Changing Challenges into Chances, an International Collaboration in Facing the Future Challenges of the Mental Health Care Psychologist ()
1. Introduction
1.1. Keeping the Collaboration Alive
In September 2022, a tradition of innovative collaboration was started, consisting of exchanging knowledge, experience, and inspiration between Portuguese and Dutch mental health care professionals. In the first meeting in September, a group of 45 Dutch clinical psychologists in training to become specialists and scientist practitioners visited Portuguese universities, public and private medical and psychiatric hospitals, mental healthcare facilities, innovation centers, and start-ups. An extensive program of working visits was followed covering the entire spectrum relevant to the work of a psychologist. Following the initial live exchange between the Dutch psychologists and their Portuguese counterparts online meetings were organized in 2023 and 2024 with diverse focuses, progressively involving more Portuguese and Dutch colleagues from the fields of psychology and psychiatry.
The lessons learned here were that exchanging knowledge about our profession, organizing scientific research and innovations in the field, and clinical evidence-based work require constant attention to promote their relevance in the field of psychology (Van den Broek et al., 2023) . Also, this collaboration supports reaching uniformity in education, training, examination, and implementation of psychologists as a profession in Europe, which contributes to the quality of the profession (Steenbakkers et al., 2023) . To keep this collaboration alive in 2023 and 2024, three online meetings were organized. First, a digital masterclass on EMDR treatment was organized, during which a Dutch expert on EMDR (Clinical Psychologist Dhr. R. van Diest) shared his knowledge. The masterclass was attended by approximately 70 Portuguese mental health care professionals (Bruins et al., 2023) . Following that there was a digital event on the organization and current developments concerning various aspects such as educational routes and quality standards of three psychologists’ associations and government agencies, from both Portugal and The Netherlands (de Jong et al., 2023) . This event attracted 22 participants and presenters. In the last meeting, the challenges in the future of mental healthcare and the role of clinical psychologists in addressing these challenges were discussed during an online symposium with a focus on scientific exchange.
1.2. Ambitions in Future Mental Healthcare
In their World Mental Health Report: Transforming Mental Health for All (2022), the World Health Organization (WHO, 2022) stated that mental health and access to mental healthcare are basic human rights. For an extended period, this issue has not been afforded the requisite level of attention, and it is crucial that we rectify this oversight promptly. One of the approaches emphasized by the WHO for transforming mental health involves bolstering mental healthcare to a level where the entire spectrum of mental health needs is addressed through a community-based network of accessible, affordable, and high-quality services and support. In the Netherlands, the ambition is set in the Integrated Care Agreement—Collaborating for Health Care (Rijksoverheid: Ministerie van VWS (2022) “Central Government: Ministry of Public Health, Welfare and Sport” (2022). These ambitions are well recognized in Portugal as well. Especially since the pandemic and the costs raising for health care in most countries in the world. The Portuguese ministry of health sets seven priorities in improving health in general; e.g. investing in general health and prevention, improving access and efficiency of National Health Services (NHS) and empowering basic healthcare (Pita Barros & Santos, 2023) . Besides, mental health policies should focus on improving the conscientious use of antidepressants, anxiolytics, sedatives, and hypnotics, particularly among older adults (Estrela et al., 2020) . In the end, to meet the expectations and needs of patients and contribute to continuous improvement, patient-reported outcomes and experiences assessment can be implemented in mental health services in Portugal (Coelho et al., 2022) . Although the position of mental health care is improving rapidly and Portugal has several mentioned ambitions, stigma can lead to obstacles in accessing psychological help. Stigma towards mental illness still exists extensively among both the general population and health professionals in Portugal (Oliveira et al., 2020) . With respect to differences between specialism according to Oliveira: psychiatrists generally exhibit lower levels of stigmatizing attitudes compared to non-psychiatry physicians and medical students. Oliveira et al. (2020) and Almeida et al. (2022) stated that medical students and professionals, including psychiatrists and general practitioners, display varying levels of stigmatizing attitudes towards patients with mental illness. However, according to Oliveira and collaborators, psychiatrists generally exhibit lower levels of stigmatizing attitudes compared to non-psychiatry physicians and medical students. These authors discovered that the presence of a relative with mental illness and age are factors that significantly impact the levels of stigmatization. According to Pinto et al. (2020) the Portuguese mental health care plan emphasizes the role of healthcare professionals in perpetuating stigma, which can lead to a decrease in help-seeking behavior and treatment adherence. Pinto stated that education and contact opportunities throughout medical school, as well as personal experience with psychiatric problems, can contribute to more positive and less discriminatory attitudes towards people with severe mental illness. Overall, there is a need to raise awareness and address stigma surrounding mental health problems in Portugal, both within the general population and among health professionals. In the Netherlands, stigma has been under the attention of mental health workers for several years. Reynders et al. (2014) found a more positive attitude towards help seeking in regions where there was less self-stigma and shame. In these regions, they also found lower suicide rates. In a European study Bracke et al. (2019) stated that next to own personal stigma beliefs it is important to have attention for cultural stigma beliefs as these can constrain the likelihood of seeking help from specialized mental health care professionals and from contacting general practitioners. They found the effect of cultural stigma beliefs to be of more impact than personal stigma beliefs. The Dutch knowledge center Phrenos (Oudejans & Spits, 2018) conducted a report on stigmatization in the Netherlands at that time. They found differences in stigmatization in terms of individuals’ participation in the workforce, between various mental health issues and concluded that greater knowledge about mental health issues was associated with reduced stigmatization.
