On this page you can read interviews with NPI employees about their work.
The NPI has been offering day treatment for pregnant women with personality problems since 2020. Carlinde Broeks (researcher, psychiatrist and one of the initiators) and Jasmijn de Vos (clinical psychologist) talk about this new NPI expertise. "If the cloud is also allowed to be black, there is more room to feel the positive aspects."
Targeted specialist mental health care for pregnant clients did not yet exist in Amsterdam. That is why Carlinde set up the day treatment for pregnant women with a colleague in 2020. A multidisciplinary team of a psychiatrist, psychologists, a systemic therapist, a psychomotor therapist and a nurse offers day treatment to a group of pregnant women with personality problems one day a week according to a fixed program, for about twenty weeks. The clients are registered through general practitioners, midwives, POP clinics or practitioners from other Arkin specialties.
Carlinde: "We see that the women in our treatment suffer less from the psychological complaints they come in with. They start to feel more connected to their unborn child."
Jasmijn: "We are enthusiastic, and the women themselves are also positive. It really helps to think once a week about yourself, your baby, your pregnancy, what kind of mother you want to be."
Why is it important that there is group day treatment for pregnant women with a personality disorder?
Carlinde: "Psychiatric problems are often passed on within families. Children of parents with mental health problems are more likely to develop mental health problems later on. This risk increases further if both parents have complaints. Especially in women with personality problems, because personality problems often manifest themselves in relationships with others, including in the relationship with the child – even if it has not yet been born. We don't know exactly how that risk is transmitted to children. It is a combination of genetic factors, socioeconomic conditions, parenting effects. But what may also contribute is that babies are exposed to stress even before birth, due to psychological complaints in the mother during pregnancy."
Jasmijn: "If you have a lot of complaints as a client, it is often difficult to think about the pregnancy and to think about the baby. This is therefore an important focus of the day treatment. There is room to exchange ideas about complaints or problems that clients encounter in daily life, but there is also explicit attention for being pregnant and how they experience it. We invite clients to think about expectant motherhood and their baby."
Carlinde: "We know that early intervention, already during pregnancy, is the greatest health benefit for children. That makes day treatment for pregnant women so important, because then we can tackle the important themes before the child arrives."
Jasmijn: "Each treatment day focuses on a different theme. For example, the pink cloud. The women in this group regularly say about this: 'Everyone says I should be happy and oh, how great is that pink cloud, but my cloud is black, I don't feel happy at all yet. That makes me very sad.' Another important part of the treatment is that we talk about what you have experienced, what you have received from the past and what you do and do not want to pass on to your child."
Can you give an example?
Jasmijn: "For example, we see that clients had a parent who was boundless, thought a lot about himself and had little room for the emotions or experiences of the children. Clients have missed an important part of this. They indicate in the group that they want to do this differently themselves, that they do want to see their child and its emotions. , but struggle with this theme and can be anxious that they can't do it. For example, other clients struggle with the conviction that they are not doing well enough, or are inclined to adapt too much to the wishes of the other. These are, for example, many shared topics in the groups: the feeling that you are not allowed to be there, that you are not doing it right. And there is a lot of uncertainty about how they are going to do as a mother."
The treatment is always done in a group. What is the advantage of that?
Jasmijn: "The women receive recognition, recognition and support from the group, which is very important. They share things with each other that they often don't talk about with the outside world. In doing so, they support each other. If the cloud is also allowed to be black, there is more room to feel the positive aspects. We also see that in the group they sometimes get a mirror from each other, that others say: 'Clever how you do it, do you also reserve time for yourself?' The group is very diverse when you look at religion, sexual diversity, culture, but also when you look at differences in characters, education level and disciplines. We see women with a wide variety of complaints: compulsion, anxiety, sadness, eating disorders, addiction problems. It is nice how there is a lot of connection through pregnancy. And it's very refreshing, such a diverse group. Then three say: 'I recognize that, I'm so anxious too.' And says a fourth: 'So I don't have that at all.' Or someone says: 'The way you stand up for yourself in your relationship, I want it too. I want to become stronger.' In this way, they learn from each other. A group encourages reflection and is also a playing field to practice different behavior. For example, by speaking out, or by taking up space."
