Introduction

Research from Wittenberg, Kwekkeboom Staaks, Verhoeff, and De Boer (2017) showed that roles of informal caregivers, such as family and friends, are not always taken into account and discussed in the care for people with psychiatric problems and that the division of different caring responsibilities is sometimes unclear. They argue that an explicit discussion on the assignment of caring responsibilities is necessary to realize good collaboration; professionals should build a relationship with informal caregivers wherein they explicitly discuss divisions of care with informal caregivers. Family Group Conferencing (FGC) offers a new decision model to discuss caring responsibilities for clients.

FGC facilitates persons and their social networks to deal with problems in a way that is consistent with their own culture and lifestyle (Jackson & Morris, 1999). It is a family-oriented approach that has its origin in New Zealand’s Maori tradition, recognizing the importance of collective responsibility for families and near community (Doolan, 2012). Studies showed that FGC can bring families and social networks closer together, strengthen family and network ties and widen the circle of support for those dealing with a problematic situation (Frost, Abram, & Burgess, 2012; Skaale Havnen & Christiansen, 2014). Sharing stories and different perspectives on a problematic situation (which was the reason for organizing a FGC in the first place) can lead to more understanding and generate ideas to deal with the situation.

In a FGC, an individual dealing with a problematic situation (or in the case of this study a client) is referred to as a main actor (we will use both main actor and client). Main actors set the agenda for the conference and decide who is invited (for example, family, friends, neighbors, professionals). The FGC coordinator has a facilitating role in this process and supports the main actor in the preparation of the conference. In our context (The Netherlands), the function of the coordinator is characterized by an independent position, meaning that he or she is not on the pay roll of a welfare or healthcare organization. Coordinators do not meddle with the content of the situation, and they widen the circle of support by visiting (potential) participants of the conference and have no interest with regard to the outcomes of the FGC (Skaale Havnen & Christiansen, 2014).

The process of a FGC has four different stages. In the first stage, a referral to the FGC has to take place, and this can be done by the main actor, a family member or professional. A coordinator is then matched to the situation and asked to support the preparation of the conference and facilitates the conference in the other stages (second stage). In the third stage, the conference takes place. This is usually one or two months after the referral. The conference itself has three different phases; in the first phase, information is shared between the participants. Professionals can share information that could be used for drawing up the action plan that is made in the next phase. In the second phase, the coordinator and professional(s) leave and the main actor and other participants (social network) discuss the information and develop a plan to deal with the problematic situation of the main actor. In this plan activities to deal with the problematic situation and the roles of the different participants are described. At the end of the conference, the coordinator and professionals come back and the plan is finalized; one of the participants is appointed to monitor the plan. Monitoring and adjusting the plan is known as the fourth stage of FGC (Skaale Havnen & Christiansen, 2014). For more information on FGC and underlying principles, we refer to our other article in this journal (Schout, Meijer, & De Jong, 2017).

We discussed the added value of FGC in (public) mental health care in this journal and underlined that FGC provides a possibility to realize partnerships between clients, their social networks and professionals (Schout et al., 2017). Based on a quantitative study, we demonstrated that FGC is a promising way to inhibit isolation, restore ownership and strengthen or widen the circle of social support in the context of coercive psychiatry (see De Jong, 2014; De Jong & Schout, 2011; Meijer, Schout, De Jong & Abma, 2017). The purpose of this article is to understand the process of FGC in the context of coercive psychiatry in order to further discover its opportunities and limitations in forming a partnership between clients, their social networks and mental health professionals.

The study

Design

This article is based on data drawn from a study into the process (qualitative) and impact (quantitative) of (the preparation of) FGCs organized for clients who were at risk of coercive treatment in psychiatry, in the Netherlands. In this article, we will focus on the process of the FGC based on qualitative data. The impact of FGC in coercive psychiatry (quantitative data) is reported on in Meijer et al. (2017). The study took place between 2013 and 2015. FGCs were organized in three regions in the Netherlands in collaboration with three mental health institutions (Groningen, Noord-Holland Noord and Eindhoven). The 41 FGCs were facilitated and organized by ‘de Eigen Kracht Centrale’, a national foundation that is responsible for organizing FGCs in the Netherlands. The coordinators are affiliated with ‘de Eigen Kracht Centrale’, but are not employed by this organization.