2. Method
In collaboration with Hospital CUF Tejo (Lisbon city, Portugal), GGZ Breburg, and GGZ Oostbrabant (The Netherlands), an online symposium was organized on April 12th, 2024. Participants consisted of mental health care professionals and were recruited not only within the organizing institutions but also externally through various platforms, including the Ordem dos Psicólogos Portugueses (Portuguese Psychologists Association) and LinkedIn. Given that international exchange and scientific development are important focal points within the training of clinical psychologists, many trainees in specialized psychology professions took part. 63 Participants registered for the symposium and ultimately 50 participants took part. During a three-hour and fifteen-minute event in the conference call feature of Microsoft Teams, three keynote speakers gave their perspective on the future of the mental health care and the role of psychologists in the context of a dynamic healthcare system, introducing new concepts and approaches to psychological care. This was followed by discussions in small groups, during which key take-home messages were shared with all participants at the end of the meeting. Participants were invited via company mailings, invitations on company intranet pages, and through LinkedIn and Facebook. The invitation was also disseminated to the Department of Psychology at the Portuguese hospital “Júlio de Matos” (Lisbon city) and posted on the event page of the Portuguese Order of Psychologists “Ordem dos Psicólogos”. Accreditation was applied for and received from The Dutch Federation of Healthcare Psychologists and Psychotherapists.
3. Results
In total, 63 participants subscribed for the event, and 50, including speakers and presenters, joined the online symposium.
Presentations were given on the following subjects:
Taking the Driving Seat: Autonomy-Connectedness and Eating Disorders
This lecture was given by Nicky Bosman, psychologist, and PhD student at the Free University of Amsterdam and GGZ Oostbrabant (Bekker & van Assen, 2017) .
Transdiagnostic factors play a major role in causing and maintaining eating disorders (Connan et al., 2003; Fairburn et al., 2003; Treasure et al., 2012) . In the search for optimal treatment for eating disorders, one of these transdiagnostic factors is targeted with the innovative and gender-sensitive Autonomy-Enhancing Treatment (AET). Previous research has established AET as both effective and cost-effective for anxiety disorders (Kunst et al., 2022) . Additionally, autonomy was found to be one of the strongest predictors of recovery from eating disorders in previous research (Kuipers et al., 2017) . AET as an additional treatment method for eating disorders was described in the presentation.
iTREATOCD: Efficacy of an Internet-Based Cognitive-Behavioral Therapy (iCBT) in Obsessive-Compulsive Disorder (OCD)
This presentation was given by Mafalda Machado-Sousa, clinical psychologist, and PhD student at the University of Minho.
In a time where there is a lack of training for CBT therapists, geographical barriers, and economic barriers, iCBT (Andersson, 2016) can be an interesting approach in reducing OCD symptoms. Possible advantages include ease of access, cost-efficiency, and the possibility for clients to work at their own pace and in their own environment (Osborne et al., 2019) . The online intervention program was described and a previewed in the presentation. The current state of research suggests that iCBT seems to be a promising add-on, immediately available treatment to traditional psychotherapy settings (Machado-Sousa et al., 2023) .
Staying in or Going Out? Flexible Assertive Community Treatment (FACT): A Recovery-Based Treatment and Discharge
This lecture was given by Eva de Bruijn, clinical psychologist, and PhD student at Tilburg University and GGZ Breburg.
As a recovery-based treatment, Flexible Assertive Community Treatment (FACT) has a very clear manual with inclusion criteria and discharge criteria. There is only limited research on discharge from FACT. In their recent study, de Bruijn et al. (2023) created a discharge profile. They found that clients who met this profile were older at the start of treatment, had a psychotic disorder which was not schizophrenia or schizoaffective disorder and had fewer contacts with non-FACT colleagues within the field mental health care. This research is a first step in better understanding discharge and its associated factors for a group of patients with complex and often lifelong issues, thereby improving mental health care and recovery chances for patients with severe mental illness (SMI). Optimizing discharge can also save costs and reduce mental health waiting lists.
