“Clinical Perspective on Today’s Issues – Lecture 2 (UNIVERSITY OF AMSTERDAM)”

In the Netherlands, the prescribed mental healthcare is captured in quality standards. These standards include recommendations or prescriptions regarding proper treatment. There are several aspects of care:

1. Prevention
2. Screening
3. Diagnosis
4. Treatment
5. Recovery and reintegration

Each step requires different decisions regarding care. The quality standards can help with the decisions in the treatment and recovery phase. A quality standard outlines what quality care looks like for clinicians and patients for particular conditions. A quality standard is developed independently in a workgroup (e.g. patients, relatives, health professionals). This workgroup collects all information about the subject and based on this, they attempt to reach consensus.

There are three types of information that is used in the workgroup:

1. Evidence-based knowledge (i.e. scientific research)
2. Experience-based knowledge (i.e. experiences, wants and needs of patients)
3. Eminence-based knowledge (i.e. experience and opinions of healthcare professionals).

There is no hierarchy in this information when it comes to creating quality standards. These quality standards are important because:

• It makes sure a person can know what they can expect and what the options are.
• It provides an excellent basis for shared decision making.
• It gives information on what to provide and when to refer a patient to someone else.
• It allows every patient to have the same care (i.e. reduction of practice variation).

Every professional in healthcare should work according to professional standards. However, these standards can be deviated from. The comply or explain principle states that it is acceptable to deviate from this standard when the patient and professional both agree on it and the professional can argue for the decision.

Good quality care at an acceptable cost refers to care that is provided in the right place (1), by the right person (2), efficiently (3) and in good coherence around the patient and his next of kin (4). This requires self-direction (1), self-management (2) and equality of contact (3).

Professional proximity refers to real contact and this is important. Furthermore, it is important to use appropriate diagnostic labels as people do not derive their identity from their complaints (e.g. do not use the term schizophrenics). A counsellor should thus focus on the person and not solely on the diagnostic label. Treatment and support must always be available to enable patients to organize their lives as much as possible as they see fit. This can create independence as soon as possible.

Recovery is not only about the symptoms. It is about the continuation of life after mental health problems or dealing with mental health problems. Recovery involves:

• Restoring identity
• Restoring self-esteem
• Restoring self-confidence
• Restoring social relationships
• Restoring social roles

There are several important elements of recovery processes:

• Connecting with others
• Hope (e.g. break through stagnation by exploring boundaries)
• Identity (e.g. redefine complaints and vulnerability and develop a positive self-image).
• Meaning (e.g. assign new meaning to past events)
• Grip on one’s life (e.g. personal growth; taking on tasks and roles; making choices).

Recovery support has to fit within the personal process. This requires looking at the world of the patient (e.g. patient’s life story). This involves:

• Strategies of the person self.
• Joint activities of clients.
• Informal help by relatives.
• Professional help by experts by experience, care providers and social workers.

Experiential expertise refers to the ability to make room for others to recover on the basis of one’s own recovery experience (e.g. former drug addict helping struggling addicts). This can provide people with hope and can be crucial in recovery groups. Experts by experience should be made available and promoted in care.

There are several things a care-provider needs to do when switching to recovery support:

• Find a common language and a common starting point for cooperation with the patient.
• Find out the patient’s life story and its interpretation.
• Make use of rehabilitation and network methods to reach social recovery.
• Discuss self-stigma and stigmatization by others.
• Pay attention to areas of tension that may exist when taking risks
• Make use of instruments for increasing self-direction and preventing crises.

There are several things to do while deploying expertise:

• Make support of experts by experience accessible in care (e.g. promote during treatment).
• Discuss the relationship with loved ones.
• Emphasize the need for cooperation.
• Involve family experts by experience if possible.

A modern counsellor has several characteristics:

• The counsellor shows himself to be an involved supporter or coach.
• The counsellor works together with the patient.
• The counsellor makes use of professional considerations and looks at patient possibilities.
• The counsellor makes use of patient experience and experience knowledge.
• The counsellor deploys professional knowledge and personal experiences.
• The counsellor works in a triad (i.e. professional; next of kin; patient).
• There is an equal relationship between counsellor and patient.

The counsellor can support recovery in several ways:

• The counsellor should make room for and connect with the patient’s life story.
• The counsellor should use the professional frame of reference cautiously.
• The counsellor should work people-oriented on the basis of equity and dialogue.
• The counsellor should match the patient’s pace.
• The counsellor should ask what bothers a person and what makes sense.
• The counsellor should have confidence and give hope.
• The counsellor should stimulate the patients towards mutual supports and look for stimulating factors for recovery.
• The counsellor should reflect on one’s own actions.
• The counsellor should reflect on one’s own standards and values.

Eating disorders are psychiatric disorders characterized by disturbed eating behaviours and serious somatic consequences. They can occur at any age but anorexia nervosa and bulimia nervosa typically start in adolescence or early adulthood.

People with an eating disorder often seek help late because of stigmatization and insufficient awareness of the illness, implying the need for early detection.

For anorexia nervosa, it is necessary to have a specialist psychiatrist who focuses on cognitive changes (1), predisposition (2), trigger factors (3) and psychiatric comorbidity (4). For bulimia nervosa and binge eating disorder, it is necessary to explore periods of time with symptoms of another eating disorder. Specialist somatic diagnostics focuses on the differential diagnosis of malnutrition and the diagnosis of complications of eating disorders.

The self-management theory presupposes the presence of insight, motivation and skills in the patient. However, awareness of the illness may be absent at diagnosis. This complicates the disorder and the consequences. First-step interventions focus on raising awareness between symptoms and complaints and to increase the understanding of the eating disorder. There are several treatments:

1. Anorexia nervosa (FBT; MGDB; CBT: AFT)
   The treatment is focused on restoring physical fitness and normalise eating behaviour. A secondary focus is aimed at reducing the overvaluation of control over body shapes (1), weight (2) and eating (3). Treatment is often a combination of physical health monitoring and psychological interventions. A nutrition policy is necessary and comorbid personality disorders could hamper the effectiveness and need to be taken into account.
2. Bulimia nervosa (IPT; CBT; pharmacological treatment).
   The treatment is focused on reduction of inadequate compensation behaviours and/or overeating. A weight reduction programme can be considered.
3. Avoidant/restrictive food intake disorder (exposure therapy)
   The treatment is focused on the intake of nutrients.

Long-term aftercare contacts in anorexia nervosa are necessary because recovery rates are low and relapse rates are high. For recovery, it is essential that the patient becomes active again which can be done through the formation of participation-goals.