A responsive evaluation within a case study framework was deployed to study the process leading up to the FGC and the process and the proceedings and the impact of the conference itself. Responsive evaluation is an approach to evaluation aimed at deriving more insight from the insiders perspective, responsive to issues, values, experiences and interests of different stakeholders and their context (see Abma, 2006; Stake, 2004). This design was used to address the deliberative and exploratory nature of the study, where experiences of participants on the process and impact of the FGC are central (See Abma, Nierse, & Widdershoven, 2009, 2016; Stake, 2004).

Every client and the FGC conference for this specific client was a case in this study and seen as unique. Although the study consisted out of 41 cases, this allowed us to gain insight into the particularities of the cases (Abma & Stake, 2014). We aimed at comprehending the different cases in line with the tradition of ‘Verstehen’ (understanding from a first-person perspective), meaning that ‘it is not so much the factual world that interests us, but the interactively constructed meaning endowed to the world’ (Abma & Stake, 2014, p. 1152). We made a case report of each case that reflects the meaning and context of that case, in order to understand the particularities of the case. In this study, the data were enriched with theory. The data collection and analysis followed an iterative process, as theory was not imposed a priori but gradually plugged in on the basis of findings, for enrichment of data and deepening of insights.

The researchers were not part of the actual FGC, but retrospectively monitored how conferences were introduced, and how clients were included and assessed the meaning and value of the FGC afterward with interviews and focus groups.

Participants

At three mental health institutions in the aforementioned regions, the option of a FGC was a consideration presented to clients by mental health professionals. Clients were included in the study when there was an imminent or actual coercive treatment at hand or a history of recurrent coercive treatments was present. All clients needed to have a municipal bond to one of the three regions. The participants in this study were the attendees of the FGCs: clients, family members, neighbors, friends, colleagues, professionals (primarily community mental health nurses and psychiatrists) and FGC coordinators.

From data to thick descriptions in a case report

Attendees to the conferences were individually interviewed on the process and impact of the FGC one to six months after the conferences took place. A total of 289 interviews, about 41 FGCs, were conducted by the research group. The interviews consisted of open and closed questions and lasted approximately 1 hour. These were conducted with a topic list on the situation prior to the conference, the conference itself and the situation after the conference. The interviews were recorded, transcribed and summarized in a case report with preliminary conclusions of the process and impact of the FGC. This was discussed in a member check with the participants of the FGC (Lincoln & Guba, 1985). In addition, participant observations were conducted to understand the process of organizing FGCs, including communication among attendees and their interactions, and led to field notes. The field notes and interpretations from interviews and member checks were described by the researchers, with theoretical and empirical memos, and discussed within the research group (Emerson, Fretz, & Shaw, 2011). This resulted in the so-called thick descriptions (Abma & Stake, 2014).

With insights from the multiple case study-approach generic themes that bind the cases together were identified (Abma & Stake, 2014). We discussed the data from the different regions, searched for themes and patterns that we encountered multiple times and that seemed underlying the cases.

Validity, reliability and rigor

Perspectives from different actors were included to obtain a rich and multiple understanding of the process of FGCs in coercive psychiatry. Interviews per case continued until no new information and no new insights on the process or impact of the conference popped up; this is an indication of methodological quality and refers to saturation of information (Guba & Lincoln, 1989; Guest, Bunce, & Johnson, 2006; Small, 2009). Finally, triangulation took place in different ways, by comparing findings between the different methods (interviews, member checks and participant observations); by comparing findings between different cases and regions; by comparing findings between researchers; and by comparing findings between different participants within one case.

Ethical considerations

The research proposal was presented to the scientific research committee of the VU University Medical Center and the three mental health organizations that contributed to the study: Lentis, GGZ NHN and GGzE. The study was approved under the condition of informed consent, taking into account safeguards concerning privacy, anonymity and confidentiality.

