Netherlands Center for Chronic Early Childhood Traumatization (LCVT) Improves Treatment for Children, Adolescents and Adults

Martijne Rensen

For many people with complex mental disorders related to chronic traumatization in early childhood, effective treatment is hard to find. Funding is insufficient and qualified therapists are lacking; the resources available for research, training and innovation are grossly inadequate. This situation is by no means unique to the Netherlands. Clinicians and researchers elsewhere in the world are doubtless familiar with the problem.

Recently, several groups of Dutch stakeholders – including clinicians, patient organizations, policymakers and researchers – have joined together to develop the Landelijk Centrum voor Vroegkinderlijke Chronische Traumatiseringz (LCVT) model, under which treatment, research, training and innovation are concentrated into Tertiary Referral Centers for Early Childhood Trauma (TRTCs) in various parts of the country. This initiative could serve as an inspiration to people in other countries. The model has been endorsed by patient organizations, health insurers, the national health care inspectorate, and the professional trade association of mental health care services. In developing the model, we devoted considerable effort to contacts with pivotal officials in health insurance and government circles.

In 2006 the Dutch national authorities, prompted by the LCVT initiative, designated the treatment of the psychological sequelae of chronic childhood abuse as a national focus in mental health care. Treatment in TRTCs has now been incorporated into the Dutch standard health insurance package in a growth model. In 2007, five TRTCs were affiliated with the LCVT, and the number should rise to about ten in 2008. TRTCs operate as subdivisions of approved mental health services. Within five to seven years, about 20 TRTCs should be operational, forming a nationwide network of qualified specialist treatment providers.

The aim of the LCVT is to strengthen the professional standards, accessibility and nationwide availability of treatment for child, adolescent and adult survivors of chronic early childhood traumatization. The LCVT is a cooperative partnership between mental health services, research institutes and patient organizations. Its central office, which includes a data management and research unit, is linked to the supraregional TRTCs that perform the diagnostics and treatment. Mental health care in the TRTCs predominantly consists of outpatient treatment by highly qualified clinicians. On the basis of current knowledge, the timeline for an adult course of treatment is expected to be at least 4 to 5 years, with an average frequency of two sessions per week. Treatment for children will generally be shorter.

The patient organizations supporting the LCVT initiative have made recommendations in a number of areas:

• availability of services. A major expansion of treatment capacity is needed to substantially shrink the current waiting lists.
• treatment pathways. Patients should be clearly informed about what the therapy will entail and what results it aims for. Families should be provided with adequate support.
• diagnostics and “patient routing.” The diagnostics stage needs improvement to ensure greater precision, an earlier start to the procedure and fewer second-opinion requests.
• communication. Better education should be provided to patients, friends and relatives about treatment pathways, medication recommendations, and the availability of crisis intervention.
• involvement of patient organizations. Patient expertise should be drawn upon when developing treatment guidelines and aligning care pathways.

Cost-effectiveness
Research shows that trauma-related disorders are a source of high expenditures in mental health, medical and social services, and that costs tend to increase sharply when appropriate treatment is not provided. On the basis of research in the USA, we estimate that the annual costs in the Netherlands now amount to €2 to 3 billion. In addition to improving the quality and geographical distribution of treatment services, the LCVT aims to promote greater effectiveness at lower cost. The LCVT treatment approach and organizational structure is expected to deliver cost savings in the following ways:

• reduction of psychiatric hospital capacity through the availability of generally intensive outpatienttreatment in frequent sessions. This should greatly limit the need for long hospital stays and inpatient crisis intervention, while still enabling brief inpatient stays when necessary 
• reduction of outpatient and inpatient mental health care expenditures by transforming lengthy patient careers into effective outpatient pathways that are relatively limited in time and cost
• reduction in social welfare expenditures by combining treatment with employment in return-to-work programs (parallel care pathways)
• reduction in general medical expenditures by alleviating psychopathology, resulting in lower utilization of medical care

