Monday, 28 September 2015

Family group conferences outcomes are not always sustainable

Gideon De Jong
Researcher, Department of Medical Humanities
EMGO+, VU University Medical Centre Amsterdam, Netherlands

Gert Schout
Senior Researcher, department of Medical Humanities
EMGO+, VU University Medical Centre Amsterdam, Netherlands


Since 2009, we have been studying the process and outcomes of Family Group Conferencing (FGC) in mental health care as a social intervention to restore ties between psychiatric clients and their social network, and promote their social resilience. This resulted in two reports: a report focusing on FGC organised for ‘underserved groups’ in public mental health care (Schout & De Jong 2013) and, recently, a second report on the possibilities of FGC in preventing coercion in psychiatry (Schout et al. 2015). In total, more than 100 conferences were analysed and 600 semi-structured interviews conducted with the participants. To date, this is the world’s most in-depth research into FGC for adult clients in mental health care.

Eighteen months after the Eigen Kracht-conferenties

We reported earlier in JAN about the successful outcomes of a conference organised in a small neighbourhood where an imminent involuntary admission to a psychiatric ward and home eviction of a client was prevented and the living conditions restored (De Jong et al. 2014). During a period that lasted several months, in this neighbourhood liveability problems were reported where a man with psychotic problems was involved. The conference that got organised in the spring of 2012 took place without the client; participation in an upcoming conference caused too much stress and thereby worsening of psychotic problems. The conference was prepared in consultation with his sister, neighbours and professionals, and a plan was maintained that helped the neighbourhood becoming liveable again while the threat of an involuntary admission and home eviction was averted. The co-operation that was set in motion during and shortly after the conference, initially ensured rest: the neighbourhood had a short communication line to the mental health services and the sister for advice on psychotic and unacceptable behaviour.

In this commentary we want to share the insight that the positive outcomes in this case, but in other cases as well, may not always be sustainable. A year after the initial successes, the living conditions worsened gradually. The neighbourhood had increasingly difficulties to keep up with the client. Moreover, they and the client’s sister experienced less support from the mental health services. At the moment the situation seemed to escalate, no co-operation between the mental health services, the local police men, the housing association and the municipality got off the ground. This finally resulted in that the client being involuntarily admitted to a psychiatric ward and evicted from his home. He was hospitalised for several months, and during his admission, professionals were looking for another place for him to live.

Several lessons can be learned from this case. First, a family group conference does not mean that professionals afterwards can stay aloof. On the contrary, professionals are needed to provide information and support so that clients and their network can establish the potential most effective plan. In this case also by providing mediating techniques so that conflicts and disruptive behaviour can be addressed when they are still small. This requires professionals who are sensitive, approachable and accessible to not only clients but also their close relatives, friends and neighbours. The conference helps professionals getting a better picture of their clients so that subsequently they can adept more effectively to the given situation. Professionals who also have more than just the psychiatric problems of individual clients in mind; who address the necessity of their socio-cultural integration; who present themselves as the link between clients and their social environment. A professional who is also able to apply the pressure that is usually deployed by police men and housing associations to curb unacceptable behaviour. When not only clients but also their social environment experience support of professionals and other neighbours, they dare to show their commitment and are better able to endure the situation.

Interviews with the neighbourhood and the client’s sister that were held two years after the conference revealed that the company of other clients in the psychiatric ward did do the client visibly well. In other words, the admission was not any longer a nightmare for him. Simultaneously, the involuntary admission was a springboard to a form of supportive housing. Although the conference did not provide grounds for a sustainable positive outcome (prevention of coercive measures) in the long run, it helped the neighbourhood and mental health services to connect with each other. The mental health services thus became a partner who has something to offer, not only to the client but also to his social environment.


Balance between direct and indirect malleability

The FGC decision-making model is strongly embedded in the tradition of indirect malleability as it encourages learning processes and self-organisation. Convening stakeholders around an issue and empowering them to come up with solutions of their own meets the complexity of contemporary issues. The problems of the client population studied in this research project are complex. Apart from the unruliness of the psychiatric symptomatology itself, most clients have other problems as well, such as addictions, social isolation, a lack of sense of purpose and daily activities, debts and housing problems. Problems which altogether have a complex character. A core fundament of the FGC philosophy is that the fusion of the brain power from a large social network with professional expertise, responds to the complexity of clients’ problems. Here it is also crucial that a wider circle of concerned bystanders gets involved, generating new ideas and solutions the other actors may not have thought of, thus preventing blind spots and providing a wider range of solutions.

Also in other cases we observed that clients and/or their social network were unable to participate in a FGC process, let alone to take part in the private family time of the conference and establishing the final plan. In all these case, nevertheless, (the preparations of) the conferences were valuable in the eyes of the interviewees. What the case as described in this commentary illustrates is that the mental health services sometimes need to act in the tradition of direct malleability by first treating psychiatric symptoms so that in a later stage – following the tradition of indirect malleability—they can bring in their expertise when clients together with their social network establish their own plan. In other words, sometimes family driven should alternate with professional driven. (e.g. Merkel-Holguin 2004).


References

De Jong G., Schout G. & Abma T. (2014) Prevention of involuntary admission through Family Group Conferencing: A qualitative case study in community mental health nursing. Journal of Advanced Nursing 70(11), 2651-2662.

Merkel-Holguin L. (2004) Sharing power with the people: Family Group Conferencing as a democratic experiment. Journal of Sociology and Social Welfare 31(1), 155-173.

Schout G., Landeweer E., Van Dijk M., Meijer E. & De Jong G. (2015) Eigen Kracht-conferenties bij verplichte GGz. Een onderzoek naar proces en uitkomsten [Family Group Conferencing in coercive psychiatrie. A study into process and outcomes]. VU Medical Centre, Amsterdam.

Schout, G. & De Jong, G. (2013). Eigen Kracht-conferenties in de Openbare Geestelijke Gezondheidszorg. Een onderzoek naar proces en uitkomsten [Family Group Conferencing. A study into process and outcomes]. Lectoraat OGGz, Hanzehogeschool Groningen, Groningen.








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