systems, beyond individuals. So, the focus will be on SYMPA on this project. OK. Here comes the overview.

You will probably know that the German government in the 30s, by the Nazis, had this idea that you should free a nation from its, basically from its too-sick patients, so they put up a prop called euthanasia, which I think is a Greek word, to mass, it was a big slaughter, it was a big murder of mentally handicapped people and of psychiatric patients. So, living in psychiatry in the ‘30s was a dangerous place to be. After world war, of course, people did not get killed any more, but otherwise the conditions remained very much unchanged. It wasn’t until the ‘60s that we were influenced from other countries. In England, the ideas of the therapeutic community developed, in France, in Paris especially, the idea of the secteur psychiatrique, I think which was also influential here in Greece later, developed, in the USA in the ‘60s when Kennedy was president and Lyndon Johnson, the community mental health experts started to establish psychiatry on a district level, and of course, maybe most important to us, the dissolution of psychiatric asylums in Italy, was maybe the strongest influence. Another important influence was longitudinal research about schizophrenia in the ‘60s, done in two Swiss universities and one German university. The most interesting research I think was done by Luc Ciompi and his colleagues [inaudible] in Berne in Switzerland [inaudible] at the time. [inaudible] they followed people with a schizophrenia disagnosis over a long life period course and  found out (a) that not all schizophrenic people go into a state of dementia praecox, in the end. He found that’s about a third of them who, after the first episode, will not have a second one. He also found that some people, after having been schizophrenic for forty years, stopped being schizophrenic at 60, not displaying any symptoms any more. So he became interested in ‘how come?’. He made another research, he looked at young men in a psychiatric rehabilitation centre and looked at them two years later again, and he asked, what decides who will be in their place two years later. And he found out, those who did not like it, and those who the others thought could do without the rehabilitation place, they were gone. So, his idea was, the best thing is if you do not like psychiatry and if other people think you can live without psychiatry. That is very useful to escape the psychiatric system. So, Ciompi said, probably acute psychiatry is a largely biologically determined process, but maybe chronic  schizophrenia over the lifetime maybe partly be an artifact of how we treat people with schizophrenia.

You may know  about the concept of dementia praecox, that early schizophrenic symptoms  will ultimately end in a state of stupidity. Ciompi’s research very much questioned this idea and brought a very optimistic note to the treatment of psychotic patients. But it took until 1975 that we had a big debate leading to the so-called psychiatry enquete, decision which was, make the state hospital small, we should found social psychiatry services, sheltered housing, sheltered working, very close to the home of the patients, and stop big asylums and the journey has usually been about 100 km away from the home of the people. There was a strong criticism that psychiatric asylum at that time was an institution with a lot of violence, and that they operated like a total institution, which is difficult to escape, and the slogan attributed to Franco Basaglia, that “Freedom heals”, was an important slogan at the time. We know that freedom alone does not heal, you must meet some more things, but freedom is an important part. And people started to participate in that, they even tried psychiatric patients to participate in the politics. And maybe I may say that now briefly I had the honor to become board member of a small association that tries to qualify for psychiatric members to become team members of psychiatric institutions. It’s called “Ex-In”, before inpatient, now supposed to become your colleagues. Let’s see how it works.

So, today, we have approximately 600 psychiatric hospitals in Germany altogether, usually located in a 20 to 100 km radius from patients´ homes. About 50 of them are traditional but modernized state hospitals. They have shrunk in size, but are still considerably big. They used to have 1000 beds and now they are usually down to 500. And we have, since the 1980s-1990s, some form of community psychiatry in every district. Within a 30-km area, You will find  a small social psychiatry service, mostly equipped by social workers, we have sheltered housing, sheltered homes for the more chronic psychiatric patients who live outside the hospital. We also have sheltered work, which is very controversial. Often it is stupid, very simple work, and we’re always debating “Cannot we give more natural work to the people?”  And we have places where people with chronic psychiatric illness can go to and stay during the day, and meet others. Hospital stays have continuously shortened. today…you will stay there on an average between 2 and 4 weeks. But of course, many people will come into the hospital, leave, come again, leave…

Hospital staffing probably was best in Germany in the 1990s. We had more psychologists, musical therapists,  social workers than before coming in,  and had a better qualified  nursing staff. Currently, the staffing is becoming worse, which has to do with a more neo-liberal way of financing our health system, increasingly, turning them into semi- profit centers.

