Need-adapted treatment

1. Introduction

Version followed: Yrjö O. Alanen's Turku need-adapted treatment (NAT), as set out in Schizophrenia: Its Origins and Need-Adapted Treatment (1997) and in Alanen et al. 1991, and as spread by the Finnish National Schizophrenia Project (1981–87). Where operational detail comes from the later multicentre API project (Acute Psychosis Integrated treatment, 1990s) or from Western Lapland, this guide says so. Open Dialogue grew out of NAT and has its own guide. It is mentioned here only where Open Dialogue practice has been folded into today's need-adapted services. [source: Seikkula 2021; Aderhold 2013; Klapcinski 2015; ISPS biography]

What it is. NAT is an integrated, individualized and psychotherapeutically oriented way of treating first-episode schizophrenia-group psychoses inside a public service. It was built in stages at the Turku University Psychiatric Clinic from the 1960s to the 1990s. The stages were psychodynamic individual therapy, then the ward run as a therapeutic community, then brief crisis-oriented family interventions, and finally a low-dose, selective use of antipsychotics. [source: Alanen 2000 abstract; DGSF Wissensportal; Seikkula 2021] It is a service and treatment-planning framework, not a session-by-session manual. Alanen's group wrote no interview manual or fixed protocol, so the procedures below are put together from the authors' descriptions. Where a step is this guide's own operational wording, it is marked [synthesis]. [source: Borchers, Seikkula & Arnkil 2014]

How change happens. A psychosis is understood as a crisis that grows out of the person's developmental history and their current relationships. Alanen joined psychoanalytic (individual) and interactional (family) explanations of where psychosis comes from. [source: Alanen 1994 BJP] Change starts in the first days of a crisis, when the patient, the family and staff meet together. That meeting lets the crisis be understood and puts the family's own resources to work. It also turns the whole treatment into a therapeutic process rather than a series of separate measures. [source: Lehtinen 1993 BJP family-interventions abstract] Individual, family, milieu, group and medical treatments are then combined, and the mix changes as the needs of the patient and the network change. Alanen's own phrase for this was "a combined use of both family- and individual-centred activities". [source: ISPS special-lecture abstract SL01] Antipsychotics play a supporting role at low dose. [source: ISPS SL01; Borchers et al. 2014]

2. Framework

NAT has no formal named phases. Its course is set by repeated therapy meetings whose frequency follows need. The stages below are an operational way of organising what the sources describe [synthesis]. The timings come from the sources cited.

Stage A: Crisis contact and initial family-centred meetings (day 0 to roughly days 7–10)

Goals: meet the patient and the family or network quickly. Hear every party's account of what happened and why now. Get a first understanding of the crisis (the informative function) and of the network's needs and resources (the diagnostic function). Contain distress (the therapeutic function). Decide the immediate setting, such as home, outpatient care or ward. [source: Klapcinski 2015; DGSF; Räkköläinen et al. 1991 as cited by Borchers et al.]
Format: joint therapy meetings of about 1.5 hours with the patient, family, other significant people and two to four staff. During the first psychotic crisis these are often daily. In Turku, family-oriented meetings opened every hospital admission. Later Finnish and Western Lapland practice aimed for a first meeting within 24 hours, at home when possible. [source: Aderhold 2013; DGSF; Klapcinski 2015] [uncertain: the 24-hour home-meeting standard is clearest in Western Lapland/API and Open Dialogue descriptions. Turku's original practice centred on the admission ward.]
Moving on: the acute danger is contained, a working first understanding of the crisis is shared, the case-specific team has been named, and the next meeting is fixed. [synthesis]

Stage B: Needs assessment and case-specific plan (roughly weeks 1–4)

