Lessons-Learned Abroad: Exchanging Knowledge, Experience and Inspiration between Dutch and Portuguese Specialized Clinical Psychologists ()
1. Introduction
Different countries have various ways in how healthcare is designed. A healthcare system focuses on maintaining physical and mental health. Countries that are members of the Organization for Economic Co-operation and Development (OECD-countries) have a regulated healthcare system. The OECD brings together member countries and a range of partners that collaborate on key global issues at national, regional and local levels. Their motto is: “better policies for better lives” (https://www.oecd.org/). Currently, 38 countries are members of the OECD. Like Portugal, the Netherlands joined the OECD in 1961.
The Dutch healthcare system is built according to the principles of the Bismarck model, which uses the principles of solidarity and self-management (Busse et al., 2017) . The basic philosophy of the Dutch care system is centered around flexibility, affordability, quality and improvement of the work satisfaction (the quadruple aim perspective, according to the Taskforce “right care in the right place” (Taskforce JZOJP, 2019; https://dejuistezorgopdejuisteplek.nl). Through the payment of taxes, healthcare funding is contributed by the government and healthcare insurance companies, so that based on the principle of solidarity, everyone has access to care. However, the healthcare system will have to be adapted continuously to guarantee cost control, quality and accessibility in the future.
In the Portuguese healthcare system, there are two circuits; a private circuit for the more affluent quarter of the population and a publicly funded basic care system for the other Portuguese (the Serviço Nacional de Saúde, SNS), which has existed since 1979. Many medical staff work in both sectors. Differences between both healthcare systems have led to differences in the approach of mental healthcare, the societal position of healthcare, the development of professions and innovations. The comparison of both healthcare systems and exchange of experiences in mental healthcare abroad inspires to seek alternative solutions to cope with domestic challenges. Further exploration of these differences inspires professionals in both countries and adds to the development of skills for the specialists in training. In this report we discuss the results of a Dutch delegation visiting their peers in Portugal, facilitated by the Dutch Portuguese Chamber of Commerce (CCPH) hoping to inspire others to seek inspiration abroad.
2. International Exchange as Part of Professional Development
The Dutch Healthcare faces all kinds of challenges such as increasing demand and costs on the one hand and declining numbers of staff because of career choices, workload and high numbers of sick leave (de Vries et al., 2023) . Inventiveness and creativity are necessary in order to realize and maintain structural solutions to keep mental healthcare available to all inhabitants now and in the future (Rijksoverheid: Ministerie van VWS, 2022; van den Broek et al., 2022a) . The education program towards a specialized clinical psychologist aims to deliver innovative professionals, working on the crossroad of treatment, diagnostics, management, and research. As scientist-practitioners, they provide a contribution towards facing the above-described challenges. Other European countries are facing similar challenges, whilst the way healthcare is organized might differ a lot. As mentioned, Portugal has the National Health Services with both a public and private branch which is quite different compared to the healthcare system in the Netherlands. Furthermore, both countries have a different history and way of organizing the profession of psychologists. The differences in healthcare organization and the way the profession of psychologists developed also reflects the culture and policies of society.
The international exchange entailed the visit of: The public psychiatric hospital “Hospital Júlio de Matos”, (https://www.chpl.min-saude.pt/instituicao/hospital-julio-de-matos/), the “Ordem dos Psicólogos” (https://www.ordemdospsicologos.pt/pt), the center for medical psychology of the private hospital “CUF, hospitals e clinicas” (https://www.cuf.pt/) and the artistical center “Manicómio” (https://www.manicomio.pt/). The visit of both a public and private hospital was insightful in the comparison of healthcare within Portugal and in the comparison between the two countries. The meeting with the “Ordem dos Psicólogos” allowed for a further analysis of both the history of psychology and the profession with respect to the cultural background of the countries, in addition to understanding the similarities and differences between the education and organization of the profession. At the CUF hospitals experiences and scientific study results were exchanged between scientist-practitioners. At Manicómio specifically stigma and the use of experienced professionals was explored. And lastly, the start-ups were introduced, and the trainees contributed in a brainstorm session.