The group offers a lot of security
Jasmijn: "That's right. This is how the entire program is set up from start to finish. We call every new participant in advance and explain the practical things such as where to go and where you can park. Every week the program has the same structure. That also gives security, you know what to expect. And we have a permanent, close-knit team. There is a lot of knowledge in-house and we have a lot of fun and sociability together. The clients see that, it also offers safety."
What effect does the treatment have?
Carlinde: "We see that the women in our treatment suffer less from the psychological complaints they come in with. They start to feel more connected to their unborn child, and they start to think better – and milder – about their own thinking, feeling, acting and that of others."
Jasmijn: "Clients start thinking about what kind of mother they want to be, and become curious about their child. It gives them more peace and less stress during pregnancy. That's nice, because it's already such a precarious time."
Carlinde: "We know all this because we have been following the women scientifically since the start of the treatment in 2020 and have also interviewed a number of women about their experiences after the treatment. We see that sharing your experiences in a group of other pregnant women who are not all 'on the pink cloud' is very important."
Jasmijn: "We are enthusiastic, and the women themselves are also positive. It really helps to think about yourself, your baby, your pregnancy, what kind of mother you want to be once a week. They feel supported, recognized and seen. And they keep seeing each other, friendships come out of it."
Postpartum
After the birth, the treatment team follows the women for another three months. Where necessary, we think along about a possible follow-up treatment. For women who continue to have problems after childbirth, there is the option of following a postpartum group. This is a collaboration between the NPI and the Gnome House. The postpartum group is given by a practitioner from the pregnancy day treatment and an IMH specialist from the Gnome House.
The NPI is TOPGGz certified. Rien Van, director of treatment affairs and Birre van den Heuvel, researcher and clinical psychologist explain what this means for the NPI, the employees and the clients. "We are always looking at: what could we do differently and what is the status of the substantiation? That keeps you sharp."
The NPI has been TOPGGz certified since 2016. That means a lot, but in short, the NPI offers highly complex clients distinctive care with highly specialized and innovative treatments. Various scientific studies are underway, the employees publish about them and the NPI contributes to knowledge transfer and training of professionals.
Rien: "We do a lot of, for example, innovation of treatment programs and are working on giving experiential expertise a place. And scientific evidence plays a role in everything we do and our entire range of care.
Lagging behind
"We have deliberately used the TOPGGz recognition," says Rien Van, director of treatment affairs. "When we started as a new NPI ten years ago, there was a backlog in the knowledge and availability of good treatments in the field of personality problems. Despite clear improvements, also nationally, we are still not there. For example, you see that there is no academic department for personality disorders, while it is very common and has major consequences. We thought: through our scientific focus, we can contribute to a better situation for people suffering from personality problems."
Everything breathes TOPGGz
The NPI is working hard to meet all fourteen TOPGGz criteria at all four locations. Rien: "We do a lot of, for example, innovation of treatment programs and are working on giving experiential expertise a place. And scientific evidence plays a role in everything we do and our entire range of care. We always look at the effect of what we do and we convey that to the outside world." This scientific method gives employees a little less freedom, says Rien. Because in order to be able to do the tests properly, they have to carry out their treatments strictly according to the methods studied. "If you make all kinds of exceptions, you don't know what you're doing. But it has its use to keep it up; Regularly, a treatment method only works after a while."
Fun in science and innovation
Anyone who works at the NPI must therefore enjoy the scientific and innovative approach, and also propagate it, says Rien. "We select our people on that, because they form the identity of the NPI. We do not only start from a certain symptom, but look from a development-oriented dynamic way at how and why it could have arisen in this person. In this way, we hope to achieve a sustainable effect."
Attractive work package
Birre van den Heuvel, researcher and clinical psychologist, clearly enjoys the NPI's working method. "We do our treatment work embedded in scientific research. This results in a very varied and attractive work package. I really enjoy working on a small scale, with clients, and very large, internationally and scientifically, with the FORCE research." Permanent innovation, an important part of TOPGGz, also appeals to her. "The NPI continues to innovate and provide optimal care. We are always looking at: what could we do differently and what is the substantiation of what we are doing? It means that as an employee you don't feel so dozed off, you stay sharp."