Quantitatively, I think the German psychiatric system is a good system. We have a lot of institutions that are reasonably well-equipped. However, the cooperation between these institutions at a regional level is not well organized. Everybody is more or less working by themselves. So if you come as a patient into a clinic, they treat you for 2 weeks, then you go out and find other treatment by somebody else, who often treats you like if previous professionals had not already worked with You, unless the patient tells you about them.  We are not happy about this insufficient coordination between services. But there are many attempts to reset that. Even within the institutional boundaries, treatments like pharmacology, psychotherapy or clinical social work, may be not well-integrated. Many psychological psychotherapists work in small private practices. They often do not dare to accept the very ill patients- those who might commit suicide, or call you at night, or scratch their arms, This would be is very heavy work for an isolated private practitioner.

Let me switch to systemic therapy. I estimate we have trained 25.000 systemic therapy-trained in Germany, or more, over the last 30 years. And we have approximately 120 training institutes, some big, many very small, with 1, 2 or 3 trainers.  The majority of people trained, today is social workers, followed by psychologists, then medical doctors, but there are also music therapists, occupational therapists, and so on. We have two professional associations, one is the DGSF (German society for Systemic Therapy, Consultation and Family Therapy), it has about 6.000 members now, and the Systemic Society, which has about 1.000 members. Let me tell you briefly about the DGSF which I know well, because I was its president for 6 years. As we grew, we  developed into regional groups, where people maybe meet l every two months, get together with 15 -20 people, maybe discuss cases, maybe tell about interesting literature, maybe discuss political events that are important for psychotherapy. We also founded 25 special interest groups– e.g. one for intercultural therapy, one for working with poor patients, one for working with refugees, with traumatized people and so on. And we have started to recommend institutions (e.g. in child care or in adolescent psychiatry) that are working particularly well from a family systems approach. It’s only 15 by now, but I hope we will have 50 soon. And that has a lot to do with SYMPA, today, because this idea came out of the SYMPA idea to train whole institutions and not only individual professionals.

Within DGSF, we have recently decided, that we could try as psychotherapists to take a position on some general political questions, that concern our work. Many of us work with poor patients. And in Germany, as you may know, some of us have a lot of money, many have reasonably good money, and about 2-3 million have very little money. They receive  welfare, nobody starves of hunger, but welfare is provided  under very humiliating conditions. People under welfare feel they have done a mistake, they don’t like to work, they are lazy, and stupid, and every week you have to go to the welfare office Its a humiliating procedure, with a lot of consequences for families with children that grow up in these families. We discuss, whether we can take a position against that kind of welfare system. We also discuss whether we can take a position on how refugees should be welcomed in Germany, and on how working conditions for people like you and I should be regulated in modern institutions, where everybody feels we are working at a faster pace, with an increased subjective pressure on doing things really well.

One of our problems is that family systems therapy is financed in in-patient treatment, but not in out-patient treatment. That has to do with our German psychotherapy law, which is good for psychologists, but not good for systemic therapy. Family systems approach is very strong, even dominant in many social services and in educational counseling. It is often available in child and family, child and adolescent psychiatry, but rarely in adult psychiatry. So I think adult psychiatry is a difficult place, and that is where SYMPA plays. If I make a conclusion, I think that in Germany theory a family-friendly psychiatry exists. We have a structured care system quite close to home, that’s good. And also the software for a friendly psychiatry exists, we have reasonably well-trained systemic and other-oriented psychotherapists,. But the software needs to be implemented into the hardware, in a structured  way, and this is why we developed SYMPA as an experiment.