Findings

The outcomes of FGC in coercive psychiatry will be discussed through different themes and stories that show what was going on in the 41 cases. The themes will be discussed in two parts: (1) outcomes of FGC in coercive psychiatry and (2) conditions in forming a partnership.

Part I: Outcomes of FGC in coercive psychiatry

Ownership over the situation and taking initiative after the FGC

Several clients mentioned that the FGC contributed to their feelings of ownership (the feeling of having control) over the situation. For example, appointments and agreements with family and friends gave more structure to the life of clients, served as an extra motivation or ensured that a client could get used to the daily rhythm of ‘normal life’ after being admitted to a psychiatric hospital. Clients indicated that agreements made with loved ones are serious, more serious than those made with professionals:

Since it—the agreements—is written on paper, and I said ‘’yes’’ to it, I cannot fool myself anymore and try to get away with it by not complying to them. That does not make it easier for me, however it does make it more serious. [Client]

In a number of FGCs, explicit attention was paid to the ‘crisis alert plan’ to prevent crisis situations; this was often brought up by the clients and involved professionals. This ensured that social networks had an overview of the signals that indicate that a crisis situation was emerging. The agreements in the FGC plan also provided more grip for the immediate family, and they experienced more control over the situation because the burden of care was divided over several shoulders:

…Now I know my sister or mother is visiting him and I don’t have to worry; I have more peace of mind. Before I had a dormant feeling because I knew that he was home alone and unhappy and that affected me of course. So this give me more peace of mind. [Family member]

There were also several cases where those involved did not experience more control over the situation after the conference, because nothing really changed; this was, for example, the case in situations where the client did not show any initiative or ownership with regard to the plan that was made. Family members or friends were sometimes really clear about their expectations:

But we've always said, we're not going to motivate and encourage him, he has to do it himself…the agreement was that he would take initiative, if he doesn’t do that. he has to deal with the consequences. [Uncle]

These fragments show that gaining ownership over the situation could be complicated and challenging at the moment that different actors did not take initiative in the situation; the conference then had little impact.

Belongingness and widening the circle of support

In the process before the conference, it sometimes happened that clients were hesitant in involving family members. They wanted to protect them and did not want to burden them unnecessarily:

I thought: I already have so much professional support, what can this contribute? I also did not want to do an appeal on my social network. I knew for sure that I wanted to have my girlfriend and my sister there, but yeah. then they were also burdened with my situation. [Client]

The cases show that by discussing the problem and asking support from those involved during the preparation of the FGC, already changed the relationships. There was more understanding for the client’s situation amongst family and friends, and sometimes they came to the realization that the situation was more critical than they thought; the problems related to their mental health, finances or housing were more severe. This led to a stronger involvement, support and willingness to take action. In several cases, it was also mentioned that the circle of those involved had increased after the FGC:

That is what a conference is for, I think, to support [name client] and to literally say: ‘’Here we are, we are there for you’’. And if you need support, just ask it. So we literally told him that we support him and that we are there for him. Others in the family have also opened up to him now. First they did not want anything to do with him and now they are committed to supporting him too. So it—the conference—has done a lot of good. [Family member]

However, there were also family networks where it was difficult to divide tasks and make plans, especially when the family experienced a lot of burden. These networks had often lost their energy, did not know how to deal with the psychological vulnerability of their relative and did not want to be involved anymore:

Family members have tried a lot in this situation, but at a certain point they could not reach him anymore and invested so much in it—in the situation—that they said we are going to let go now. Because they could not handle it anymore. [Professional]

In some cases the FGC alone was not enough to widen the circle of support and to mobilize more people. The fragments below show that in cases of severe and ongoing mental health problems, the role of continuous and durable professional support is crucial in forming a partnership with families and friends; they need to know whether a professional is there to back them up, especially in crisis situations, before they express commitment to support the client (again). We will discuss the role of professionals further on in this section and in the discussion.