3. The Profession of the (Clinical) Psychologist
The professional field of the psychologist in the Netherlands is relatively young when compared with other professions in healthcare such as medical doctors and nurses (less than 100 years versus over 150 years). But the formal registration of the association and profession in Portugal is an even more recent development. Since 2008 the Portuguese Board of Psychologists (Ordem dos Psicólogos Portugueses, OPP) was founded and in 2010 the profession was formally registered (https://www.ordemdospsicologos.pt/; https://www.ordemdospsicologos.pt/ficheiros/faq/lei_57_2008_de_4_de_setembro.pdf). In comparison: In the Netherlands the association for psychologists (NIP) is 86 years old and the association for psychotherapists (NVP) is 92 years old (https://psynip.nl/; https://www.psychotherapie.nl/). Despite the relatively youthfulness of the profession in the Netherlands, it still has quite a rich history when compared to Portugal. However, compared to the Portuguese Board and the influence on national policies they accomplished, we found it not necessarily to be an advantage. The more recent establishment of the Portuguese Board seems to make them more organized as one entity, which makes them more decisive and influential in their country. This allows the psychologists in Portugal to have a direct advising role for the national government. The board is requested to contribute in all kinds of matters involving mental health, such as the COVID-19 pandemic and behavioral change such as climate change (http://mkt.ordemdospsicologos.pt/vl/182a827aef49f41b85bcf3f896-9249529845d238en2e0e16M0e; https://www.ordemdospsicologos.pt/en/noticia/3774; https://www.ordemdospsicologos.pt/ficheiros/documentos/contribuicoes_da_ciencia_psicologica_para_a_crise_climatica.pdf). Furthermore, they aim to normalize mental healthcare and decrease stigma. Their strong position enables them to have a huge impact on society.
Another difference is the way in which the profession and its education are organized. The OPP is the keeper of the database of registered psychologists and is also leading concerning the education and specializations. Just like in the Netherlands, the OPP is looking for ways to organize the specializations (such as neuropsychology, forensic psychology etc.). At the moment there are 3 general specializations and on top of those there are another 12 advanced specializations. This “stacking” of specialization does not seem beneficial to the clarity of the professional field. In the Netherlands such diversification led to fragmentation and internal quarrels in the past. The Portuguese colleagues should be attentive to such unwanted side effects because it was the unity they radiated in particular that inspired the Dutch delegation. In the Netherlands we are now focused on more clarity and less specializations in order to regain unity (NIP & NVP, 2022; https://beroepenstructuur.nl/). It seems to be a recurring challenge for a relatively young profession to give room for specialization on the one hand and to remain united on the other.
4. Exchange of Evidence Based and Practice-Based Research
Prof. Dr. M. Torrado (Head of Psychology Unit of Hospital CUF Tejo (HCT) and Assistant Professor at Faculty of Medicine, University of Lisbon) and his colleagues informed the Dutch delegation about recent scientific and practical developments. With the recent creation of the first autonomous Department of Psychology in a Hospital from the private sector, a specific model of the organization of psychological care in HCT has been implemented which takes different needs and populations into consideration. Adding to four domains of care (psychology and mental health of adults, psychology and mental health of children and adolescents, clinical neuropsychology and liaison psychology) a Research & Development domain (psychology R&D) seeks to evaluate clinical practices, to create quality standards and to develop new research projects, in a close contact with Academia and community stakeholders. Dr. H. Barreto (psychology advisor to the National Board of Mental Health Policies, Minister of Health) spoke of differences between Dutch and Portuguese forensic healthcare. In Portugal (Conselho Nacional de Saúde, 2019) , it has been customary to secure the society from deviants instead of helping them. Underlaying problems, such as poor cognitive capacities of psychological problems, have long been ignored. If there was a treatment, generally it was only pharmacotherapy (Vieira, 2009) . However, since 2019 there’s a new policy: mental healthcare for delinquents has been legitimized by law and specific interventions are being developed since.