Let me give you a brief history of the family systems development in Germany. After the Second World War, everybody was looking to America. So, from our perspective, systemic therapy of psychosis started in the United States, you may know about the work of Frieda Fromm-Reichmann, in Chestnut Hill, Philadelphia. She coined the horrible term “schizophreniogonic mother”, which we are still fighting with. As a psychoanalyst she saw individual patients, they were telling terrible things about their mothers, and she developed –she was not a mother herself—a theory about that. On one end this raised an interest on the families of schizophrenic patients, but it was very difficult, because every family member thought he was guilty, for the schizophrenia of that daughter, especially mothers. The National Institute of Mental Health, in the ‘50s to the ‘70s, did a lot of research on family therapy. There were people like Lyman Wynne, Helm Stierlin, Murray Bowen and others, who worked there together. You may know about Gregory Bateson and the Palo Alto group, who in the 1950s developed the ideas about the double bind, the paradoxical communication where you’re not allowed to talk about the paradoxical aspects of the talking. And it was in San Jose that Loren Mosher founded Soteria House, a small unit for acute psychiatric patients, to be treated with little or no psychopharmacology during their  the acute period, but with very intense personal attention. And it was in Denver, Colorado, in 1968, that people said ‘Let’s only accept every second patient for inpatient, and let’s go home to every other one, let’s do in-home treatment and let’s see who gets better. Basically, both groups of patients recovered equally well, but the home treatments patient remained better socially integrated stay more with the family, visit the institutions less frequently Interestingly Ronald Reagan, the later right wing US-president, invented psychiatry reform in California in the 1960s, not for humanistic  but for financial reasons. He put most of the psychiatric patients out of the hospital, they would sleep under bridges, and California thus resolved its financial deficit

But also in Europe, social psychiatry started in the late 1960s and early 1970s. - in Trieste, where Franco Basaglia worked in Arezzo,  in London, in Bern. Then in 1975 Mannheim became the first centre of social psychiatry in Germany Today it’s the centre of biological psychiatry, but it was, then, a social psychiatry centre. There were also small towns with large hospitals where some of our heroes of the social psychiatry movement, like Klaus Dörner or Asmus  Finzen  worked in the 1980  de-institutionalizing long term patients from state hospitals.

Up in Turku, in Finland, a group around Prof. Altonen, started to treat young people who turned psychotic for the first time. They visited their homes. They were mostly psychodynamic therapists and then also became systemic family therapists. Especially interesting are the experiments reported from Lapland. Lapland is very cold, very high up, few people  live there, and they have a lot of time [laughter]. So, they decided: whenever a young person turns psychotic, two mental health professionals go to his home. One of them comes from a hospital, and one of them comes from out-patient service. They go to t he home, they ask who knows this kid, who likes him, who wants to participate in a meeting?. Then they conduct  a meeting with 2, 3, maybe 20 people, for 2 hours, 3 hours, time doesn’t matter, and they discuss what do you know about him, what do you think, why do you think he became psychotic, what do you think you should do with him? And they stay for 2-3 hours, and then a decision is usually made. Maybe the decision is to have another meeting the next day [laughter]. So, there is no hurry to get the patient into a hospital, and in Lapland there is no hurry to give him neuroleptic medicine, but people will wait, understand, see, care. Jaakko Seikkula has published research that shows that treatment results, especially in terms of staying long in the hospital, taking a lot of additional services, dropping out of school and so on, are better than in other approaches. Volkmar Aderhold and Nils Greve have introduced this Scandinavian approach to Germany around the year 2000.  In Norway they have a wonderful place, called Modum Bad where the king used to make holidays, and there they have an inpatient unit now, for families, where you can come with your family for 4 weeks and get complete inpatient family therapy with a lot of interesting things along the way.

Finally, three other influences have become important to us. Dorothy Buck is  a woman who was sterilized during the Nazi times as a mental patient. She later became a poet and an artist. She said : ‘I want to understand my psychotic ideas of it’, and since she was a good writer, she wrote books about that, and became famous. She met a young psychologist, Thomas Bock, and they both started psychosis seminars. That’s where psychotic patients meet, not acute but in remission states, and maybe their relatives come, and maybe some professionals come. And people tell stories, what happened to them, and try to make sense out of the story. Soteria exists today in Bern in Switzerland, too, as a small in-patient unit, where you can postpone decisions about psychopharmacological treatment..

