Mental health care in the Netherlands: macro- meso- and micro-scale complexity

More than ever, societal challenges seem to have us concerned with how to do things differently. We are looking for the new, but how do we let go of the old? These are complex issues that we can only change systemically, plurally and sometimes through ecosystems. Take the high figures around mental dysregulation, psychiatry no longer coping with this demand and the high costs involved. Judith Buysse at Sioo interviewed Floortje Scheepers, Head of innovation in mental health care at University Medical Centre Utrecht, scientific director at knowledge centre Phrenos and chair of the quality council. She asked: how should things change in psychiatry?

Translated from the original interview in Dutch: https://sioo.nl/actueel/blog/hoe-anders-ggz-hoogleraar-floortje-scheepers/

Are we a medical specialty or a socio-community entrepreneur?

Mental health care as a macro- meso- and micro- scale complex phenomenon.

To start: what exactly do we understand under mental dysregulation?

We need to look at mental problems as complex phenomena. One of the characteristics of complex phenomena, especially when it comes to open complex systems that are adaptive, is that there are no inherent linear relationships between cause and effect. There are many interactions that influence each other back and forth. And that means that sometimes something very small can set a complex system in motion and also throw it off balance. Through those same interactions, we need to search for how you can bring that system back into balance, and that can be the old balance, but it can also be a new balance.

"Actually, we cannot scientifically prove that those disorders really exist as separate entities."

If we maintain this phenomenology, we think more in terms of 'dysregulations' rather than 'disorders', where -according to the logic of disorders- there is one defect that linearly leads to a certain disease that you need to treat. And precisely this thinking has been a very dominant model in the entire healthcare sector in recent decades.

And that model is too simplistic for complex issues; how do you notice that?

I notice it, among other things, by the fact that after decades of much research, we still haven't found any biomarkers for mental disorders, that we actually have no valid evidence for the disorders as we have classified them in the DSM, the boundaries we have agreed upon in it. Actually, we cannot scientifically prove that those disorders really exist as separate entities.

I also notice it by the fact that the more complex the problems become, the more classifications people receive during their treatment in Mental Health Care, some even ten different ones.

Additionally, our protocolled interventions work insufficiently for a large group of people, especially those who are most dysregulated. We see that they need long-term support from Mental Health Care, which sometimes is more about 'care' than about 'cure'.

I also notice it because figures from, for example, the Trimbos Institute show that 47% of people get a psychological disorder at some point in their life. Then you can no longer speak of a disorder. That's just normal variation. So, there's a certain mental dysregulation that belongs to being human, but according to current opinions, we still look too unidimensionally at adjusting it. We just have to acknowledge that the boundaries of what we consider normal and abnormal are arbitrary, that we have thought them up ourselves.

It's strange that, for example, you must have 7 out of 8 symptoms to meet the criteria for ADHD. What are you then if you have 6; an exaggerator? Whether you meet enough criteria thus determines the boundary between not wanting to and not being able to. This increases the need for a label: after all, in the current healthcare system, in one case you are entitled to (more) care and recognition while in the other case you have to figure out how to deal with it yourself.

So if not the number of people with a disorder is growing, what is growing then?

If you get a diagnosis in the current system, then you get an identity with which you get space for your imperfections as it were. It's a legitimization for the things that are difficult or don't succeed in life. That's obviously a very powerful mechanism, and with it, we are actually reinforcing the classification model that we have conceived ourselves.

So what seems to be growing is the discomfort we feel with failure without a 'cause'. It's difficult to accept that some things are difficult and that you can't be successful in everything. The pursuit of perfection is, I think, also strongly influenced by the power of social media. That is clearly visible on the external level, but equally on a mental level; that we keep "challenging ourselves" on all fronts.

"If you get a diagnosis in the current system, then you get an identity with which you get space for your imperfections as it were."

These are developments in recent years in which both prosperity and the number of choices for designing your life has increased. It has become increasingly difficult to accept that despite all those choices, things fail and are difficult. The world is not black and white. On the one hand, successful through one's own actions and on the other hand vulnerable and 'sick'. We are all in the grey shades between.

You can talk to a professional about problems, but we should more often share on the playground or at a party how difficult it is to raise a child, for example. How do you lower the bar for yourself, without getting 'FOMO' or being afraid of the lack of understanding from your environment? How do you ask for help or indicate that you should not take on anything extra?

The burnout figures are telling, but it's often not just about work pressure, but the pressure we put on ourselves, in all areas of our lives. We need to engage in dialogue about the impact of, for example, social media on our self- and worldview before the GGZ [effectively, the Dutch mental health care system] completely bursts at the seams. I wonder if we will be on time or if it really has to come to the point that two out of three people just can't handle it anymore.

If there are so many unknown factors that influence our mental well-being, how can we then set up good treatment frameworks?

I think a conversation should always start with making it clear that we are trying to understand the problems together and that it won't be simply solved. It's your recovery process: what can you adjust in your life, beliefs, or relationships with others? How can you be helped by your loved ones and what can professionals add to that? In other words: how can I [a mental health professional] connect with your own network to push you a bit in the right direction so that you yourself will find that new balance to move forward with.

I think we're doing it the wrong way round at the moment with 'how can I help you?'. Precisely because mental problems are fundamentally about interactions, you'll have to be clear about that from the very beginning, and that has two advantages. First, there will be a group of people who currently turn to the mental health care system, who can solve a large part themselves with the help of advice and with their loved ones. Together, we can look at where their potential lies and which "knobs" they can turn. Then you see that much less [formal] mental health care is actually needed.