And for us, that our care—for the client—was taken care of, because my father did not sleep at a given moment. He did not go to work anymore or he went to work occasionally. He could not handle it anymore, so much worries […] So yes, at a given moment you will suffer from it yourself, or there are people who suffer so badly that they will experience consequences in their own lives themselves. [Family member]

The last four member checks make it clear that family members dare to participate in a conference if mental health professionals are a continuous factor, are available to the family and are clear about their role and responsibilities. As soon as they experience doubts about the accessibility or availability of the mental health professionals the family members are reluctant to actively participate in the conference and take responsibility in the plan that is made. (Empirical Memo, no. 40).

Part II: Conditions in forming a partnership

Disclosing shameful feelings and embracing vulnerability

The experience of shameful feelings was a barrier when inviting people for the FGC. Clients and close relatives did not always dare or wish to widen the circle of support and involve too many people:

I constantly had the feeling of; I really have to cross the threshold and go to someone again, give them an explanation about the situation I’m in. And invite them to the FGC…[Client]

The psychiatric problems of the clients were often accompanied by shame and (self) stigma:

The constant comparing with other people and then uh yes, saying: ‘I'm lying in the gutter and what have I done with my life’ and stuff like that. And also, well that does not have anything to do with his depression maybe. What I noticed when we meet with our eating club is that he found it very scary, very exciting to come into a social group. [Friend]

Asking others for support required openness from clients and their relatives, people sometimes had to overcome embarrassment and were challenged to confront their vulnerability. If participants experienced troubles related to the foregoing, this could have as a consequence that the situation was not discussed openly. Ultimately, this could lead to a situation wherein the plan did not meet the needs of the client or to what the social network needed or could offer. On the other hand, it also occurred that a FGC was a reason to break with taboos and prejudices in social networks and contributed to strengthening the relationships.

Avoiding confrontations

We saw that the loved ones sometimes avoided the confrontation because of what occurred in the past. They focused on the future, avoided confrontation and did not make an effort to discuss concrete agreements, with the result that plans were not concrete enough regarding to boundaries and expectations.

In some cases where participants made plans in the conferences, these plans were later labeled as ‘romantic’ or insufficiently capable of preventing new crisis situations. The plans did not provide a clearly defined path; there was little regard for the various relationships and underlying expectations and insufficient attention was paid to the concreteness of the plan. Some social networks did not seem to have the capacity to come to a plan that could meet the needs of those involved in the crisis situation, and in the conference they avoided discussions about difficult situations:

We did not discuss—in the conference—his psychiatric problems, which he experiences regularly. [Family member]

There were some social networks that wanted to keep peace and did not took the effort to confront the client, because they were afraid of losing contact, leading to social isolation of the client. In many situations, those involved were ready to take responsibility and did not avoid ‘the place of difficulty’ as they participated in the conference, the following memo illustrates this:

During the member check it becomes clear that the client (whose situation was a motive for organizing the conference) is satisfied with his quiet and peaceful life. In the conference this was not discussed, attention was given to the point of view of the family, they think he should make more of his life. The family did however not participate in the member check and avoided the ‘place of difficulty’. Perhaps because the family was absent, the client stood up for his own opinion about his life.[Empirical Memo, no. 44]

The above example illustrates what we often encountered in our study; in the conference, participants were involved and made plans with each other. But in hindsight it became clear that actors did not always confront each other and did not discuss different expectations.

Change of attitude needed amongst mental health professionals

The logic of a FGC with an independent coordinator, a conference that takes place outside the mental health care organization and where professionals contribute to a plan that the family group makes, is distant from mental health practice. Professionals had to discover how to deal with situations that occurred during the FGC and which roles and responsibilities they had.