Now I come to the main topic: SYMPA.  SYMPA is basically a training project. We have started in 2002, to  train whole staff in four hospitals. Three of them are in northwest Germany, one of them is in Switzerland. And in 2011 we started to do that in four other hospitals. Until today, we have trained in eight hospitals. The SYMPA philosophy wants to have family participate in hospital treatment. We want them as experts about the patient, they know the patient better than we do, they have a lot of useful information for treatment. And they are burdened themselves, they have gone through hard times. So, for us, family members have a double role: They suffer, and they need help, but they are also experts on how to work with this patient.

The second idea is: we reflect on “How are we co-operating?”, and ‘Is this useful to the patient?’. Third,  we want to give a patient and their relatives influence on how we do the treatment, and how we can help so that in-patient stays become more co-operative and less violent. In Germany, one out of three patients does not come voluntarily into the hospital, he’s forced to come.  Sometimes, they are reacting very violently and then they are fixated to a bed. We hope we can decrease that. We think some attitudes are useful. (1) We think diagnosis is important for medication and for talking with other professionals. But diagnosis does not immediately inform us about what to do. We think that we should always respect family binds and loyalties, even if they are pathological. Even if parents seem overly caring, or not enough caring, if they seem to communicate crazy, we think they are the best people to co-operate with, and we respect them. We should not try to say, “forget about your families, come to us, forbid them to see”, we do not do that. Finally, we want to be optimistic about change, but we want to not exert pressure. So the idea’s ‘Yes, we believe you can change, but maybe you must not, we believe you must not become a chronic patient but maybe you will do it.’ So, in practice, we favor a strong real presence of the family in the clinic, and also a strong virtual presence in the hospital. We will often do genogram interviews, and hang up the genogram at the wall when we talk with the patient. We will often do circular questioning, make a demonstration of the family with little puppets on a table. We may do family therapy without the family present., which means, individual therapy but we will talk a lot about family in the individual talk. We will try to explore carefully what the patient and the family expects from treatment. We will work with their subjective theories, the explanations patients bring to therapy, and we will rarely do classical psychoeducation. Sometimes yes, but not usually. And we always use reflective teams.

One of our goals is to negotiate about treatment planning and about critical events in the hospital. F: How long should treatment it be, what should be done, and what not; , Maybe some people just want to have psychopharmaca and no psychotherapy; some just want psychotherapy and no psychopharmaca.; some don’t want any of that. Some just want to have a few days of rest away from home, and to have a bed and friendly people around them. We see in-patient psychiatry as a multi-phenomenon, with many services, but not everybody wants all of these services at all times. So we ask what we can do for them, and discuss what they really want to have. Because if they don’t want what we offer,  they will not co-operate. Then treatment will be useless, and a waste.

We also talk about diagnosis. You can look at psychiatric diagnosis in two ways: “Are they correct?” (Do they fit with DSM or ICD conventions?’)  But you can also ask “How useful are they?” ‘Do they make the life of the patient, the relatives, the professionals, easier or more complicated?’ For some people, to know ‘I have ADHD’ is wonderful, because ‘I do not anger the other because I’m nasty, it’s a handicap that I have’. Sometimes it’s good to know I’m psychotic, because I may get a pension, I may get a leave, I may get even sheltered housing in an expensive city, where I could not afford an apartment. To be a schizophrenic on the paper has a lot of advantages. But maybe my partner doesn’t like me so much if I’m schizophrenic. So, could I be schizophrenic on the paper, but not in the eyes of my partner? I once met  a 35-year-old state officer, a very intelligent  man, his wife was a social worker, working in social psychiatry. He had a first episode at age 34, went into the hospital, came out of the hospital, started couple therapy with me. They were both very educated and they would read our book, also the book of the director of that hospital, which was a very psychodiagnostic and psychopharmacologically oriented hospital. He participated  in a research project, in which the other hospital would call him every 3 months and would read him a long list of symptoms, and ask  him “Do you have this? Do you have this? Do you have this?”  And then he came to the next meeting to me and said, “You know Dr. Schweitzer, I think I am really psychotic, because they gave me this list and I had 15 of the 40 things, I said yes, so probably I am really psychotic” [laughter]. When he went back from me, he said “I behave psychotically, sometimes, on some occasions”. Then came a period he was offered a mid level leadership position upper position, but the position demanded to travel significantly and he got very nervous. I asked, “What makes you so nervous?” He said ”‘You know, my father was a travelling salesman”, “Yes”, I said, “what?” “He became the father to many children by many women in our area” [laughter]. I said “ok”.’ And he said “He looked very much like me” [laughter].  A northern guy, very tall, very good-looking, and obviously there was a nervosity in him, that he could be more similar to his father than he wanted to be. He was very trustworthy, his wife was sitting next to him, she  listened, and I said “Maybe you should develop two different diagnoses for two different occasions. If you do not want to take this job, you should say to yourself ‘I am really schizophrenic’, and not take it. But your wife doesn’t like you to say ‘I am really schizophrenic’. So maybe you can say to your wife ‘Occasionally, I have behaved in a psychotic way’ [laughter]. And maybe you can use the sometimes the one diagnosis, sometimes the other”.