"We need to engage in dialogue about the impact of, for example, social media on our self- and worldview, before the mental health care system completely bursts at the seams."

The second advantage is that you don't fall into the trap of setting more and more treatment on the individual and on symptoms, while other matters are playing in that life that can contribute positively or negatively to mental well-being. It's a mechanism that arises if you approach the problems too much from one perspective.

What does that change require from the ecosystem around psychiatry?

It requires future psychiatrists to dare to step off their expert pedestal, to engage in person-to-person contact first and to use their professionalism appropriately when it adds value.

Additionally, I think we need to move away from that whole 'blue thinking'*; that you can determine in symptom questionnaires whether the treatment has been successful. We should focus on personal goal achievement. From the beginning of the trajectory together formulate: what are your personal goals and what do you want to achieve with this treatment? Then you agree when you will evaluate together and then you can discuss whether goals should be adjusted.

That's about value-driven care: what is important for someone and which care could help in achieving those personal goals and that value for the patient? In somatic medicine, you sometimes hear 'operation succeeded, patient died'; you can do everything exactly according to the guidelines, but that doesn't necessarily mean that you have added value.

This is why we also call it a 'wicked problem'. How do you change that system? What keeps us in its grip is working according to protocols aimed at preventing incidents and calamities. Focused on safety and on accountability.

We need to move to a system where you allow learning and improvement again and where you say: the knowledge we now have about care is not a strict guideline but offers a toolbox that you can use, whereby you gain new insights during the treatment relationship with the patient and can flexibly respond to them.

"What keeps us in its grip is working according to protocols aimed at preventing incidents and calamities."

That requires sufficient moral awareness at care organizations about what they are for, to be able to organize that care together well. That also requires space and time to do, but also budgetary certainty. The healthcare system is still very production-oriented: the more you produce, the more you get. And only then can those organizations keep their staff working. You could also secure those budgets and guarantee that remaining budgets can be used for innovation. And that also requires a dialogue at the macro level between parties such as insurers or municipalities, care organizations, professionals, patients, and citizens who want to have a say in where the money goes.

Psychiatry has long been searching for its identity: what are we? Are we a medical specialty or are we a socio-community entrepreneur? I think it's both and actually, that applies to the entire care sector. I would like to see care more embedded in society, focused on prevention and a healthy lifestyle, what people can do themselves. Care organizations that are part of a public dialogue about what health is and what we find important together. What do we want to pay for show solidarity for? And where do we think someone's own responsibility also plays a role?

That could give a huge boost to that conversation in society. Maybe we should tear down the hospitals and be much more in society with health centers or walk-in centers where you can discuss your health with professionals. And of course, there should still be buildings somewhere where complicated operations can be performed, but then they would rather be supplementary to that basic care.

Where to begin - what concrete challenges do you think can be tackled in Dutch psychiatry?

The most important challenge lies in bending the individual view of problems and solutions towards a network approach. So empower people and the networks around them: there as a mental health care system to connect instead of 'temporarily taking over'.

The second challenge lies in formulating how we are going to focus on the prevention of mental dysregulation in society: what should we do differently in our upbringing and in our schools? What should we do differently in our organizations for employees, to remain in balance? By that, I mean that as individuals we are responsible for creating peace and space in our lives, but employers cannot make do with offering yoga as the pinnacle of their wellness policy.

"The most important challenge lies in bending the individual view of problems and solutions towards a network approach."

Third, it would be handy for the whole system if we try to move away a bit from that whole blue*, orderly working. And create space for that complexity and allow creativity to deal with that complexity.

What are, for you as a change agent working with these complex issues, the specific challenges?

For the past ten years, I have been busy at various levels: macro-, meso-, and micro-level implementing changes. You can't foresee what you're going to encounter but diverse it certainly is. Machiavelli said a long time ago that change agents call a lot of misery upon themselves. Care professionals who feel resistance because they are afraid of losing their identity as a medical professional. Patients who stubbornly cling to a classification because they get recognition through it. Parents who demand that their child gets a label, because they are afraid that otherwise, they are not supporting their child to perform to the maximum.

Leaders that change and who don't want to continue the work of their predecessor, but want to set up something new themselves. Scientists who dedicate their careers to certain knowledge about a certain disorder and who don't want to let go of that. Financiers who believe in old, traditional science and therefore do not accept new research as evidence.

Regions where interests are related to money and position so that one organization is not willing to transfer part of the resources to another organization. There are many obstacles.

It's tough going, but we must not give up, we must be happy with small steps, constantly go through the change cycle again and again understand: what's happening here now? And then just try something and slowly notice that something is moving.

At University Medical Centre Utrecht, we try to set up a self-learning system where we reflect on what we do with patients and professionals. A kind of cyclical process of constantly looking together: are we doing the right thing? Where does that lead and do we need to adjust? And keep repeating this.

"There are many obstacles. It's tough going, but we must not give up, we must be happy with small steps."

If we succeed, then you reduce the administrative burden and make time to hold dialogues, start reflection sessions with which job satisfaction grows, and more peace and space are experienced. That could become the 'new working'.

Furthermore, I hope that we get strong regions in the Netherlands, that as regions we work together much more for all those citizens living there. When someone comes to me in the consultation room, it's about the person and their network and I find information from other caregivers and previous trajectories in one file. I look at how I can connect to that.

I will keep working towards that future, until I retire or end up at home with a burnout, which is also possible.

* In the Netherlands a very popular taxonomy to think about the different schools of change has been created by two professors and they use colours for that. Blue thinking is a rational, plan-based approach that assumes that what you measure is reality, and that you can make the world as you want it. https://managementmodellensite.nl/kleurenmodel-caluwe/