There were families and friends who were suspicious of the mental health care organizations that the professionals represented, through experiences with these organizations. They felt abandoned but wanted to be heard. The following fragment illustrates the foregoing and shows that the family eventually seemed to need recognition from professionals:

We also felt left alone by all the professionals, they only had attention for her, while she was actually the problem. There has never been a conversation with us, no one ever talked to us. So at one point we were done with them. I have called all general practitioners, all kinds of mental health professionals and some of them did not even want to talk to me, only to her [the client]. That was the end of it. [Family member]

It was indicated by family, friends and neighbors that they were happy to meet the professionals and to exchange information during the conference. Professionals could respond to this for example, by providing information about the problem (in consultation with the client). In the few situations in which the latter occurred, we often saw positive outcomes; the client continued to work on his plans for the future, together with family, friends and professionals:

…because you just know each other, in terms of face to face contact, because you have a lot to do with each other, the line is short, so that makes it easier to stay in contact and reach out to each other. And maybe that is the advantage of the FGC in this case, that the thresholds are gone when it comes to contact—with the social network. [Professional]

It is important to note that this support by professionals led to shared control and not to more coercion. In some cases, we also saw that professionals felt it was important to ensure that the situation prior to the FGC was as optimal or comfortable as possible for the client. But also afterward, ensure that the process after the conference is as positive or hopeful as possible:

The plan described what the professionals from our organization had to do. The part of the network was completely missing. So I sent the plan back and they—client and social network—will soon come together to adjust it. This is the second time I have sent the plan back to them. I want to read what the social network can do at the moment that the client faces a crisis situation. For example visiting him, people going on trips with him, some housekeeping and administration maybe. In the plan this is not described. They have to discuss this further. The family keeps me well informed about this process. [Professional]

We also saw that professionals had different attitudes toward the FGC and its process; sometimes they found it hard not to interfere in the situation or the FGC rose awareness of the importance of involving family in the treatment of clients. Supporting clients and their relatives, however, was experienced as difficult and was sometimes distant from professional work routines. The following fragments exemplify this:

He ([the involved professional] also said to me at the end of the conference, you have to think about this and about that—with regards to situation of the client and family. I said; I do not have to think about anything, just let the family do the thinking. He could hardly let that go, but that is his role. He is good at his job and is someone who stimulates ownership over the situation. Still, I saw that he found it difficult to let this go. [Coordinator]

The facilitating role of the coordinator

The coordinator had a facilitating role in the process of forming a partnership. This role was valued positively when they were able to give guidance to the conference, as a prelude to a plan that offered support. Coordination with the client and the network, but also with professionals (with regard to coercive measures), was of importance and was sometimes missed. A clear structure and procedure of an FGC gave the participants grip on the process:

So I had a very clear assignment, which I also prepared with Mrs. So for me it offered a lot of clarity in that sense; that I could prepare myself very focused and knew what I could or could not do [in the FGC]. [Professional]

There were, however, also situations wherein the coordinators saw that the discussed plan was not very concrete and sometimes struggled with their role, as illustrated in this fragment:

Nothing was mentioned—in the plan—about helping with things or doing something together; it was all about what the client should do. I tried to facilitate them in this, actually I do not allow myself to interfere with the content, but I did that a bit. It was good that they all came together in the conference and talked—that was good and valuable in itself, but more could have been done. [Coordinator]

Discussion

Meleis (2011) points out that there are many nursing theories, perspectives and views on the essence of the nursing domain. Her work and that of Kim (2010) underline this variety, but central views are that nurses support self-care and empower clients to care for themselves, and to manage their symptoms and their life transitions by utilizing available resources and creating new resources. Nurses focus on affecting the ability for coping, self-care, human becoming and adaptation, not only for individuals but also for communities. These central concepts separate nursing’s orientation from that of disease (Kim, 2010, p. 4–5). Supporting and facilitating of informal structures, such as families and communities who are engaged in caregiving, helping individuals, families and communities to cope with the stress of illness and life events, is central to many nursing theories (see Meleis, 2011, p. 87–108). Helping to cope reflects a modest rhetoric, a rhetoric which fits the way of thinking in the field of FGC. Mobilizing resources from family and communities is central in both lines of thought.

