Interventionsphase: systemisch psychiatrischen arbeit mit patienten und angehörigen
SYMPA - Projekt Ruprecht- Karls-Universität - Heidelberg Handbook "Systemic Acute Psychiatry" Instructions for Use
This handbook describes the way of working within the SYMPA-Project starting in
October 2004. The content of this handbook has been “ripened” by experiences
within the SYMPA-training, it has been put to test within the homework assigned and
carefully reviewed by the project coordinators.
The table of content specifies all clinical procedures. Each procedure is described
with regard to „objective“, „external conditions“ and „proceeding”.
At the end of this handbook you find a classification of these procedures according to
- SYMPA-basic program: what should be applied to all patients
- SYMPA-plus program: what should only be applied in special treatment situations
We hope this handbook „Systemic Acute Psychiatry“ contributes to the success and
Table of content I. Systemic Settings of Conversation 1. Geneogram 2. Systemic one-on-one interviews and family talks 2.1. Systemic one-on-one interviews 2.2. Systemic family talks 3. Systemic group therapy 4. Further conversational offers on request
- cooperational talks
- ward rounds for relatives
- consultation hour for relatives etc. II. Reflective Meeting Culture on the Ward 1. patient-centered team meetings (intervision) 2. patients as team supervisors III. Negotiating Culture on Admission 1. Systemic planning of therapeutic goals: contracting, case conceptualization, systems therapeutic treatment offer 2. Negotiating on medication 3. Negotiating on (alternatives to) compulsory measures/restrictions of personal freedom 4. Negotiating on (alternatives to) abrupt discharge 5. Conversation on diagnosis 6. Read through/brief talk on discharge summaries IV. Survey of SYMPA Basic and Plus Program I. Systemic Settings of Conversation ___________________________________________________________________ 1. Geneogram Objective:
The geneogram offers a quick survey on complex family structures. You get
information on the historical development of the familial relationships from the
patient’s point of view. Based on the dynamics perceived, it is possible to build
hypotheses that can lead to a re-formulation of the past and to new solution ideas
The geneogram should be developed as soon as possible after admission, taking the
patient’s resilience and willingness into account.
If possible the geneogram should be created with all patients during their hospital
stay. It should be constructed by all ward employees according to arrangements
between the different professions. The geneogram is developed in one-on-one
Three generations should be described using the following information:
1. Structure of the family: name, age (date of birth/ date of death) of all family
members and their biological and judicial relations.
2. Demographic data: place of residence, profession, etc.
3. Critical incidences in the familial history: marriages, divorces, loss, suicide,
4. Further information on the current problem.
5. Optional: quality of familial relationships (close, reserved, conflict-ridden,
A geneogram determined for the file follows the symbols agreed upon. It should only
A copy of the geneogram can be used in therapeutic conversations for further
therapeutic work. This copy can be marked in more detail.
2. Systemic One-on-One Interviews and Family Talks Objective
Systemic one-on-one interviews and family talks are meant to encourage changes in
constructions of reality as well as different communication patterns. They aim at an
understanding of the current life-situation and serve as a base for the development of
External Conditions Systemic one-on-one interviews
During the hospital stay each patient should have at least one weekly therapeutic talk
of 15-30 minutes with employees of different professions.
Systemic Family Talks
During the hospital stay at least one family talk should take place between admission
and discharge. Family talks take place together with those persons who are
important within the patient’s environment and who want to contribute to a solution.
These "social families“ do not have do be identical with the "biological“ or „judicial
Within the SYMPA-project we do not speak of family talks in the following cases:
- Systemic talks only with the patient, even if they focus on family themes (“family
- Psycho-educative talks which focus on information about the disorder and
trainings that focus on relapse prophylaxis according to the "Expressed
Proceeding Questions on reality construction
Unraveling the problem: What is it all about? What is the problem according to the
patient and others present? Gathering information on different descriptions of the
problem, different points of view and differential reactions on the problem.
Contracting: Asking for the expectations of those present.
Who wants what (and who doesn’t) when (and when not)?
When would the problem be solved? Who would be the first to realize this and
how would it be realized? What can I/can we contribute to this? What would
be a successful result of this talk (definition of goals)?
Questions on possibility construction
- Miracle question (visions on a life without the problem)
Combination of solution-focused and problem-oriented questions:
- The advantage of keeping the problem (temporarily)
- questions about conscious relapseCircular questions
The aim of circular questions is to describe and clarify (vicious) cycles, mutually
caused processes and relational patterns. Questions that point out differences
Classification questions, percent questions, questions on degree of agreement create
new information in the system and encourage new perspectives and ways of
thinking. The perception of differences is a basis for change. Reframing
Reframing aims at a reinterpretation and reformulation of the current reality
construction and the according stories told and experienced. That way the stories are
reset in a different context and solutions and changes are made possible.