Prof. Dr. D. Neto, lecturer and researcher in ISPA (the first school of Psychology in Portugal, a private University, https://www.ispa.pt/) provided a global view of the presence of clinical psychologists and psychotherapists in health care contexts and the needs of integration of an increasing number of professionals in hospitals and primary care as some country regions have very little support. Despite a prevalence of lifetime mental health disorders above 30%, Portugal is failing to achieve an effective mental health system according to Perelman et al., (2018) . This failure is partly due to inadequate financing mechanisms of mental health care. Perelman proposed an innovative payment model for mental health providers by “designing a four-dimension model that focused on 1) the prevention of mental disorders early in life; 2) the detection of mental disorders in childhood and adolescence; 3) the implementation of a collaborative stepped care model for depression; and 4) the integrated community-based care for patients with serious mental illnesses”. Some years ago, the CUF Hospitals and Clinics’ Group started a path to develop sustainable strategies and is making funds available to support society. Mrs. M. Fiadeiro presented pilot-programs which focus on mental health promotion in high prioritized educational contexts, such as S’cola. Psychologists, a pediatrician and IT programmers cooperated to develop an app which focusses on health improvement and lifestyle changes among children and adolescents (CA). But it also focuses on basic education such as language. Furthermore, several psychological topics such as identity, attachment, and emotions integrate challenges proposed to CA through gamified toolkits (Villasana et al., 2020) (more information: https://www.expatica.com/pt/healthcare/healthcare-services/mental-health-portugal-104327/#prevention).
Dr. Bandeira de Lima (psychologist in HCT and autism expert at the International Consortium for Health Outcome Measurement (ICHOM; https://www.ichom.org/) spoke about the aims and goals of ICHOM. It aims to find the best interventions for different pathology. A recently developed questionnaire for autism measures symptoms, the daily functioning, quality of family life and comorbidity (https://connect.ichom.org/patient-centered-outcome-measures/autism-spectrum-disorder/). The questionnaire provides a selection of recommendations about diagnostics and evaluation which the Dutch treatment standards could benefit from.
After the contribution by the Portugese, the Dutch delegation organized two parallel symposia in which they presented various scientific studies and its results. The speakers presenting at symposium number 1 were Dr. L. de Vroege, presenting about “Cognitive dysfunctioning and its associations with personal characteristics” (de Vroege et al., 2022) ; Dr. M. Ouwens had a presentation about Treatment of personality disorders in older adults (Videler et al., 2021) . Subsequently Drs. H. Niels commented on “The association between perfectionism and suicidal ideation in depressed adults” (Smith et al., 2017) , followed by Dr. Y. Stikkelbroek presenting “Relapse risk and prevention of anxiety and depression in adolescence” (Robberegt et al., 2022; Robberegt et al., 2023) . Simultaneously at symposium 2 Drs. A. van Schooten presented results about “Animal assisted therapy” (Maber-Aleksandrowicz et al., 2016; Hediger et al., 2021) . Drs. F. Steenbakkers presented his research with respect to “Attachment Style in Virtual Reality: Closing the gap between in vivo and Virtual Reality” ( Steenbakkers et al., 2023 , under review); Dr. E. de Heer informed us about 'Pain and the consequences of developing psychological problems, including suicidal behavior (de Heer et al., 2018; de Heer et al., 2020) . Who is at risk and what can we do about it?’ and in the end Dr. A. van den Broek, presented a campaign and results of a survey about mental health of healthcare workers in mental healthcare during de COVID-19 pandemic (van den Broek et al., 2022b) .
5. Innovations in Healthcare
The position of mental health in Portugal is improving rapidly, but stigma remains a complicating factor. Stigma leads to delayed demand for help and slows down recovery of people. With different innovations the Portuguese colleagues seek to reduce stigma in their society. One such innovative project is Manicómio. Developed from a department for creative therapy in a public psychiatric hospital, Manicómio is an independent new organization for talented individuals that also cope with psychological or psychiatric problems. Formal psychiatric patients are facilitated in their creative process, provided that they can function independently, going through their own processes of creation and work. If necessary, they have the opportunity to ask for additional psychological support. Furthermore, they receive financial and material assistance and support in the marketing and sales of their work. The Dutch delegation experienced the ambience as no way near what you would expect in psychiatry. Both the artists from Manicómio and other entrepreneurs were working side by side. The Dutch delegation introduced a different way in which individuals with experience as a patient could have a role in society and healthcare; as an experienced professional (Weeghel et al., 2019) . The different views and angles on the topic of stigma was a lively and interesting discussion.
