The development of CARe in Holland and other countries

CARe: from the eighties into the new century.

In the seventies mental health in Holland was dominated by ‘the medical view on psychiatric illnesses’. People with psychiatric diseases where mainly seen as people with a medical illness and where treated in large groups in large institution. The illness itself was seen as a kind of defect, and recovery could not happen in most of the situations. Although in Holland we never had the big hospitals like in the USA, our hospitals met with the criteria of Goffman’s total institutions. People lived, worked and recreated together in large groups. Although we did not have much research data yet, the medical view was considered as the most important way of looking at and explaining psychiatric illnesses. An important counter movement in this period of time was the so called anti psychiatry (Laing Pearls).

And also a growing movement developed: consisting of care professionals who where not satisfied by the dominance of the medical model and its implications. The ‘new movement’ tried to see the clients as a whole human being and not as ‘an illness’ or ‘an addiction’. This resulted in a lot of new ‘alternative’ housing facilities for clients.

In the mid eighties the rehabilitation approaches came to Holland. One important approach was the Individual Rehabilitation Approach from Boston. It showed us that there are many possibilities to live with psychiatric diseases: if there is sufficient support. So we started to work systematically with individual clients.

From the English approach (Bennet and Sheperd) we learned that the environment is an important part of this support. So we started to work with the natural environments in which clients spend time, but also in wards in the hospital with the most disabled clients.

In this respect the rehabilitation movement was also a counter movement: not only was it important to giving good ‘recovery oriented’ support to clients, it also worked as a force for change.

When these rehabilitation ideas came to Holland, we were very enthusiastic about it.

The rehabilitation movement in Holland was picked up by critical professionals who also worked in the hospitals and institutions for mentally disabled people.

So the rehabilitation approaches played an important role in the ‘change movement’: the people who tried to change the mental health care into a system in which each individual client has an individual face and an indicial voice.

In the eighties: although the English and American approaches also became very popular, a Dutch approach on rehabilitation developed. This development was carried by people who worked with the most vulnerable clients. Our main concern was the all these nice views and methods would only reach a smaller part of the clients: the clients who are already able and willing to set life goals and to work together with the professional to reach these goals (in ‘Boston terms: the clients who already showed ‘readiness’).

The change movement had strong roots in the hospitals and sheltered living facilities where over the years clients came with problems of increased complexity: a complex of vulnerabilities like double trouble (addiction and psychiatric problems) , or even triple: also clients with mental disabilities

So there was a need of translating the rehabilitation principles into two ‘new’ directions:

How to work with clients with extensive and complex vulnerabilities

How to improve the quality of the environments of the clients

Main stream rehabilitation is mainly about one entrance: how to support individual clients. The Dutch approach added two entrances (called ‘steering principles’): vulnerability and environment. Combining these steering principled gave the CARe approach her name: the Comprehensive Approach on Rehabilitation.

In Holland the Individual Approach (Boston) and the CARe approach ‘lived together’ for many years, initially more in competition, gradually in peaceful co-existence, recently working up to cooperation. There will always be a need of more flavors than one, and no approach gives us the One And Only Answer.

The CARe approach was adopted in Holland and implemented in all parts of Holland and all kinds of facilities: form working with homeless to working in closed wards in the hospitals. More and more tools where created to meet the needs of the different groups of clients and the different settings: clients with autism, with psychiatric problems, with mental disabilities, with forensic psychiatric problems, the elderly, the young clients, the homeless, the addicted and many combinations.

So rehabilitation became ‘normal’: we have rehabilitation departments, rehabilitation professionals, rehabilitation wards and rehabilitation signs on many doors.

And the CARe approach was exported.

GGZ Nederland (the organization of all mental hospitals and addiction services in Holland) gave money for training in several; (mainly eastern European countries. So CARe is now used in: Estonia, Lithuania, Czech Republic, Slovenian Republic, Hungary, Bulgaria, Georgia, Romania, Albania, Belgium and Denmark.

Evaluation 20 years of developing and working with CARe

After 20 years of slow and gradually developments it was time to evaluate, in 2008 and 2009. Two conclusions where drawn:

1. The building of CARe with its extensive toolkit makes it not easy to focus on the deeper core.

2. Rehabilitations has changed from a counter movement to and institutionalized concept and has become a ‘normal service’. But in the process of doing so, it lost a bit of the ‘critical counter movement idea’.

So we looked for ways to get back to the real core and found inspiration in 2 directions:

The so called Presentie –approach (Andries Baart, Holland)

The Strengths Model (Charly Rapp, Kansas, USA)

The ‘presentie approach’ is much more than it’s literarily translation: the presence approach. It is the Dutch expression for: ‘to really be there’, without hidden agenda, as a human being for another human being. And so it brings us back to the real core and basic attitude: to be there as a professional for your client, as a human being with another human being. And sometimes we cannot do anything so that’s exactly what we do. So there is a specific focus on working in relation dimension.

The Strengths approach brings us back to the real core of working in activity dimension: first we focus on finding, specifying and reinforcing strengths (and maybe later on the limitations).

And: the Strengths Model it is evidence based! And the evidence shows that working with core elements of this approach really supports recovery processes of the client!

So in cooperation with Kansas University we integrated these core aspects of the evidence: 1. working with the Personal Profile (= Strengths assessment on individual and on environmental level) and 2. Working with group supervision (a team based method of learning the principles in the working practise).

Recent Developments in CARe



Douglas Bennett Award to Jean Pierre Wilken and Dirk den Hollander

Together these core principles (strengths based and presence) form the heart of the CARe approach. So we changed methodology (a bit): now we always start with only 2 tools: a Personal Profile (which is a Strengths assessment) and a Personal Plan.

This generates the energy to work together and really supports recovery processes of the client. And we use the metaphor of the cupboard to describe the CARe toolkit now: it us a cupboard with several drawers. In the top drawer we find the two tools we always use.

In the second drawer we find some tools that are often useful. And in the third and fourth drawers we find tools for several specific situations. And there are tools for the client (self assessment tools) and tools for the professional. Most tools can be used by both working together.

The experiences so far are great. When you start with a good conception of the core (what is really important) and only a few (powerful) tools, working becomes pleasant for clients and for professionals. In a way we have encountered in Holland ‘a second wave of enthusiasm’: the first wave was when we started in the 80-ties. We were full with ideas and energy. And we now found that the focusing on the core aspects generates the same energy, with both clients and professionals. Also some financiers showed interest because the focus on strengths generates recovery. And we systematically monitor successes by sharing experiences of success in every meeting.

This more ‘simple approach’ proved to be really successful with psychiatric clients and homeless clients and clients with addictions and clients with mentally impairments. And we are generating experiences with other target groups like clients with autism.

Another nice experience:

Basis trainings in the Care approach, focusing on the core principles, can be relatively short and the used methodology can initially be kept simple. So the main assessment we teach participants, is the strengths assessment.

Next to this, there still is an elaborate way of CARe assessment on five areas as we teached the Tepla trainings Tepla Trainers can use CARe methodology on an expert level, as trainers should. But in there trainings they also can focus on the core elements and use the elaborate CARe assessment and the CARe cupboard in case they are needed.

Dirk den Hollander

Senior Trainer CARE and Strengths

Rino groep Utrecht