Goals: build a case-specific treatment plan that matches what this patient and family need right now. That means choosing among family therapy, individual psychotherapy, milieu and ward care, group work, rehabilitation and medication. In API practice, antipsychotics were held back for the first three to four weeks in first-episode cases while the situation was understood. [source: DGSF; Aderhold 2013] A shared formulation is built in the staff team as well (the shared image guiding the treatment process). [source: Aaltonen & Räkköläinen 1994]
Format: meetings continue, often several times a week, then thin out. Only the next meeting is booked each time. [source: Aderhold 2013]
Grouping used for planning: the Turku group sorted patients into three groups, mainly by how well they functioned socially before the psychosis. The family-oriented methods and their focus differed from group to group. [source: Lehtinen 1993 BJP abstract] [uncertain: the content of each group. Guidance that ties each group to particular modalities is in §4 and is marked synthesis.]
Moving on: everyone has agreed the plan in a meeting, the modalities have started, and the team responsible over the long term is set. [synthesis]

Stage C: Continuing treatment process (months to about 2–5 years)

Goals: carry out the combined treatments and keep them fitting each other. Keep the same people involved. Recovery, rehabilitation and a return to work or study follow. [source: DGSF; Aderhold 2013]
Format: therapy meetings become rarer, about 5–7 a year in later phases. They are called on request and at points of change, such as discharge, a staff change, a change of method or setting, or a major life event. Individual psychotherapy, where chosen, often runs at least weekly. Across the regions about 25–40 meetings took place over five years. [source: Aderhold 2013; DGSF] [uncertain: individual-therapy frequency is not given.]
Moving on: symptoms and functioning are stable, the network can manage on its own, and the patient and family agree in a meeting to taper the work. About 60% of treatments in the Western Lapland data had ended by two years. [source: Aderhold 2013]

Stage D: Ending and follow-up

Goals: hold a closing therapy meeting and agree how the patient can get back into the service. Review each case's outcome at about five years. [source: DGSF; Aderhold 2013; Seikkula 2021]

3. Guiding principles

Alanen's principles are listed in slightly different forms over the years. The original five include follow-up. Later summaries, including the National Schizophrenia Project wording, add rapid intervention and psychological continuity. [source: Seikkula 2021; Klapcinski 2015; Aderhold 2013] [uncertain: exact 1997 wording. These are paraphrases.]

Rapid early intervention. Practical meaning: answer a first psychotic crisis within hours or a day, while what happened can still be talked about. [source: Seikkula 2021; Klapcinski 2015]
Case-specific, flexible planning adapted to real and changing needs. Practical meaning: there is no standard package. Choose and re-choose the modalities for this patient and this network, and say aloud in meetings that the plan can change. [source: Seikkula 2021; Aderhold 2013]
Psychotherapeutic attitude in both examination and treatment. Practical meaning: every staff member, prescribers included, tries to understand the person's history, what triggered the crisis and what is happening in the network, and works with the person from that understanding. Assessment is itself treatment. [source: Aderhold 2013; Borchers et al. 2014]
Different therapies support, not compete with, one another. Practical meaning: individual therapist, family workers, ward staff and prescriber share one plan and one formulation, and individual therapists come to network meetings. [source: Aderhold 2013; DGSF]
Treatment as a continuing process. Practical meaning: avoid routine fixed series of sessions. Each meeting decides the next step, and the whole course is treated as one process. [source: Aderhold 2013; Lehtinen 1993 BJP]
Psychological continuity. Practical meaning: the same professionals stay responsible through ward, outpatient and rehabilitation stages, and staff changes are handled in a joint meeting. [source: Klapcinski 2015; Lehtinen 1993 Acta]
Therapy meetings as the core. Practical meaning: decisions about setting, team, medication and changes in treatment are made in joint meetings with the patient and network present. [source: DGSF; Aderhold 2013]
Family and network as resource. Practical meaning: invite relatives as partners in understanding and treatment, not as the cause to be corrected. [source: DGSF; Klapcinski 2015]
Patient participation. Practical meaning: the patient is present whenever their treatment is discussed and is treated as the expert on their own life. If they refuse to attend, they are kept informed. [source: Aderhold 2013; DGSF] [uncertain: framed this way in German-language secondary summaries that merge NAT with Open Dialogue.]
Minimal, supportive medication. Practical meaning: antipsychotics are used selectively and at low dose, as support for psychotherapeutic work, and are decided together. [source: ISPS SL01; Borchers et al. 2014; DGSF]
Strengthen the adult side and normalise. Practical meaning: speak to and build on the patient's competent, adult capacities and ordinary roles rather than settling into regression. [source: Seikkula 2021]
Follow-up of patients and of the system. Practical meaning: review each case's outcome, at five years in the original projects, and review the team's own results. [source: Seikkula 2021; DGSF]

