Implementing the ‘Triad cart': a study on the use of an instrument to help to clarify the needs and role of informal care givers of people with severe mental illness

Background/Objectives: The ‘Triad card’ is an instrument to be used in the interaction between the triad of informal caregivers, workers, and clients in mental health care. The card was designed by Ypsilon, the Dutch association of family members of people with schizophrenia or psychosis, to shed more light on the role of caregivers, both relatives and other members of the social network, of people in mental health care. The card asks for the necessary contact information from mental health workers and caregivers. Its main focus however is on the questions about the kind and amount of support that caregivers do and/or want to provide. The aim of a pilot study was to investigate how the card was used and how satisfied all parties in the triad were with this new initiative.

Methods: A first version of the card was tested during two periods of six months indifferent mental health settings: a project for supported living, an inpatient unit for long term care, an inpatient treatment unit, a specialized rehabilitation unit for young adults and four community based outpatient teams. During this period the use of the card was monitored, caregivers were sent a short questionnaire on their expectancies and experiences working with the cart, and in-depth interviews were held with members of fifteen triads. To examine what factors influence the implementation process, in every setting group interviews were held with team leaders and workers.

Results: In 30% of the cases, the content of the card was discussed within the triad. Between 2 to 20% of clients did not give permission to contact their caregivers about the card. This varied over the different locations, with those having a longer tradition of cooperating with family members showing the least refusals, and those with client groups with longer careers in mental health showing the most. In the other cases, care givers were not available, did not feel the need for a meeting on this subject, or could not be contacted in time. In the triads that made use of the card, all persons involved were very enthusiastic about the way the cart helped to structure the conversation so that all parties could speak their minds. The needs and role of care givers was more clarified which lessened their burden and added to a more positive perspective on cooperation with the mental health centre in the future. Although workers were not all happy with the extra time and effort asked and sometimes felt it difficult to ‘manage’ the meetings, most were enthusiastic about the increase in involvement of caregivers. Most clients thought the cart to be a good idea to discuss what the help family members could give. However, some found it hard to participate in the meetings.

Discussion/Conclusions: During the pilot it became clear that the Triad card needs some adaptations both in content and form but it also proved to be a good starting tool to facilitate the dialogue between mental health workers, caregivers and clients. To guarantee a better implementation day to day practice, efforts should be made to create procedures matching the specific policies of the teams. There is also a need for a facilitator in the teams to stimulate the accurate use of the card. At this moment, a great number of mental health organisations have shown interest in the cart and have started to work with it. In Groningen, a second study is now in progress with the new version of the Triad cart, comparing involvement and satisfaction of caregivers with clients in mental health teams working with the cart and in those teams without.

Funding: Association of Friends of Ypsilon, VSB-fund (bank), Dutch National Fund for Mental Health (Fonds Psychische Gezondheid, grant no. 20076201).

Keywords: Involvement of service users and carers, family, implementation.