Another national innovation in Portugal is the transition of large (clinical) treatment centers to smaller local, regional and community-based facilities. Across the country 40 of such centers are being developed of which 20 already are in place, with pilot projects. This movement was strongly influenced by psychologists and psychiatrists and is in line with the European guidelines by EUCOMS (European Community Mental Health Services Network). EUCOMS aims to improve prevention and facilitate easy access to healthcare for everyone (https://eucoms.net). In comparison the collaborative innovation of Mental Healthcare Centers, in which specialized mental health care and general mental health care centers and Health Insurance Company invest, form a sustainable coalition which is presented as a possible solution for manageability of the mental healthcare system in the Netherlands (van den Broek et al., 2022a) . This coalition aims to improve the public values of mental healthcare as a desirable answer to the demand for an appropriate and future-proof Mental Healthcare. Furthermore, Lisbon is a hub for start-ups which also cover healthcare. However, the innovations of these startups are not widely implemented yet. The struggle to implement (technological) innovations is comparable to the Dutch situation (Lindenberg et al., 2022) .
6. Conclusions and Clinical Relevance
- Both countries are transitioning from large (clinical) treatment centers to community-based healthcare.
- Psychologists in Portugal are becoming strongly organized and united. They are asked for their input at a national level on topics such as the COVID-19 pandemic and climate changes. In the Netherlands there is fragmentation due to the establishment of various professional associations and it is less obvious to involve psychologists in national developments outside mental health care.
- Stigma is being addressed but remains present and hampers seeking help on time among others. Furthermore, stigma can be subtle, and it constitutes one of the most robust barriers to mental health care. We need to challenge each other to seek out our own limitations.
- In both countries psychology has a strong scientific foundation which provides a rich base of knowledge to exchange with each other regarding future developments.
- There are opportunities to collaborate with our Portuguese colleagues in scientific research. For example, on the topic of the mental wellbeing of healthcare professionals (de Vroege & van den Broek, 2021) .
We hope to inspire others to exchange experiences and knowledge across international borders. Differences in the way health care is organized, as well as regional variations, determine the diversity of difficulties faced by countries. At the same time, the focus on national problems can limit the options to look for solutions in a broader perspective. Diversity of thinking patterns and approaches can be of added value (Van den Broek et al., 2023a) . Looking beyond national borders can help prevent a narrow focus. Making international use of each other’s competences and complementarity, across national borders, can contribute to value-based health care (Van den Broek et al., 2023b; Porter & Teisberg, 2006; Porter, 2010) .
The collaboration between the Dutch and Portuguese Clinical psychologists will continue digitally in 2023. Exchange of and cooperation in scientific research takes place during a conference. A masterclass on trauma treatment will also be organized in collaboration with Hospital Júlio de Matos and the Ordem dos Psicólogos Lisboa will exchange experiences with the Dutch Institute of Psychologists (NIP). In the autumn of 2023, an event will be organized in collaboration with Manicómio with respect to Experiential Expertise.
Both the Dutch delegation and the Portuguese colleagues hope for a long-term cooperation and exchange of knowledge!
Acknowledgements
We thank GGz Breburg and GGZ Oost Brabant for facilitating the study trip and the Dutch-Portuguese Chamber of Commerce (CCPH) for organizing the network and activities. Hospital CUF Tejo, Lisbon city, Portugal; Manicómio (Artes e Saúde mental em Portugal); Hospital Júlio de Matos (the public psychiatric hospital), the National Board of Mental Health Policies, Minister of Health (PT) and the Ordem dos Psicólogos Purtugueses thanks for their hospitality.