1. Toronto 05.06.08 Prof. Dr. Thomas Bock University Hospital of Hamburg
The Trialogue Experience Explications and Implications Contribution to deconstruction
Toronto
Prof. Dr. Thomas Bock
University Hospital of Hamburg

2. 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)

3. Two cultures Culture of trialogue Evidence based medicine
Telling stories
Looking for sense
Exchanging subjectivity
Accepting chaos
Evidence based medicine
Investigating
Collecting knowledge
Claiming objectivity
Constructing order

4. 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

5. 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

6. Comparison Trialogue-Seminar Psychoeducation
Members:
Contents:
Aim:
Learning:
Themes:
Roles:
Language:
Anonymity:
Participation:
Trialogue
Telling stories subject. perspect.
Empowerment
mutual
agreed
open
Every day
possible
independent
Only patients
Common knowledge
Compliance
one-sided
defined
traditional
clinical
unusual
By Indication

7. 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)

8. 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

9. 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”

10. 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.

11. 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

12. 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

13. 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

14. 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”

15. 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

16. perspective
From evidence based medicine to Experienced based Work

17. „Wo aber Gefahr ist, wächst das Rettende auch“
„But where is danger,
There also graws salvation“
(Hölderlin)

18. Thank you for your attention

19. The Trialogue Experience Consequences for the Illness Concept and Daily Practice
Workshop 6
June 5th, 3:00 - 4:30 pm

20. 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

21. (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, ....

22. Develompent of Trialogue in 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

23. 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)

24. 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

25. 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: persons came in exactly three parts - a great need

26. 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

27. (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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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!)

34. 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

35. Trialogue in Practice: (4b) Initial Family Conference
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

36. 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

37. „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

38. contradictionary concepts
Realization of illness
Patient 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)

39. 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

40. A special out-patient-service what 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

41. 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)

42. Thank you for your attention