4. Intervention inventory

The sources describe service-level interventions rather than micro-techniques, and there is no NAT manual. The steps under each entry turn the authors' descriptions into concrete practice. Steps not stated in a source are marked [synthesis]. All example language is illustrative. No verbatim Alanen wording on in-session phrasing was found.

4.1 Rapid crisis response and the initial family-centred therapy meeting

Purpose and when: this is the first professional response to a first or new psychotic crisis, or to any admission. It has three functions: informative (what happened and what led up to it), diagnostic (what the patient and network need, and what resources they have) and therapeutic (holding the patient and network). [source: Klapcinski 2015; Aderhold 2013; Räkköläinen et al. 1991 as cited in Borchers et al. 2014]
Steps:
1. When the call comes, the psychiatric service takes on the job of organising the meeting. Aim for the same day or next day, at home if the family agrees, or on the ward at admission. [source: DGSF; Aderhold 2013]
2. Invite the patient, the family, other significant people who are willing, and professionals already involved, such as the GP, earlier psychiatric contacts or social services. Keep the invitation ordinary in tone. [source: DGSF]
3. Staff: two to four people from different professions. Include a doctor when a medical assessment is needed. Choose people who can stay on the case. [source: DGSF; Aderhold 2013] [synthesis: the doctor's presence at the first meeting]
4. Open by saying who you are and why you are meeting, and that no decision about the patient will be made without them. [source: DGSF; Aderhold 2013]
5. Ask each person in turn for their account: what happened, when things changed, what worries them most. Start with whoever made contact, and give the patient room at every point. [source: Aderhold 2013]
6. Listen for the history and the triggering situation, such as separations, losses, developmental steps like leaving home, and changes in the family. Ask about earlier coping and who helps. [source: Aderhold 2013; Alanen 1994] [synthesis: the trigger examples]
7. Let strong feelings such as fear, helplessness and anger be said out loud. In the first days of a crisis, difficult material is often easier to voice than later. [source: DGSF; Aderhold 2013]
8. Do a standard risk assessment (suicide, violence, self-care, physical causes of psychosis) inside the meeting where you can. If you need to see someone alone, tell the meeting you are doing so. [synthesis: integration of standard risk and medical work-up]
9. Agree the immediate setting (home, day care or ward) and who stays with the patient tonight. Book the next meeting, often for the next day. [source: DGSF; Aderhold 2013]
10. End with a summary of the topics discussed and the decisions made. [source: Aderhold 2013]
Example language (illustrative): "We'd like to hear from each of you how things have been and what happened in the last few days. Nothing about your treatment will be decided without you here." / "Before these last weeks, when did you first notice something was changing?" / "Let me sum up what we've heard and what we've agreed for tonight and tomorrow."
Watch for: family members talking over or about the patient (bring the patient back in). Staff rushing to a diagnosis or to medication (the "right" diagnosis is meant to emerge over the meetings) [source: Seikkula 2021]. A family that feels blamed. Signs it is working: the patient and relatives speak about the crisis in their own words, tension drops by the end, and the family agrees to come back. [synthesis]