Contributing to vocational training
NPI's permanent contribution to vocational training – another requirement of TOPGGz – also keeps the organization and employees on their toes. Rien: "Many people in training do an internship here and many permanent employees are teachers at one of the courses or supervise. Our employees can also develop continuously."
"We do our treatment work embedded in scientific research. This results in a very varied and attractive work package. I really enjoy working on a small scale, with clients, and very large, internationally and scientifically, with the FORCE research."
Valuable effort
Every four years, a review is carried out to determine whether the NPI meets the strict TOPGGz requirements. That was the case in 2016 and in 2020 and now in 2024 for the third time, says Rien. "That's quite an effort. Among other things, you have to have all the data in order, show publications about research, give presentations during the visitation, articulate everything well." But it is worth it, he thinks. "It makes visible what we stand for and where our focus lies."
Opportunity for improvement
Birre sees another improvement for the organization behind TOPGGz. "I would like more substantive interaction. We could benefit a lot from TOPGGz as an organization or from their network, but I don't notice much of that yet. I think there is still an opportunity to be more connected to another TOPGGz institute for personality disorders and to benefit from each other."
New perspective
The clients do benefit fully from the NPI's TOPGGz certificate, Birf notes. "You don't just get the TOPGGz certificate. TOPGGz concerns, among other things, highly specialized care. Clients therefore know that with us they are most likely to be treated as well as possible. Often they have had previous treatments that did not work. This means that they have sometimes pinned all their hopes on the NPI, or sometimes expect nothing more. But with our involvement, and our knowledge and expertise to the latest scientific insight, we always try to create a new perspective for them. I think the TOPGGz recognition is something to be proud of; We have all achieved this together."
The NPI has started NPI Online. It works, it is fun and it is pleasant for clients and practitioners. "I often forget that the screen is in between."
"We just do what we always do at the NPI, only online," says Hans Stolk, manager of operations at NPI Online. In other words: treatment via video calling, in English and Dutch. To see if NPI Online was really a good idea, a pilot was first held in 2022 with 25 individual schema therapy treatments. "That is the most manageable treatment in number of sessions and approach," explains Hans.
"It's in the air," says Hans about the reason for NPI Online, "and the government wants it. And if you start thinking about it, you see a lot of benefits."
Just fun
"It's in the air," says Hans about the reason for NPI Online, "and the government wants it. And if you start thinking about it, you will see many advantages. Fewer waiting times for the client, more flexibility for the practitioners. It has been accelerated by corona. Then we had to, and we noticed that we could do a lot. Now it is no longer necessary, but it is possible. Now it's just fun."
Voluntary
Online treatment is always voluntary, Hans emphasizes: "Client and practitioner have to like it, otherwise it won't work. It is also important that the client must remain safe." Clients who are likely to have a crisis are better treated face-to-face. Hans: "You have to be able to make agreements about what to do in the event of a crisis. It has hardly happened, but if necessary, someone in crisis can visit one of our branches for psychiatric support. In the introductory phase, we estimate whether someone can travel to us, if necessary." "We also always send the GP a letter about the online treatment, and we call about it," says online practitioner Safiye Yinelek.
More flexibility
The pilot was a success. There are many advantages, for the practitioners and for the clients. Practitioners have more flexibility. They can work from home more, if they want. And after moving, they can still continue to work at the NPI, or go to work at the NPI, even if they live far away.
Hans: "Working for NPI Online can also be a godsend for a colleague whose partner is going abroad. Another big advantage is that we don't lose expertise because someone moves." Safiye Yinelek worked as a psychotherapist at the NPI. Especially during the corona lockdowns, she felt torn between the Netherlands and Turkey, where all her family lives. In 2021, she moved to Istanbul. "I preferred to stay with one foot in the Netherlands, at the NPI, and with the other in Turkey, to live there. That turned out to be possible, because my manager asked if I wanted to work for NPI Online. Now I have the best of both worlds."
Satisfied practitioners
The practitioners are positive about working online, according to the evaluation of the pilot. They are satisfied with the extent to which they can make contact with the client. The practitioners also have a good feeling about their team, despite the fact that they only see each other online during intervisions and client meetings. Safiye: "I often forget that the screen is in between. The weekly meeting with the online team is a must, I really need that. Because I miss being able to walk into a colleague's room, or run into each other in the corridors or the lunch room. Then you share things. That's why I also work in a clinic in Istanbul."