This is a brief, funny example, but there are many more we believe, that diagnoses should also be judged by their consequences. Do they relieve pressure? Do they help to find a home or a pension? Do they help to find a lover, a job, You may also ask the patient who should be informed about the diagnosis. Do you want the general physician to know that? Or would you rather we just give the letter to you, and not give it to your physician?

We also want to negotiate about pharmaca. In Germany we have a saying, when you want to feed a little kid: ‘One spoon is for mama, one spoon is for papa...’ do you have that too? [Audience: Yes, we do], ‘One is for your sister...’ [laughter] so maybe one pill is for you, one is for your partner, and the third pill is for the nurse on the ward who wants to have a silent evening [laughter]. We believe that often people take classic neuroleptics with many side-effects, because somebody else wants it very much, and they do not want to disappoint the other person. This view opens up a lot of negotiation possibilities, You can thus come to good decision-making. And we believe this will reduce a certain amount of conflicts about pharmaca intake in the hospital.

Finally, when patients become dangerous, they get restricted, either by more pharmaca, or by physical restriction. That’s always a very difficult situation. So, it’s useful that the staff makes clear to the patient that if they behave in a certain way, they will have to be restricted. But maybe we can find ways to avoid it, especially in the quiet times in between aggressive periods.  ‘When do you become aggressive? How do you respond to whom and what can will you come to a SYMPA-hospital you might expect this to happen: In the first phase, after intake, you will have a talk with your treatment manager, usually the doctor or psychologist, or the nurse, alone, and maybe one with the family to find out what happened, and what could we do in the hospital. Regularly, we’ll have a genogram which is done usually by a nurse, usually during a 30-minute interview, maybe 45 at most. This genogram will be stored  into the file. Staff members can  take it out from the file,, everybody in the team can take it out and say ‘OK, he’s the only child of this parent’ or ‘he has five elder sisters, and no wonder that he is so dependent’. We will try to develop with the family an understanding of why they came here in this situation, and what could each of us do for the therapy. During the middle phase, we have individual talks, maybe another family or larger systems interview, group therapy. We do not do classical supervision any more, where ten team members talk about an absent patient. We invite the patient to come into “his or her” supervision, if possible together with his family members. So, today, I do it in adolescent psychiatry often, we have 15 hours at the most and I meet 15 minutes for the team, what do you want to get out of the supervision, then the family and the kid comes in, I talk with them for half an hour, the staff are sitting around, maybe 10 or 12 people, then I ask them to share their ideas with the family and me, and then we continue. Maybe we have a critical point, like ‘How long should he stay? Should he go back to the same school or to another school? What can we do so that she does not hurt herself anymore?’ and we’ll focus on that and have a joint debate, the patient, the family and not all of the staff, but many of the staff. And we try to negotiate about pharmaca, about diagnosis. At the end, we want to do a discharge interview, we want to... it’s possible, in Germany we write little letters to the doctors about diagnosis, treatment suggestions. We want to give this letter to the patient, before he leaves, and have him read this paper, and give him the chance to say “This is not correct, I don’t think so”, or “I think we did something different”’, or “I would suggest... You forgot one suggestion”’. And then we discuss it, we put it on a note and then it’s over. And the patient should have a certain influence on the document that we produce about them. Finally, often people leave us and they come back another time. And if they will come again, in a very upset state, maybe we talk today, how we should treat them, when next time we cannot talk to them, because they’re totally aroused and no talk is possible. So we may ask them at the end of this day, “How should we treat you next time, when we cannot have a calm talking?”.