3. Systemic Group Therapy Objective
The systemic group therapy is a supplementary measure within the systemic overall
context. It is supposed to deepen the results of geneogram creation, contracting,
treatment planning, systemic one-on-one interviews and family talks. Induced
changes in reality construction and habitual communication patterns are further
reflected and practiced in direct contact with the fellow patients. Aim of systemic
group therapy is a guided perception of one’s own strength and possibilities as well
as the amelioration of competences and the patient’s scope of action.
The group therapy takes place on a weekly base in an open setting and lasts about
60 minutes. Apart from bedridden, advanced mental patients or patients in a highly
acute state which could not manage such a group setting, there are no diagnostical
restrictions to participation. The team decides on participation guided by the
physician in charge. The group is lead by senior physicians or ward physicians
accompanied by one or two nurses and a social worker.
The choice of methods is based on our humanistic, resource- and growth oriented
world view. According to the key-note of a solution-focused systemic perspective we
implement methods that make use of hypothesizing, circularity and all-partiality in
order to contribute to the promotion of the patient’s development.
In order not to promote the orientation on diagnostic categories already existent we
prefer working according to a trans-diagnostical concept.
Group structure: brief „weather report“, working on the problem of a group member,
work out and deepening of common patient-related topics, homework for deepening,
conclusion and résumé, brief finish.
Way of working: hypothesizing, systemic questioning (questions on reality
construction and possibility construction, circular questioning and questions that
focus on differences), resource and solution orientation, reframing, reflecting teams
4. Further Conversational Offers on Request: 1) cooperational talks 2) ward rounds for relatives 3) consultation hour for relatives etc. II. Reflective Meeting Culture on the Ward 1. Patient-centered Team Meeting (Intervision) Objective
Within a solution and resource focused meeting culture the patient is believed
capable of actively resolving and influencing his course of disease. Activated from
outside he can recognize, transfer and use these skills and resources.
Patients are perceived as clients who negotiate their wishes and mandates with the
professionals. By using circular questioning it is possible to focus on psychological,
social and material resources: How can the things perceived be related in a coherent
and sensible manner? The team can discuss possible solutions or reframe behavior
Besides the team meetings already running, the group intervision can be used to
discuss several patients (e.g. particularly difficult cases) in more detail. Intervisions
should take place on a regular basis once or twice a month. In-house intervision can
be separated from supervision with the latter being led by an external supervisor.
Proceeding 1) Choice of a moderator who is in charge of:
- collecting central questions with regard to the relevant case
- making sure the group does not get side-tracked
2) Brief description of the problem and its context; previous approaches to the problem 3) Objectives: „What do we want to clarify?“ 4) Collecting hypotheses 5) Evaluation of hypotheses: What kind of “hits and blanks” can be identified with regard to the objectives? Further processing: Which “hits” can be translated into concrete ideas? 6) Ideas for solutions 7) Final evaluation: “What do we want to realize?” 2. Patients as Team Supervisors Objective
By establishing patients as team supervisors we intend to achieve three goals. First,
the patient plays an active, responsible and autonomous role. Second, the team
practices solution and resource orientation and still brings up critical topics in an
appreciating manner. In addition, transparency is established for the patient who
gains insight in what is done to him and why. External Conditions
Each patient is supposed to be present at one to two case conferences the least. It is
agreed with the patient when he takes part in the conferences. The patient takes
along a confidant (fellow patient, relative, carer, etc.) or is accompanied by his
Proceeding Announcement of the team meeting to the patient and establishing a time structure – making an appointment with the patient: When is it going to be „his/her 1. The moderator welcomes the patient and states or asks about the focus of feedback 2. The professionals speak about the patient present, focusing on:
- or descriptions of the current situation
The team exchanges resource-oriented perspectives:
- What causes astonishment/need for clarification?
- Are there any hypotheses on what experienced problems could be good for?
3. Reflecting team of the patient and his confidant on the things stated by the professionals 4. If there is a result it is written down and shown to the patient III. Negotiating Culture on Admission 1. Systemic planning of therapeutic goals: contracting, case conceptualization, systems oriented treatment offer Objective
We assume that patients are experts for the resolution of their problems. Thus we do
consider them as important co-creators in the planning of their therapeutic goals.
Frequently, a similar thing can be said of relatives, other persons close to the patient
and important external treatment institutions.
Their expectations with regard to the treatment should be explored and used as far
as possible (contracting). A shared case conceptualization is developed on how the
patient got into the psychiatric crisis and what could help him out. Based on
contracting and case conceptualization treatment elements are chosen which seem
to be helpful in terms of improving the systemic situation of the patient (system
This procedure is based on an attitude of curiosity (about the social situation of the
patient), an extensive neutrality (with regard to different life concepts) and a position
of not-knowing (what is best for the patient).