Own familiar environment
Online treatment also has advantages for clients. It is accessible and accessible, it takes less time and clients do not have to take time off for it. "During a treatment session at NPI Online, you are in your own familiar environment," says a client. "You can furnish it the way you like it. I like the fact that I don't have to travel after the treatment and have to go back into society immediately. This gives me more time to process." Clients indicate that in the online conversations they can tell what their complaints are and what they encounter in daily life. All clients feel that their practitioner has gained a good picture of who they are and what their complaints are in the online conversation.
"I often forget that the screen is in between. The weekly meeting with the online team is a must, I really need that."
Promising
Not much research has been done on online treatment. But the studies that have been done are promising, says Hans. Research shows that results from online treatments are at least as good as those from on-site treatment. Hans: "Sometimes the quality is even better." To what extent exactly, is not yet known. He can only speculate about it. "Perhaps because the client and the practitioner consciously choose this form. Perhaps as a practitioner you give the method more pure, because you have less distraction from the non-verbal signals you receive in a room."
Shorter waiting times
A big advantage of the online treatments is that the waiting times are shorter. Hans: "The starting point is that if clients want to use NPI Online, we will also treat them quickly. So far, we have succeeded; including intake within four weeks. But we don't yet know how big the demand for online treatment will ultimately be." NPI Online is slowly expanding. During the intake, people who are suitable for online treatment (see box) are asked whether they would like online treatment. Hans: "We are now looking at what question comes our way and whether there are other treatments suitable to do online." Safiye: "The great thing is that it works.
For which clients is online treatment suitable?
The client:
Cluster C personality disorders are common, but little research has been done on which treatment is effective for whom. With the FORCE study, Martine Daniëls and Birre van den Heuvel of the NPI are changing this. Both are committed to giving clients with cluster C personality disorders the attention they deserve. Martine talks about their research.
About half of the clients who enter the NPI have an avoidant, dependent or compulsive personality disorder, or a cluster C personality disorder. There are all kinds of treatments for these clients, individually and in groups. But strangely enough, little is known about the effectiveness of these treatments and what works for whom.
Why is that?
Martine: "This target group suffers in silence, they don't shout it from the rooftops. People with, for example, cluster B personality disorders, such as borderline, are more externalizing. Much more research has been done on this. Cluster C clients are less conspicuous and adapt. They are also often very popular, because they work hard and long, for example. The environment does not suffer so much, but they themselves suffer greatly. This group needs attention."
Ideal place
Martine and Birre, both clinical psychologists at the NPI, started the FORCE study three years ago to investigate and improve the treatments for these clients. The NPI is the ideal place for their research. Martine: "The strength of the NPI is that we already have a very wide range of options for personality problems; We have schema therapy and psychodynamic therapy in different variants, individually and for groups." Martine compares three forms of individual therapy (I-FORCE), Birre compares three forms of group therapy (G-FORCE) (see box). A specific protocol aimed at cluster C has been drawn up for each form of treatment. "We don't know which treatment is best for which participating client. There are ideas about that; We can now test them."
Do your colleagues work well on FORCE?
"Certainly. The investigation runs throughout the NPI. All branches and all practitioners cooperate – for I-FORCE alone, this is about seventy practitioners. It requires quite a bit of extra effort from them. I notice it myself; I participate as a practitioner in Birre's G-FORCE study; You have to do all kinds of small actions, such as turning on the audio tape every session and entering the intervention list. FORCE also allows you to deviate less from the protocol, even if you would like to do it slightly differently. That sometimes chafes. On the other hand, you increase the power of the treatment by following the protocol more purely. We can be really proud of how well the practitioners participate."
And the clients?
"They are also doing well. Their motivation is often that they want to contribute to improving quality and maintaining care. They are willing to do something for that; They have to fill out several questionnaires and give a number of one-hour interviews. But it is also attention for them. And at the end of the treatment and in two of the three follow-up measurements, they can see their results. Then they can see their progress."
Have you already received all participants in FORCE?