4.2 Ongoing therapy meetings (treatment meetings)

Purpose and when: these are the core of the model. They are the forum where the patient, the network and the team share understanding, and where every change in treatment, setting or team is decided. They run throughout treatment. [source: DGSF; Aderhold 2013; Borchers et al. 2014; Räkköläinen et al. 1991 title]
Steps:
1. Frequency: daily in the first 7 to 10 days of a crisis, then several times a week, then about 5 to 7 a year. Call extra meetings at points of change such as discharge, a staff change, a change of method or medication, a relapse or a life event. [source: Aderhold 2013; DGSF]
2. Same core people every time. Bring the individual therapist in at the start, at transitions and at crises. [source: Aderhold 2013; DGSF]
3. Open by asking what has happened since the last meeting and what people want to talk about today. Topics are not planned beforehand. [source: Aderhold 2013]
4. Review how each part of the plan is going (family work, individual therapy, ward, medication, work or school) and whether needs have changed. [source: DGSF; Borchers et al. 2014]
5. Discuss any proposed change openly with everyone present before it happens. Aim for agreement. [source: DGSF; Aderhold 2013]
6. Close with a summary and book only the next meeting. Meetings last about 1.5 hours, shorter as treatment goes on. [source: Aderhold 2013; DGSF]
Example language (illustrative): "What has changed since we last met, for you and at home?" / "Anna's therapist has joined us today. It might help to hear how the individual sessions are going, if Anna is comfortable with that." / "We are thinking about reducing ward days. Let's hear what each of you thinks before we decide."
Watch for: meetings turning into administrative case reviews (keep the psychotherapeutic attitude). Decisions being made outside the room (bring them back in). Signs it is working: plans are revised with the network rather than imposed, fewer emergency contacts are needed, and the patient takes part more. [synthesis]

4.3 Case-specific needs assessment and treatment planning

Purpose and when: to choose and combine modalities for this patient and network. This starts from the first meetings and is revised continually. [source: Borchers et al. 2014; Aderhold 2013]
Steps:
1. Collect, across meetings: how the person functioned socially before the illness, whether they live with or apart from their family of origin, how intense the family's involvement is, the type of onset, capacity for reflection, substance use, and work or study situation. [source: Lehtinen 1993 BJP (premorbid functioning as the main dividing factor); DGSF (autonomy and onset for individual therapy)] [synthesis: list assembled]
2. Place the case on the Turku three-group dimension of premorbid social functioning. [source: Lehtinen 1993 BJP] [uncertain: group definitions] Working rule [synthesis]: (a) good premorbid functioning, already separated from family, acute onset: offer individual psychotherapy prominently, with family meetings mainly around the crisis. (b) A young person still closely tied to the family: family therapy is central. (c) Poor premorbid functioning or long-standing difficulties: supportive and rehabilitative work, and steady support for the family.
3. Propose options in the meeting and let the patient and family say what fits their language, lifestyle and interests. [source: DGSF]
4. Write the agreed plan into the record with the responsible people named. Revise it at each meeting. [source: Borchers et al. 2014] [synthesis: documentation]
Example language (illustrative): "From what we've heard, some things might help: regular family meetings, someone for you to talk to alone, help getting back to your course. Which of these sounds useful now?"
Watch for: defaulting to the same package for everyone. Signs it is working: the plan differs visibly between cases and changes over time. [synthesis]

4.4 Forming the case-specific team (psychosis team)

Purpose and when: to give each patient a stable, multiprofessional group of staff who carry the whole process. It is set up in the first meetings. [source: DGSF; Aderhold 2013; WPA obituary]
Steps:
1. In the first one or two meetings, agree who will be the responsible long-term team. Usually two closely cooperating staff form the core, drawn from a regional psychosis team of two to four. [source: Aderhold 2013; DGSF]
2. Add other services as needed, such as addiction services, social services or the inpatient ward, and name who links between them. [source: DGSF]
3. Check how well the team fits the patient and family. Fit matters, so be ready to change members through a joint meeting. [source: Aderhold 2013]
4. Make sure the medical role (prescriber, physical health) belongs to the team and is not handled separately. [source: Borchers et al. 2014 (psychiatrist works as part of the team)]
Example language (illustrative): "Maria and I will be the people you can count on through all of this, whether you're at home or on the ward. Dr K will join the meetings for the medical side."
Watch for: staff rotating out without a meeting. The team becoming part of the problem system, for example by taking sides in a family conflict. Teams are expected to watch for this. [source: Aderhold 2013]