With every patient –if possible with the relatives, too- a stepwise contracting is done
at the beginning of treatment (during the creation of a geneogram, in systemic one-
on-one interviews, in family talks). At the end of this initial phase a shared case
conceptualization is developed and therapeutic goals are derived that are written
This can be done by all ward members according to arrangements made between
the different professions. It is important that contracting is done with the patient and
Each patient is presented the different treatment options: what has to be taken
obligatory, what can be dropped? With regard to the latter the patient can express
Who…?: Who is contract partner in the treatment and who is not: The patient
himself? The relative? The general practitioner? The court?
…wants what?: What exactly is wanted from the assortment of stationary
treatment offers?: Medication? Psychotherapy? A sick certificate? „Hotel
…when?: How long is the stay supposed to last? Is time ripe for a change? Or
is it too early or already too late for that?
…how much?: How intensive/urgent is the patient’s need for treatment?
…what for/against : What are official and unofficial results expected from the
Shared case conceptualization
In which systemic constellation did the patient get into the current psychiatric
What could all persons involved do (at least the patient, relatives and ward
staff) in order to help the patient out of this crisis?
Guidelines for agreements upon therapeutic goals
first person formulation; which goals are seen by the patient?
goals that are introduced by the treatment personnel are negotiated with the
a contract-hierarchy is established that is valid for the first 14 days, afterwards
weekly revision with patient if necessary
briefly stated in a written form (max. 1 page) by physicians and nurses
signed by the patient; patient receives a copy
Criteria of goal formulation: positive concrete und specified observable attainable by own means fitting in the context in the patient’s tongue 2. Negotiating on Medication Objective
The patient is meant to become aware of his own influence on medication and
consequently exert influence on medicational decisions in a more conscious way.
That for, it is helpful to point up the mostly unconscious social indications of
medicational decisions (for whom’s sake or against whom does or doesn’t the patient
Choice and dose of medication is negotiated with the patient. Relevant perspectives
include pharmacological criteria (innocuousness, side effects, symptom reduction) as
well as social-systemic criteria (effects of intake or non-intake on the patient’s
relations on the ward, in the family, at work, with his friends etc.). Proceeding
1. These effects are asked about in a circular manner:
• Reactions of relatives („What would your wife do if you would discontinue
• Reactions of the patient on these reactions („If your wife would threaten to
get divorced – would you retake the Haldol?“)
• Variations of the current relational patterns with regard to medication intake
(„Given we would find a medication with less neurological side effects
which would leave you less affected optically – would you take it for your
2. The ward physician points out to the patient:
• which decisions of the patient (intake, refusal, change of medication) will
be followed by which inevitable reactions of the ward staff (ranging from
„doesn’t matter“ to „dismissal due to non-cooperation“ and „compulsory
• how much leeway the patient has (which variations of medication are
possible) and where it ends (which kind of medication will not be accepted
3. Following the discussion of consequences for the patient’s relationships (1.)
and the patient’s leeway (2.) a decision is made – if possible in agreement.
3. Negotiating on (alternatives to) compulsory measures/restrictions of personal freedom Objective
The objective of systemic negotiating is to keep compulsory measures and inevitable
restrictions of personal freedom as little as possible but as extensive as necessary.
In situations of self-endangering or other-endangering behavior the nurses and the
physicians respectively discuss with patient how he or she can avoid or minimize
impending restrictions of personal freedom.
1. The treatment personnel makes clear to the patient which inevitable reactions
(ranging from „doesn’t matter” to “no time off without company” and “fixation”)
are to be expected following self- or other-endangering behavior. The
treatment personnel further points out how these reactions can be influenced
by the patient himself through his words and actions within the next
2. The treatment personnel asks circular questions:
• on the measures perceived to be less threatening (“What would be a less
• on attachment figures who could help the patient to get out of the “danger
zone” without restrictions of personal freedom (“Are there any fellow
patients or relatives who could calm you down effectively?”)
