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![Page 1: The Trialogue Experience Explications and Implications Contribution to deconstruction Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg.](https://reader036.fdocuments.us/reader036/viewer/2022070305/5513d9ee55034674748b5105/html5/thumbnails/1.jpg)
The Trialogue Experience Explications and ImplicationsContribution to deconstruction
Toronto 05.06.08
Prof. Dr. Thomas Bock
University Hospital of Hamburg
![Page 2: The Trialogue Experience Explications and Implications Contribution to deconstruction Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg.](https://reader036.fdocuments.us/reader036/viewer/2022070305/5513d9ee55034674748b5105/html5/thumbnails/2.jpg)
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)
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Two cultures
Evidence based medicine• Investigating• Collecting knowledge• Claiming objectivity• Constructing order
Culture of trialogue• Telling stories
• Looking for sense
• Exchanging subjectivity
• Accepting chaos
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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
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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
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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
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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)
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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
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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”
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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.
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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
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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
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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
![Page 14: The Trialogue Experience Explications and Implications Contribution to deconstruction Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg.](https://reader036.fdocuments.us/reader036/viewer/2022070305/5513d9ee55034674748b5105/html5/thumbnails/14.jpg)
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”
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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
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perspective
From evidence based medicine to
Experienced based Work
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„Wo aber Gefahr ist, wächst das Rettende auch“
„But where is danger,
There also graws salvation“
(Hölderlin)
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Thank you for your attention
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The Trialogue ExperienceConsequences for the Illness Concept
and Daily Practice
Workshop 6
June 5th, 3:00 - 4:30 pm
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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
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(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, ....
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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
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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)
![Page 24: The Trialogue Experience Explications and Implications Contribution to deconstruction Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg.](https://reader036.fdocuments.us/reader036/viewer/2022070305/5513d9ee55034674748b5105/html5/thumbnails/24.jpg)
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
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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
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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
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(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
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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
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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
![Page 30: The Trialogue Experience Explications and Implications Contribution to deconstruction Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg.](https://reader036.fdocuments.us/reader036/viewer/2022070305/5513d9ee55034674748b5105/html5/thumbnails/30.jpg)
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
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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
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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
![Page 33: The Trialogue Experience Explications and Implications Contribution to deconstruction Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg.](https://reader036.fdocuments.us/reader036/viewer/2022070305/5513d9ee55034674748b5105/html5/thumbnails/33.jpg)
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!)
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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
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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
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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
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„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
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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)
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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
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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
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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)
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Thank you for your attention