4.5 Family therapy and family interventions

Purpose and when: to change the family interaction that surrounds the psychosis, to support relatives, and to help young patients with separation and individuation. It was central in Turku, especially at the start of treatment. [source: Lehtinen 1993 BJP; Alanen 1994; DGSF]
Forms described: (a) crisis-oriented family-centred therapy meetings (see 4.1 and 4.2). (b) Brief systemic family therapy, which in Turku was influenced by the Milan school. Its short-term emphasis was later dropped in favour of continuity. (c) Longer conjoint family therapy where needed. [source: Aderhold 2013; Lehtinen 1993 Acta] Finland's first regular family therapy training started in Turku in 1979. [source: ISPS biography]
Steps (operational) [synthesis, built from the forms above]:
1. Agree the frequency in a therapy meeting, usually every one to three weeks after the acute phase. Have two staff co-work.
2. Explore each person's view of the problem and how the family responds to it. Ask circular questions about relationships, for example who is most worried and how others react to that.
3. Link the onset of the psychosis to family life-cycle tasks, such as a young adult leaving home or a parent's illness.
4. Give information about psychosis, treatment and early signs of relapse in the family's own language.
5. Support each person's separate space and voice, and protect the patient's age-appropriate autonomy.
6. Review progress in the larger therapy meeting.
Example language (illustrative): "When Jussi stays in his room, who notices first, and what do you each do?" / "It sounds like this started around the time he was getting ready to move out. How has that been for everyone?"
Watch for: relatives hearing exploration as blame. Alanen's family research came from a pathogenesis tradition, and a modern framing is resource-oriented. [source: DGSF] [synthesis: the caution] Signs it is working: less criticism and anxious over-involvement, the family manages crises with fewer emergency calls, and the patient is more autonomous. [synthesis]

4.6 Individual psychodynamic psychotherapy (adapted for psychosis)

Purpose and when: to give a continuous personal relationship in which the patient can understand the psychosis, strengthen the healthy and adult parts of the self, and resume development. This was the first stage of the Turku model. In regional data about half of first-episode patients chose it. [source: Seikkula 2021; DGSF; Alanen 2000 abstract]
Indications: a more autonomous personality, often someone who has left the family of origin and had an acute onset, with some capacity for insight, low acting out, and an available, continuous therapist. It can be focused or long-term. [source: DGSF] In Finland people with psychosis have a legal entitlement to psychotherapy. [source: Aderhold 2013]
Steps:
1. Introduce the therapist in a therapy meeting. The therapist attends early meetings and returns at transitions and in crises. [source: Aderhold 2013; DGSF]
2. Set a frame with regular sessions, flexible in format during the acute phase. Shorter or seated-by-the-bed contacts are acceptable. [synthesis; frequency not specified in sources]
3. Build the alliance with a supportive, real and reliable presence before interpreting. Focus on strengthening the adult side and normalising, not on regression. [source: Seikkula 2021] [synthesis: sequencing]
4. Work out the personal meaning of psychotic experiences and how they connect to the life events that set off the crisis, without arguing about content. [synthesis, consistent with Alanen's integration of psychoanalytic understanding]
5. Pay attention to fears of separation and of dependence in the relationship with the therapist. Interpret sparingly and concretely. [synthesis] [uncertain: specific technical rules from Alanen 1997]
6. Keep the therapist consistent through all settings. [source: DGSF; Klapcinski 2015]
Example language (illustrative): "You've told me the voices got louder after you moved to the new city. What was that move like for you?" / "You managed your course for two years before this. That part of you is still here, and we can work with it."
Watch for: overwhelm from deep exploration in the acute phase (go back to support). The therapist working alone, cut off from the team and family work. Signs it is working: the patient keeps coming, starts linking experiences with their own life story, and functioning improves. [synthesis]