The process of FGC is, however, complex and builds on the contribution of different actors: the client, the involved social network, professionals and the FGC coordinator. A FGC can contribute to feelings of ownership over the situation (the client is in) and to a stronger involvement and support amongst social network members. Many factors determine the success or failure of an FGC, but the commitment of these actors is essential. Schout and de Jong (2018) mention, however, that professionals, such as nurses, tend to underestimate capabilities of the client and social network and overestimate professionals’ capacities. They argue that this is the result of bureaucratization, legalization and risk aversion. These market-driven incentives together with an emphasis on privacy legislation and ‘medicalization’ are an obstacle in mobilizing informal support in psychiatry. FGC requires a change of attitude for mental health professionals; it means more than involving family in the situation of the client. Instead of focusing on the individual clients, professionals support the primary group to deal with the situation at hand; with their expertise, they contribute to the plans of clients and their social network taking over as little as possible, validating their commitment and control over the situation. Schout and de Jong (2018) describe this professional stance as ‘egoless’ care, where professionals mobilize social resources and have confidence in the ability in the group to deal with challenging situations.

Jansen, Baur, De Wit, Wilbrink, and Abma (2015) developed a partnership framework as a practical tool to facilitate dialog between different stakeholders, consisting of four components: values, relations, actions and conditional factors. They based their framework on Hook (2006), who identified eight partnership facets between clients and professionals: relationship, power sharing, shared decision-making, patient autonomy, shared knowledge, participation, communication and professional competence. These elements are relevant in the forming of a partnership between the different actors in FGC. They show the importance of disclosing shameful feelings, embracing vulnerability, confronting each other and discussing different expectations between the involved actors. Furthermore, the framework stresses that professional competence is important when it comes to shared decision making.

Additionally, participants of a FGC need to be challenged by mental health professionals and the FGC coordinator to discuss difficult situations and confront each other about their expectations and roles. The concept of ‘courageous conversations’ fits well here. This concept is often used in work on race and gender or social justice and encourages to take risks in conversations, speak the truth and experience discomfort instead of avoiding it (Arao & Clemens, 2013; Singleton & Hays, 2008; Singleton & Linton, 2006). Arao and Clemens (2013) complement this with the suggestion of cultivating ‘brave spaces’ instead of ‘safe spaces’, where courage is needed in the dialog with others. If you have to embrace your vulnerability, courage is required and this is rewarded with a deeper understanding of the situation and mutual trust. Courageous conversations can pave the way to forming a partnership, as mutual trust is being built this way and underlying expectations are discussed. An FGC can facilitate a dialog on values, relations, actions and conditional factors in forming a partnership. Further research into the facilitation of courageous conversations in a FGC seems necessary.

Limitations

Our intention was to continue with conducting interviews per case or conference until there were was no new information and no new patterns. This is an indication of methodological quality and refers to saturation of information (Guba & Lincoln, 1989; Guest et al., 2006; Small, 2009). In one single case, it was only possible to reconstruct the process of the FGC from the perspectives of the FGC coordinator and involved professionals. As the research project progressed, different patterns emerged between the conferences; at one point reviewing new cases would have probably provided little new insights. The researchers did not participate in the actual FGCs, and they were, however, closely involved in the organization and discussed with FGC coordinators the organizing of conferences—developing a comprehensive image from multiple perspectives was therefore important.

By looking back on the data from a more nomothetic perspective, different themes emerged that run through the cases. New themes were uncovered, like the input of theory on courageous conversations, which provided a new and deeper insight that can be used to reduce coercion and strengthen partnership in psychiatry.

Conclusion and implications

The process of FGC in the context of coercive treatment in psychiatry is complex, as it builds on the input and commitment of different actors. Together these actors enact an open and new actuality enabled by the platform of a FGC. This study shows that FGC has the potential to provide a learning platform for partnership between professionals, clients and families affirming ownership and empowerment of the latter. It is of importance in forming this partnership that vulnerability is embraced and that courageous conversations are started. Furthermore, FGC requires a change of attitude for mental health professionals; instead of focusing on the treatment of individual clients, they need to support the primary group to deal with the situation at hand and contribute to the plans of clients and their networks, with their expertise. Mental health professionals need to understand hesitations and fears while encouraging actors to take part in ‘brave spaces’ instead of avoiding them. By studying this process further, with explicit attention for the pitfalls and possibilities in starting courageous conversations and creating a partnership, the application and potential of FGCs in psychiatry is explored.