4. Discussion Topics
In breakout rooms in small groups of participants the following topics were discussed, and some interesting statements were formulated.
4.1. Changing Challenges into Chances: What Chances Do We Take from This Challenges?
Although the Portuguese and Dutch mental healthcare systems have some differences in the way they are organized, the discussion groups agreed that both countries face similar challenges with the closure of psychiatric facilities, more individuals are being directed to general hospitals. While this may be beneficial in cases of medical comorbidity, there is often a lack of specific facilities focused on community-based recovery. We have an insufficient number of psychologists to provide appropriate treatment to everyone in need, exacerbated by the aging population and the need to cater to the elderly. An opportunity lies in the development of methods for treating individuals at home without institutionalization. Additionally, there should be encouragement for the education and training of psychologists to be more flexible and resilient in the face of these developments. According to Ribeiro et al. (2010) especially the aging population in Portugal poses a challenge for mental healthcare services, requiring improvements in research, education, and clinical training in geriatric mental health. More educational and clinical training programs for specialists are needed, as well as a broader commitment to aging research and increased interest in working with older adults among students across disciplines. And to improve geriatric mental health services delivery, they stated that multidisciplinary work involving researchers, psychiatrists, psychologists, and other health professionals is crucial as is connecting research with clinical practice (Ribeiro et al., 2010) . A difference seems to be the extent to which stigma plays a role in the community. Portugal may potentially benefit from the attitude and education regarding mental health in the Netherlands. On the other hand, in Portugal psychologists are more involved in government-led initiative which is a valuable learning experience for the Dutch psychologists as well. To summarize collaboration in identifying the chances seems logical as sharing knowledge, scientific research, best practices, and implementation strategies can lead to better quality of mental health care services in a cost-efficient way.
4.2. The Psychologist and the Future of Mental Health Care: What Are the Pros and Cons of Online Treatment?
This topic evoked a lot of responses. Due to the pandemic effect, technological advancements, and availability there is a growing recognition that the chances for online treatment should be explored, although carefully. The key message was that it is an option that should be taken into consideration as a practice and discussed with our clients, not only as a full online option but also as a blended option. Important is that both therapist and client feel comfortable with working online and consider it promising. Current knowledge posits as a valid channel, even though posing new challenges to therapeutic relationship and needing further evidence, especially when it is used with some particular clinical groups. There were different opinions about the ability of establishing a working relation online. In general, the balance between distance and closeness emerged as a point of consideration. A difference was noted between the approach in Portugal compared to the Netherlands, as there the affectivity between client and therapist can be of a more physical, yet professionally appropriate, nature than what is customary in the Netherlands. In the end all participants agreed that there are many pros and cons in online treatment, as there are for face-to-face treatment. Therefore, both options and a blended form should be taken into consideration with quality of treatment, accessibility, flexibility, comfort, affordability, and deployment of mental healthcare professionals in mind.
5. Conclusion and Clinical Relevance
In conclusion, we can look back at a successful symposium and international collaboration. All participants agreed on the relevance of working together internationally as mental health care professionals. As we face similar challenges for the future combining our knowledge and passion can lead to better solutions sharing the tasks in finding these solutions. Furthermore, we can collaborate in building a future-proof profession. Sharing knowledge, resources, and expertise, can contribute to achieving joint goals. As we both face scarcity of mental healthcare professionals and resources, sharing best practices and innovative approaches to improve mental health care can be a way to deal with this scarcity and achieve the best possible mental healthcare in both countries. This can also lead to reducing disparities in access to mental health care (e.g., in online therapy, exchanging experiences and programs). Exchanging research and developments can also contribute to sharing financial burdens and promoting research implementation, which may lead to improvements in interventions and treatments. By collaborating in this field, more effective responses can be made to needs in mental health care at the European level. This meets the goals of the WHO in transforming mental health to a level where the entire spectrum of mental health needs is addressed through a community-based network of accessible, affordable, and high-quality services and support (WHO, 2022) . Considering all aspects collectively, we have observed that change of perspective requires clinical leadership. In this way, challenges become new opportunities. New opportunities bring job satisfaction and happiness at work and thus contribute to increasing the appeal of mental health care. The result: challenges can be turned into chances!
Acknowledgements
The organizers of this online symposium wish to express their sincere appreciation to all individuals and organizations who contributed to the successful planning and execution of this event. We are deeply grateful to Hanneke Niels-Kessels, Maria João Brito, Lars de Vroege, Susana Eusébio, and Maria Inês Martinho for their dedicated efforts in organizing the symposium. Special thanks are extended to Toon Bierman for his technical support during the symposium. Furthermore, we would like to acknowledge the invaluable contributions of our esteemed speakers and moderators, whose expertise and insights enriched the symposium program.