4.7 Other individual therapies (CBT for psychosis) in present-day NAT services

Purpose and when: later need-adapted services also offer cognitive therapy, especially for persistent positive symptoms. The sources treat psychodynamic and cognitive approaches as compatible within the model. [source: Aderhold 2013; DGSF] This was not part of Alanen's original Turku practice. Use the CBTp guide for technique.
Steps: decide on it in a therapy meeting, name the therapist in the team, and have them attend meetings at transitions, exactly as in 4.6. [source: Aderhold 2013]
Watch for: CBT running as a separate track with its own formulation that clashes with the team's shared image (see 4.11). [synthesis]

4.8 Inpatient therapeutic community and primary-nurse relationship

Purpose and when: when hospital care is needed, to make the ward itself psychotherapeutic. This was the second stage of the Turku model. [source: DGSF; Klapcinski 2015]
Steps:
1. Decide on admission and discharge in a therapy meeting with the family. [source: DGSF]
2. Give each patient a named nurse whose task is to build an empathic, steady relationship. [source: Klapcinski 2015]
3. Run the ward as a therapeutic community, with community meetings, shared daily activity and staff who treat the milieu as a treatment tool. [source: Klapcinski 2015; DGSF] [synthesis: the listed components]
4. Use regular team supervision to build a shared understanding of each patient (see 4.11). [source: Klapcinski 2015; Aaltonen & Räkköläinen 1994]
5. Keep stays as short as needed. Turku reported average stay falling from 272 to 132 days across stages. Plan discharge in a meeting that includes outpatient team members. [source: Klapcinski 2015; Lehtinen 1993 Acta]
Example language (illustrative): "I'm your nurse while you're here. I'll check in with you every shift, and I'll be at the family meetings."
Watch for: the ward working separately from the outpatient team, and coercive measures that shut down dialogue, which the model aims to avoid. [source: Borchers et al. 2014] Where coercion is legally necessary, follow local law and discuss it afterwards in a meeting. [synthesis]

4.9 Group therapy and group activities

Purpose and when: group work is one of the modalities that can be combined into the plan, through ward groups in the therapeutic community, outpatient groups, or art and activity groups. [source: version hint/Alanen 1997; DGSF] One secondary summary says group therapy was rarely used in later Finnish practice. [source: DGSF] [uncertain: format, frequency and Alanen's indications for groups not given]
Steps [synthesis]: offer a group only after the acute phase, once the patient can tolerate other people's material. Agree on it in a therapy meeting. Keep the group leader linked to the team.
Watch for: early group exposure making confusion worse. [synthesis]

4.10 Need-adapted medication decisions (minimal, supportive pharmacotherapy)

Purpose and when: to use antipsychotics selectively, at low dose, as support for the psychotherapeutic process. The decision is made jointly in therapy meetings. This was the last stage of the Turku and API development. [source: ISPS SL01; DGSF; Borchers et al. 2014] Dosing is outside the scope of this guide. Follow current prescribing guidance.
Steps:
1. In first-episode cases, the API experimental protocol deferred antipsychotics for about three to four weeks while the crisis was understood. Sleep and anxiety were treated first with non-antipsychotic options. [source: DGSF; Aderhold 2013] Today: apply this only within current guidelines, with medical oversight, and with risk and severity judged case by case. [synthesis]
2. Discuss the question of antipsychotic medication openly across therapy meetings. One description says it is discussed in three meetings before a decision. [source: DGSF; Aderhold 2013]
3. If medication is started, start low, increase only if needed, reduce when side effects appear, and review it at every meeting. Minimal means lowest dose and shortest duration. [source: DGSF; Borchers et al. 2014]
4. The prescriber is an active, open participant in the conversation and does not simply enforce compliance. [source: Borchers et al. 2014]
Example language (illustrative): "Medication is one option. Let's talk about what it could help with, what worries you about it, and decide together over the next meetings."
Watch for: severe agitation, danger, or no response to psychosocial care, which needs an earlier medical decision. Prescribing done outside the meeting. Signs it is working: medication is agreed and understood rather than imposed, and side effects are raised in meetings. [synthesis]