Now let me come to training. I, personally do not work in psychiatry today. I work in a little department called Medical Psychology. But we do training, usually to state or city hospitals. We offer an 18-days training, distributed across about 2 years, And we form  training groups of 25mixed along  professions and hierarchies. There may be a young nurse and a head physician in the same group. Ideally, we offer the training not only for hospital staff, but also for community staff that works with the same patients. So, they get to know each other during training.  We teach basic systemic family therapy concepts, attitudes and techniques, and we teach some particular clinical practices that we have developed specific psychiatric techniques include illness concepts, how to write records in a solution-oriented perspective, or how to invite patients as team supervisors.

SYMPA takes time. Where do we take this time? Our favorite idea is we save on documentation. In Germany we usually have double documentation, separately by the physicians and by  the nurses Germans  like to document a lot, so, a lot of time is wasted on documentation. One hospital has developed a joint documentation for nurses and doctors. There, that is quite difficult because you vie late certain professional self-understandings. In Germany, nurses are very proud to belong to  an independent profession try to become an academic profession, so they need the documentation of their own, which becomes a bit ridiculous in a SYMPA  context.

When we did this training, smoking was still allowed in psychiatric units [laughter], and I was told in the beginning I could teach whatever I want but nothing longer than 45 minutes [laughter] because then half the team would have to go out and have a cigarette. Now, around 2006-2007, smoking became forbidden in all hospitals and today you can do longer teaching units [laughter]. Getting together in the bar in the evening was an important part of the training [laughter], and of course we did pictures to remember who was with us. . Any questions about that?

Question from the audience:  After this practice, did the staff, everyone, manage to hold on to this teaching?

JS: In well-organized clinics yes, in badly organized clinics no. It depends very much if the physician in charge continues to support it. So, in Germany, if the head of the system changes, he may reintroduce a totally different style. Yes, we have a lot of fluctuation, especially among the medical doctors. They stay half a year/a year, and then somebody else comes. Also, we have an inside-hospital fluctuation in the nursing staff. They stay for three years and then they go to another unit. So we need continuing training. But we have enough people in the hospital who can do that. Interestingly, from the first project five physicians, who continued and went through a 4-year training program a tour  in Helm Stierlin Institute in Heidelberg. Some of them are now part of the training unit in the hospitals. We also had twenty nurses from this one hospital who continued and became systemic counselors. Note that one hospital has twenty systemic counselors in the nursing staff!  They have gone around the different units. Four  of them have become teachers of our SYMPA stuff, which is  great It is  much more convincing if you have a nurse standing there, saying’s ‘we’ll do it’, it’s ten years, and we can do it as a nurse. It’s more convincing than if I say that.

For those of you who are a little research-interested: what are the results? We asked  six psychology students in 2003 and six in 2005 and asked them to spend 4 weeks in 6 psychiatric units, each of  them equipped with a camera, they were filming, and asking the staff every night ‘What did you do with Mr. Mueller, with Mr. Meier, with Mrs. Schultz?’ They counted who talked to whom in what way? Talks with patients increased, talks with larger systems members increased, talks with family members increased, but talks with family members absent --that means, I only talk with the mother, but I don’t talk with the patient--, they decreased. And that’s what we liked.

