Trialog—an exercise in communication between consumers, carers and professional mental health workers beyond role stereotypes

Community mental health work strives for person-centeredness, resource- and recovery-orientation [1]. Person-centered recovery-oriented care in the community needs well functioning communication and collaboration between mental health workers of different backgrounds with users of services and their families and friends. During the last years in mental health—as in other medical fields—patients have been assuming a more active consumer-role in a partnership model of care instead of being the passive subject of treatment in a paternalistic relationship. New forms of collaborations require new skills of clinicians, service users and their families and friends.

Trialog stands for the encounter of the three main groups of individuals who deal with psychiatric problems and disorders and with the mental health system—people with experiences of severe mental distress, family members and friends and mental health professionals—on equal footing. Trialog occurs under special conditions—outside the family, outside psychiatric institutions, outside a therapeutic setting. It is the aim of the Trialog to facilitate communication about the personal experiences in dealing with psychiatric problems and disorders and their consequences. The participating groups strive towards giving up their isolation and lack of common language. Mutual understanding and necessary delimitation from the vast variety of the participants' different backgrounds concerning experience and knowledge are to be established. Trying to understand and sharing the complex and heterogeneous subjective experiences leads to a common language and a basis for a culture of discussion as is necessary for working together effectively. It is widely argued from different areas of research that acknowledging the personal experiences of users and their families and friends in planning, organizing and doing practical work is necessary to improve both research and practice in dealing with psychiatric problems and disorders [2]. Engaging in the Trialog is the necessary training to further enhance this process.

In German speaking countries about 5000 people are engaged in well over 100 groups and obviously benefit from their participation in Trialog. The European Families' Organisation EUFAMI [3] in 2003 recommended trialog groups for their European membership. Trialogs have started in French speaking Switzerland, in Poland and Lichtenstein. Interest in English-speaking countries like US and UK is growing. An experiment with a Trialog in Turkey in 2006 during a Congress of the World Psychiatric Association went very well and collegues from as far as Trinidad and Tobago felt encouraged to follow-up on the concept of Trialog in their home country. Looking at example of topics covered by Trialog groups—e.g. stigma and discrimination; work and social integration; diagnosis as a trap—being put in a box: religion and psychosis; silent users—who is helping them?—does lend credit to the idea that people all over the world might benefit from such exchanges. Trialog groups also lead to initiation of outside activities, such as serving on quality control boards and trialogic training courses for police officers.

The ‘First Vienna Trialog’ was established after the World Conference for Social Psychiatry in Hamburg in 1994 by a small group of people representing users, relatives and professionals. Since then, Trialog meetings are being held twice a month with 10–40 people in attendance. In the beginning, the meetings were only publicized verbally, followed by newspaper ads and announcements within user- and professional organizations. Trialogie is an open group—everyone interested in participating is welcome. It was our experience from the start that users formed the largest share of regular participants, followed by family members and friends and professionals (social workers, psychologists, nurses, patient's advocates, guardians, psychiatrists). As an open group, the number of attendants and the compositions of members from the three groups vary each time, and there is a mix of regulars and of those who drop by to see what the group is like. During the time of the group's existence the venue of meetings has changed a couple of times. Besides financial considerations, we strived towards finding a place outside psychiatric institutions, unaffiliated with a particular self help organisation and apart from therapeutic or family relations thus offering a ‘neutral ground’ that does not offer an advantage or a privilege for any of the participating groups. For the same reason, we prefer a rotating system of different members in the role of moderator to a model of professional moderation.

A role model for the ‘First Vienna Trialog’ was the ‘psychosis seminar’ in Hamburg. The over 100 trialogic seminars in Germany, Switzerland and Austria use different names, such as ‘exchange of experiences with psychosis’ or ‘From dialogue to Trialog’. As a result of a meeting of many different members of such groups a team of people began to evaluate the results of the psychosis seminars and published a guideline in 2000 [4].

We hope that the published accounts of our experience [5], which we reported in a trialogic format, succeed in demonstrating how new, different, extraordinary and unusual this type of encounter is. We emphasized the unique personal and professional learning opportunities trialog engenders as well as highlight the difficulties that can arise when you engage in a trialog as a whole person, start to accept the different members of the group as equally entitled experts, and try not to avoid relevant conflicts of interest. However, when we encourage taking trialog serious we also point out all the fun that it brings. “There is much laughter within the Trialog, which is seen as a powerful remedy” is one important conclusion by a mother talking about her experiences as a trialog group member.

Bock and Priebe [6] describe characteristics, history, and possible benefits of psychosis-seminars and trialog groups. From experience and from the few data on Psychosis Seminars in Germany it looks like many participants are characterized by a lot of experience, often over many years. Main benefits for carers stem from gaining knowledge, sharing experience and being able to discuss concrete issues they struggle with within their family with persons, who know similar situations from their own experience, but with whom they are not intimately entangled through emotional and biographical bonds. Consumers benefit from respect for their psychotic experiences and a chance to make sense of these and other experiences in their personal social and biographical context. Professionals value not only the opportunity to gain new insights into the experience of psychiatric problems, but also review their role and their practices in new and comprehensive perspectives. Many attendants share the wish to improve current psychiatric practices and advance the concepts of mental illness and health.

Trialogues are inexpensive, widely seen as beneficial, and has developed concepts and terminology which differs from a biomedical model of mental illness (which is still widely prevalent in the mental health system). Specifically, it provides an opportunity to interact outside role stereotypes, and a learning forum for working together on an equal basis—as ‘experts by experience’ and as ‘experts by training’.