4.11 Shared Image Guiding the Treatment Process (SIGTP) and team supervision

Purpose and when: to build a staff team's shared understanding of a patient's symbolic and non-symbolic behaviour and symptoms. This lets everyone respond consistently and helps the patient organise their experience more realistically. It was developed for inpatient teams and is also useful in outpatient teams. [source: Aaltonen & Räkköläinen 1994; Borchers et al. 2014]
Steps:
1. Hold regular systematic supervision sessions for the whole case team from early in treatment. [source: Aaltonen & Räkköläinen 1994; Klapcinski 2015]
2. Each member shares concrete observations, their own emotional reactions, and fragments of the patient's speech and behaviour. [source: Aaltonen & Räkköläinen 1994 (integrating staff experiences)] [synthesis: specific content]
3. Work towards a shared picture of what the psychosis expresses in this person's life. The authors analysed this using Peirce's sign types (index, icon, symbol). In their study a shared image formed early in 32 of 54 cases. [source: Aaltonen & Räkköläinen 1994]
4. Feed the shared image back into the therapy meetings and individual work. [synthesis]
Example language (staff supervision, illustrative): "When he barricades the door, what do each of us feel? What might he be showing us that he can't yet say?"
Watch for: splitting, where different staff hold incompatible pictures of the patient. Signs it is working: staff responses become consistent and the patient's behaviour becomes more understandable to everyone. [synthesis]

4.12 Widening the network: rehabilitation, work and school, and activity therapies

Purpose and when: to help the person return to ordinary roles. It comes in from the middle phase onward. [source: DGSF; Aderhold 2013]
Steps: invite teachers, employers or employment-office staff to particular therapy meetings when the patient agrees. [source: DGSF; Aderhold 2013] Add art therapy or occupational and "training on the job" support where useful. Vocational rehabilitation is described as secondary. [source: DGSF] Keep the agreed plan in the meeting record. [synthesis]
Example language (illustrative): "Would it help to invite your supervisor to the next meeting so we can plan your return together?"
Watch for: pushing a return before the patient is ready, or losing the network once symptoms settle. [synthesis]

4.13 Continuity across settings: transition meetings

Purpose and when: to keep the treatment a single process through admissions, discharges and staff changes. The five-year Turku follow-up found that the crisis focus had weakened long-term relationships, especially for more chronic cases. The authors concluded that continuity needed more emphasis. [source: Lehtinen 1993 Acta; Klapcinski 2015]
Steps: call a therapy meeting before any change of setting, therapist or team member. Have both the departing and the incoming staff attend. Name the person who carries continuity. [source: Aderhold 2013; DGSF] [synthesis: departing and incoming staff together]
Example language (illustrative): "I'm moving to another unit next month. Before I go, let's meet with Liisa, who'll take over, so we can tell her together what has helped."
Watch for: dropout around transitions. [synthesis]

4.14 Closing meeting and long-term follow-up

Purpose and when: to end the treatment deliberately and to check outcomes. The original projects reviewed every case at about five years. [source: DGSF; Seikkula 2021]
Steps: agree the ending in a therapy meeting, review what helped, and agree early warning signs and how to come back. Set a follow-up contact. Audit the team's own outcomes, such as hospital days, symptoms, work and medication use. [source: DGSF] [synthesis: content of the closing meeting]
Example language (illustrative): "Looking back over these two years, what made the most difference? And if things start to slip, who will notice first and who will call us?"
Watch for: an ending decided only by the team. [synthesis]

5. Handling problems

The sources say little about troubleshooting. Items marked [synthesis] are this guide's own guidance, consistent with NAT principles.