The Rating Inventory of solution oriented interventions  is an interesting instrument. It has been created by Guenther Schiepeck, in Salzburg, and his colleagues. You look  at  video clips of staff patient talks, what happens in these talks In the chart You see that after the training in 2005, there is more negotiation of treatment procedures, (“Do you want to stay another week, or do you want to go home today?”. “Can we agree that you take this pharmacon, or do we disagree?”) -  in the beginning it happens only on 8% of the video clips, and in the end it happens in 36% of the video clips. Another intervention is resource orientation. Here, the therapist may say “I understand you have a hard time, but some things work quite good for you, don’t they?” and we talk about the things that still are working good, the resources, the capabilities, and you see that also increases strongly. Some Interventions do not increase, like alternative thinking with regard to the usefulness of diagnosis. This takes a lot of training. The nicest thing was that we could show that staff stress is greatly reduced in the Maslach Burnout Inventory, and it remains reduced even 3 years after the training program. In June 2006, a young colleague went round the hospital and asked ‘What are the thing that you learn to do? The genogram was introduced very fast, but it’s not done so often anymore, because it takes more time, and it’s always not quite clear what to do with  the results of the genogram. Family talks, were adopted very gradually, but continued, and the reflecting team is done very slowly, especially if you need many people to do it. How do the professions develop? The nurses say, “We feel more important. We have a more important function with the patients, the relatives and even the other professionals.” The psychiatrists and the psychologists are ambivalent, depending  on their self-esteem. Those with a good self-esteem say ‘we have less work and that’s beautiful, the nurses are doing a lot of work that we should do but have no time to do.’ But some of the less asserted say ‘Well, they become very important here today, and they are more experienced than we are, so...’[laughter] ...do we really like this?’

We could also show that team co-operation in the so-called Team Climate Inventory became better on two of the four scales, but that did not maintain itself in 2008, when members changed. So, a good team atmosphere depends on those particular members and it’s not transferred when other people enter the team. If I ask people what happened in the end, they say, ‘We introduced the genogram interview because it has been an occasion to get to know the patient intensively’, especially for nursing staff. ‘We know him from every day, we meet during dinnertime or when we give the pills, but now we took 30 minutes to ask him about his mother, his father, and his relationships’, and especially the nurses said this has given them a different perspective.

The clarifying of expectations, yes, it happens, and we find that patients take more responsibility for what happens. They are co-thinkers, more than before. And also, we develop more realistic goals. We have many ideas, what the patient should do, but they are not interested in that. So, we stop having these unrealistic goals and make smaller goals. We write down therapy goals, for instance “Mr Mueller wants to be less aggressive against his wife and beat his children no longer.” We write this down on a piece of paper, Mr Mueller has this paper in his pocket, and he goes to occupational therapy, he goes to work therapy and he says: “This is my therapy goal, just so you know, and now let’s start”. We find that less fixations, not very much less but less fixations are done, people, partly staff, feels less offended by the patients because they understand more the background. Patients like it very much that they’re invited to the case conferences. Not all. Some are too afraid. They do not want to speak in front of fifteen people. But some like it very much and afterwards they say, ‘Wow! So many thoughts that you made about myself, I didn’t that!’, so you make a good impression on your patients, by inviting them to case conferences.

Some things rarely happen. Reading the discharge letters today doesn’t happen often, but mostly because people do not write the discharge letter early enough, they are usually written a week or two weeks after the patient has gone. This is the latest thing you will do. And I think a well-structured systemic intervention on the units still needs a lot of improvement.

Here is a sample of the patients that we had in the first SYMPA project. You see, it’s mostly schizophrenic patients, patients with affective disorders, patients with adaptional reaction and thirdly, mostly, borderline patients with personality disorders. Now, here comes our problem. We were not able to show that treatment results during 15 days of stay become significantly better. You see, the effect sizes of the differences are small. So, we were very unhappy about that finding, but it becomes quite understandable, because this hospital’s worked quite well before, so symptom reduction was better than in other hospitals, they were quite advanced hospitals. Second problem was inpatient treatment has been long enough to show symptom reduction but it takes longer to improve along lasting interpersonal styles, and quality of life and the social support overall. I was very discontent afterwards with the measures that we used. Finally, we started to evaluate after the twelfth day of training, which is a little early, and the treatment results are very different across the hospitals! We had one hospital with very good results, and one with very lousy results. This had to do with the internal quality of organization of the hospitals.