Martine: "We had hoped for that, but we are about halfway there. It is a long-term project." As of December 2023, 151 of the targeted 264 I-FORCE clients were in and 181 of the targeted 219 G-FORCE clients. "It's a huge job. But what matters a lot is that Birre and I have a lot to gain from each other. We also have a whole team of research assistants and GioSsen who work hard, and it is widely supported in the MT. I really like it, that alternation of treatment and research."
Are there any results yet?
"That will take a while. However, for her thesis, a master's student in psychology looked at whether there are factors that predict whether someone chooses individual or group treatment. We have made an initial analysis of this. I can't reveal those results yet, but we will present them soon. We also gave a presentation at the Society of Psychotherapy Research conference in 2023. We notice that there is a lot of interest in our results. I do need that; We are working hard, it is very nice if you can present results. It is nice that we can put this vulnerable and modest target group in the spotlight and help improve care for them."
Healthcare psychologist Andrieke van der Loop and Mental Health Nurse Specialist Pascale Bekkering both work at the NPI. Within the specialty, the number of no-shows was on the high side. Something that plays Arkin-wide and causes low productivity. They wanted to change this and introduced a new model. With the important condition of not disturbing the relationship with the client.
"To start seeing positive results, you have to continue to draw attention to it continuously and consistently. The starting letter also helps to clarify expectations from the start of the treatment and to immediately discuss the agreements about deregistration. The fact that it has been substantiated and signed by management helps. It improves the treatment relationship, the process runs more smoothly and the closure is more pleasant. We think it gives the client a bit of autonomy and positive attention."
What else is the consequence of a no-show?
In addition to the financial effect, which prevents us from writing direct time, there is a gap in your agenda. This can also be pleasant for some practitioners because they can, for example, get rid of administration. But it ultimately affects the continuity of treatment. This affects both client and practitioner. The chance of recovery is smaller, but you also have to realize that not showing up is sometimes part of someone's problems.
Is there a difference per type of client in terms of no-shows?
Yes, some clients are very predictable or disorganized with chaos in their lives. In addition, the no-shows are a lot higher. Or you have to deal with clients who get out of the picture or cancel appointments shortly beforehand.
You have started working on this, tell us!
Because there was no policy, we started looking for a solution. This is how we came up with a policy document in which the traffic light model is central. Firstly, we work with a starting letter in which we indicate what a client should do when they cannot come or when there is a crisis situation. Then we take the traffic light model and work with three colors (green, orange, red). With the green color, we also look at the start to see if there are signals from the client that could jeopardize the continuity of the treatment. There is no no-show in this zone (yet). If a client is in the orange zone, there is one no-show per ten appointments. Here we mention interventions that you can use as a practitioner. For example, actively discussing or checking whether the SMS reminder is working properly. In order to work well with the traffic light model, it is highly recommended to number your sessions to get a good idea of how many sessions have been missed.
Does this help?
Yes, that is our experience. Because we are much more on top of it and make it negotiable, we see good results. Clients also feel that they are being taken more seriously.
What happens in the red phase?
With two or more no-shows, you will discuss it more directly. For example, you can suggest taking a time-out. During an open conversation, you can find out better what the reason is for not showing up, being late or canceling. For example, I paused the treatment for one client and stopped it prematurely for another, in good consultation. We have set up practitioners to keep track of how many no-shows there are so that they stay sharper. That is something that is not (yet) in My Quarant.
How do you deal with it within the team?
We take the model at every meeting and the attention officer then inquires about the no-shows. It ensures that we as a team pay extra attention to it.
Do you also see an Arkin-wide implementation possible?
Yes, but we also realize that there may already be a lot of attention for no-shows in other specialties. Our traffic light model could be a good added value where this is not the case.
Does the model also offer other advantages?
Yes, what we notice, in addition to a direct production and treatment advantage, is that you can sometimes also close earlier during the last phase of a treatment. This allows us to treat new clients faster.
Does the entire NPI apply the traffic light model?
Yes, it is being used more and more. But it is something that really needs to be implemented and supervised within the team. It was not always received enthusiastically, but thanks to good information, we see more and more teams using it.
And can you already say something about the results?
They are actually quite positive. For example, at the NPI Oost location, we saw almost a halving of no-shows in eight months. We can't say that it's purely because of our model, but I'm sure it helped. We also see a decline at some other NPI locations.
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