Patient refuses to attend the meeting. Go ahead with the family. Tell the patient they are welcome at any time and may listen from another room or through an open door. Make no decision that concerns them without them. If danger forces action, tell them beforehand. [source: DGSF; Aderhold 2013] Then offer a short one-to-one contact with a team member the patient seems to trust. [synthesis]
Family refuses, is absent or is unavailable. Bring in other significant people (friends, partner, flatmate) and earlier professionals. Absent members can join by phone during a meeting or be consulted by others. [source: DGSF] For an isolated adult, individual therapy and the primary-nurse relationship carry more of the plan. [synthesis]
Family feels blamed, or a parent dominates. Reframe the meeting as gathering everyone's knowledge to help. Give each person equal turns, and name the parents' exhaustion and fear. Arrange separate support for relatives if they need their own space. [synthesis] Families tend to be willing to cooperate in a first episode. Use that window. [source: Klapcinski 2015]
Acute overwhelm in the meeting (escalating psychosis, rising agitation). Shorten the meeting, slow down, and reduce the number of speakers. Let a trusted staff member sit with the patient. Agree the minimum for the next 24 hours and meet again tomorrow. Re-assess risk with standard tools and decide on a more protective setting, including the ward, openly in the meeting. [synthesis] Suicide or violence risk: follow standard risk assessment and local emergency procedures. Do not let the wish to avoid medication or admission delay necessary care. [synthesis]
Stuck process (no change after months). Call a review meeting and go back over the case-specific plan. Ask whether the modality mix still fits current needs, whether a key person is missing, and whether the team has become part of the problem system. [source: Aderhold 2013 (team as part of the problem system); DGSF] Take the case to SIGTP supervision (4.11). Consider adding or changing individual therapy, CBTp for persistent symptoms, or a medication review. [source: DGSF] [synthesis: sequence]
Non-adherence (missed meetings, therapy dropout, stopping medication). Treat it as information to explore in the next therapy meeting rather than as defiance. Reach out at home. For medication, revisit the decision jointly, including the option of lower doses, with medical safety in view. [source: Borchers et al. 2014 (no compliance-enforcement focus)] [synthesis: outreach and exploration]
Ruptures (with the therapist or team). Name the rupture in the meeting and own the team's part, for example a decision made without the patient. Change team members through a joint meeting if fit is poor. [source: Aderhold 2013 (fit matters)] [synthesis: repair steps]
Loss of continuity (staff turnover, the crisis focus fading). This was the Turku follow-up's main lesson: crisis orientation without continuity harmed patients and families with more chronic illness. [source: Lehtinen 1993 Acta] Respond with a transition meeting (4.13), a named continuity person, and protected long-term individual or family work for groups b and c. [synthesis]
Modality competition (individual therapist and family team pulling apart, or prescriber outside the process). Bring all of them into the therapy meeting and the shared-image supervision. Restate that the therapies must support each other. [source: Aderhold 2013; DGSF]
Pressure for fast medication or admission from family, staff or systems. Explain the reason for deferring and deciding jointly. Set a clear review point, such as the next meeting, and keep risk criteria explicit. [synthesis]
Long-term or poor-premorbid-functioning patients (Turku's weaker outcomes). Expect a slower, more supportive and rehabilitative course. Give steady family support and education, and never discharge only because the acute crisis has passed. [source: Lehtinen 1993 Acta; Salokangas 1994 (need for family support and education)] [synthesis]
Service-level erosion (funding cuts, loss of psychosis teams). NAT declined in Finland during the 1990s financial crisis and health-care reorganisation. [source: WPA obituary] Protect the core: therapy meetings, a named continuity team and supervision. [synthesis]
Mixing models. Present-day services often blend NAT with Open Dialogue elements, such as reflecting talk and polyphony. These are Open Dialogue additions, not Alanen's own. Use the Open Dialogue guide for them. [source: Klapcinski 2015; Seikkula 2021]

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