So, my conclusion in 2008 was, SYMPA training works, [when] it’s utilized the clinical practices change, team cooperation is better, the cooperation between physicians  and nurses changes, but symptoms would not yet demonstrate an improved overall patient outcome.

If we look at the conditions, what does it need so SYMPA becomes important? You need good top-down support from the hospital directors, not only from the medical director, which we had, but also from the nursing director and the administrative director, which we not always had. And the hospitals must think thoroughly before the start: ‘Do we want this?’ So, today, we have a period of several months negotiating with the hospital, describing what we would do, and discussing “Do you really want it?”. We found that our teaching style helped very much, especially for nurses. Nurses are afraid that it would become academic, and there will come a few doctors and psychologists who will speak academic language, they will give boring lectures, and at the end we won’t know what to do.  So you must practice a very lively and experiential style. And I think it’s good if you have nurses on the training staff, in particular.

I think the better we had a cooperation between the hospital, and the outpatient services, the better it became and it’s a tricky relationship in German hospitals between physicians and nurses, and there’s a lot of negotiating about who’s responsible for what, who may do what, who may not do what, and if this is well done, like in our favorite hospital, it works wonderful. If you have a strong conflict between the nursing director and the medical director, this will make the project much more complicated.

Valeria Pomini: Can we ask you something for the research results?

JS: Yes

VP: Did you evaluate fashions about relapse and re-hospitalization, or days of re-hospitalization...

JS: No, not at the time

VP: Or neuroleptics doses, for example

JS: We do that now, in the new project, but we didn’t then

VP: Because you may see some difference in that parameters

JS: I think so, I think so

Question from the audience: Did you mention how many hospitals participated in SYMPA?

JS: Yes. The research project had three hospitals only, and so we trained four hospitals in 2005 so, 2003, 2005, 2006, then we had a pause, and since 2011 we started training again four other hospitals.

And if you have a little more attention, it’s long now, I have to finish... Briefly, about the new project: This is SYMPA for mentally handicapped patients. You see pictures of patients with severe mental retardation who [live] in the area around Munich in Southern Germany, and you see they’re living in beautiful but remote places like former Catholic monasteries, like the one up there. Beautiful villages, very nice in terms of the housing, but of course very much by themselves. And this is the psychiatric hospital around Munich, and this white circles shows a little house, that is the house for mentally retarded patients, they have 16 beds. Itis a small unit.

There, we want to see if we can help them reduce aggressive episodes, and reduce physical restrictions of patients, And we want to help the mental health workers to stay longer on their job, to stay more healthy and have more fun with their job. This work is very hard. Mentally retarded people, when they do not understand a situation, some of them may beat you, or beat themselves, or maybe knock their head against the door, or may destroy furniture. And if you are present there as a worker, you must be cautious not to be hit yourself. So, you are always afraid of “can something happen to me?” And if you can avoid it you go someplace else - thus they have a lot of fluctuation, and the job is not always attractive for well trained people. In research, we look at staff burnout, workability, sense of coherence, and perception of the atmosphere on the ward. We document exactly how many aggressive episodes are happening, how many fixations happen, how often pills are changed, and how often people switch between the hospital and the home.

Participants are one hospital department, eight residential homes and 75 mental health workers from both types of institutions. - 50 from the homes and 25 from psychiatry. We started training in 2014, it will finish in June 2016, and we measure very often the health of the workers, and the aggressive episodes. We want to do two follow-ups in 2017 and in 2018. We now also start to follow 16 patients, through their live events over one year. A new team member, a psychologist in Munich, will travel around and every 3 months she will visit the patients and the families, and make an interview with them, and see what’s happening. So, to develop stories that are not only numbers.

OK, so I think I’ve been talking quite long, thank you very much for this long attention span. [applause]

Read the next article:

ARTICLE 7/ ISSUE 8, April 2016

The “depends on” and the “and”: The therapist’s resources in the era of magical images

Charis Katakis, Founder and President of the Laboratory for the Study of Human Relations
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