• on treatment measures which could help the patient out of the “danger
zone” without restrictions of freedom (“Let’s assume we would relocate you
on ward X where fellow patient Y could not hassle you …would you be able
to stop shouting there?”; “Let’s assume we would let you retreat to the rest
room without fixation but in the presence of nurse Z – would you be able to
Treatment staff and patient agree upon the proceeding in a consensual manner as
4. Negotiating on (alternatives to) abrupt discharge Objective
The objective of this kind of negotiation is to open up alternatives to unamicable
If abrupt discharges are in the air (either at the patient’s request, “against medical
advice” or on behalf of the treatment staff due to breach of ward regulations), a ward
member addresses the patient: “ I got the impression that you actually want to leave
In case of an affirmative answer the treatment personnel discusses with the patient
1. what or who puts the patient off his stay or motivates him to leave the ward
2. which beneficial or adverse consequences (familial, professional, with regard
to fellow patients or health, etc.) would follow the patients ward leave
3. what the patient himself considers to be a good way of leaving and –if
4. if or how the treatment personnel could facilitate the best possible leaving or
the best possible continuance for the patient
5. if the patient wants to make a decision on staying or leaving in a conscious
manner or if he prefers leaving this decision up to other people or the
While discussing these options the treatment personnel act neutrally (except for
forensic patients): Leaving the ward and continuance of the stay are equally
honorable and arguable. In-patient treatment is neither fundamentally good nor bad.
The treatment personnel show great interest in the patient’s perspective and assist
him in finding a conscious (or unconscious if wanted) decision that fits to his point of
5. Conversation on Diagnosis Objective
The aim of conversations on diagnosis is to develop an understanding of the patient’s
diagnosis that enables the patient to realize as many desired options of living as
possible (that is to say the least reduction of social opportunities as possible).
This can lead to a context-dependent communication of diagnoses – e.g.
“professionally accurate diagnosis” when communicating with the health insurance
vs. a “diagnosis beneficial to love” when communicating with the spouse. External Conditions
The decision on a psychiatric diagnosis is discussed with the patient (provided there
is scope of decision as well as his way of dealing with the allocated psychiatric
We assume that diagnoses (strictly speaking: the communication on diagnoses) do
have context-dependent, frequently even contradictory effects. Diagnoses facilitate or
complicate communication between professionals. They ensure or endanger the
financing of treatments and care. They offer security and detract from work-related
demands and job loss. They enhance or lower self-confidence and social
The diagnostician discusses with the patient:
1. What is the diagnosis the patient himself considers to be appropriate? And
how good or bad does this self-diagnosis do to him?
2. The diagnosis set by the diagnostician:
(1) Which thoughts, hopes and fears are caused by this diagnosis?
(2) The diagnostician briefly states why he supports this diagnosis (health
insurance billing, choice of a best fitting medication, protection from
environmental demand, etc.) and asks the patient which of these reasons
(3) What will the reaction of important others (partner, children, parents,
employer/colleagues, court, annuity insurance,…) be like?
3. To what extent can the patient agree on the diagnosis of the diagnostician?:
Which positive side effects („new chances“) and which negative side effects
(“restrictions”, “stigma”) are to be expected for the patient? Can the
diagnostician (temporarily) revise his decision depending on the results?
4. How should the diagnosis be communicated?:
(1) What is the diagnostician supposed (not) to tell others?
(2) What does the patient (not) want to let others know?
6. Read through/brief talk on discharge summaries Objective
The objective of letting the patient read through his discharge summary is to provide
a maximum amount of influence on the patient-related notes that circulate within
The patient is enabled to read the discharge summary and –if he/she wishes- to
participate in its writing. Objective: to strengthen the feeling of influence on circulating
communication about oneself (if wanted).
1. A brief, time-effective letter-writing-procedure is developed within the clinics
that enables the patient to get an insight in his summary a day before
discharge or on the day of discharge the latest.
2. The patient is offered to let the physician know if there are any wishes for
amendments. These are integrated in the text (in case of mutual consent) or
included as special votes below the text (in case of disagreement).
3. If the clinic policies leave room for that, the patient decides whether he wants
to take along the letter of discharge himself and if further copies are sent to
Handbook "Systemic Acute Psychiatry" SYMPA – BASIC PROGRAM 4 out of 6 items have to be fulfilled. An item can be replaced by an item from the plus 1. Development of a geneogram, submission to the patient’s file 2. Systemic planning of therapeutic goals: contracting, case conceptualization and treatment program are developed together with the patient 3. One systemic family talk per stay 4. One systemic one-on-one conversation a week 5. Systemic negotiating on conflicts on the ward (at least once): - medication intake - compulsory measures - abrupt requests for discharge 6. One systemic talk of discharge per stay SYMPA – PLUS PROGRAM 3 out of 6 items have to be fulfilled 1. More than one systemic one-on-one conversation a week 2. More than one systemic family talk per stay 3. Systemic group therapy 4. Patient is discussed (at least once) in: - systemic intervision and/or - systemic supervision 5. Patient and/or relative takes part (at least once) in: - systemic intervision and/or - systemic supervision 6. Preparations for discharge (at least one of the following items) - Conversation on diagnosis and/or - let the patient read through the discharge summary and/or - exchange with following treatment institutions
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