Evidence-based care
The LCVT-affiliated Trauma Centers link their outpatient treatment program to evidence-based practice. To achieve uniformity in diagnostics and treatment, the organizations collaborating in the LCVT have drawn up an initial state-of-the-art program, as set out in LCVT guidelines for diagnostics, treatment and evaluation which all TRTCs are required to follow. The LCVT is now working with leading institutes for research and quality in health care and with professional associations of psychotherapists, psychologists, psychiatrists, general practitioners and nurses to develop uniform guidelines applying to all treatment providers nationwide (including those outside the TRTCs).
Membership of TRTCs in the LCVT is subject to certain conditions. All Trauma Centers must cooperate within the LCVT framework to build and share expertise and to contribute to nationwide research on treatment outcomes. They are expected to:

• work on the basis of alignment of diagnostics and treatment which are rooted in evidence-based guidelines
• participate in developing these treatment guidelines and the quality circles associated with them
• take part in data collection and nationwide treatment outcome research
• train their staff to work in accordance with the LCVT guidelines participate in national-level consultations and innovation activities. 

Training
The LCVT has developed a mandatory training program for all clinicians working in TRTCs. An advanced-level course of training will start in 2008 for clinicians, both TRTC staff and others, who specialize in treating mental disorders related to chronic childhood traumatization. The expected course duration is 18 months.

Outcome research
LCVT members commit themselves to a research agenda. All treatment interventions carried out by TRTCs will be systematically monitored via a data collection procedure, to enable research on treatment outcome, patient satisfaction and cost-effectiveness. A Research Advisory Board comprised of leading national and international researchers has been appointed to oversee the research unit’s activities.

Estimates
The LCVT estimates that approximately 4,000 adults and 3,200 children per year will be identified for treatment at TRTCs. In 2007, the pioneering group of five TRTCs took a first step by providing 380 treatments (for 300 adults and 80 children). Treatment capacity will be expanded in 2008 with the expected addition of five new Trauma Centers. The LCVT hopes to achieve nationwide coverage within four to five years. This will involve 10 to 12 TRTCs for adult treatment and 10 to 12 for child treatment.

Dutch pragmatism and responsiveness to stakeholders
The LCVT combines an ambitious vision with Dutch pragmatism and responsiveness to the community. All stakeholders are informed clearly that we are setting out to deliver tertiary care in a situation where systematically tested treatment methods are not yet available. Many focuses therefore still need to be developed and researched. This pragmatic approach is combined with objectivity – delivering statistics, establishing an evidence base for the approach, and anticipating innovative developments in the wider mental health field. Nevertheless, we are making an important point: formidable though the problem may be, the solution is fairly straightforward. We have described our solution above.

One of the LCVT’s success factors so far, designed to safeguard the tertiary status of the initiative, has been to introduce a stringent selection procedure for mental health services wishing to join the LCVT. It sets high standards for the agencies in matters such as currently existing expertise, the availability of tertiary care clinicians, and previous experience in organizational development, research and innovation. By virtue of such standards, member agencies stand to derive additional benefits from LCVT participation, beyond their expanded potential for specialized treatment. They can maintain a high profile as specialist mental health centers at a time of increasing competition in the health care sector. They can set themselves apart from other institutions by providing tertiary-level quality, and they can demonstrate their innovative capabilities.

A second key factor in the wide acceptance of the LCVT thus far lies in the transparency of the TRTCs about the quality they deliver, their openness to evaluation of their services, and their willingness to adapt services in response to feedback from patients and researchers. These qualities have played a critical role in gaining the support of health insurers.

The involvement of patient organizations is a third significant factor. These groups are capable of pinpointing the problems that exist and the needs that patients have. They have made clear how long many survivors of chronic childhood abuse and neglect have been seeking adequate treatment. Health insurers are sensitive to signals like these from patients. From the companies’ own experience, they are keenly aware of the problems inherent in the treatment of such patients. Yet an effective, high-quality alternative had never been provided up to now, and the message from treatment providers has been that they have nothing to offer these severely traumatized patients. Health insurers are now giving increasing recognition to effective treatment methods which, in time, may even save them money.

Last but not least, it is a rewarding experience for clinicians and patients alike to work or receive therapy in the TRTC environment. Clinicians pride themselves on the professional recognition and specialist expertise they are gaining, and they derive much satisfaction from the successful therapies which are reducing the patients’ suffering and improving their mental health. Staff can now also count on more support from colleagues in these often strenuous therapeutic processes. Patients better understand the quality of their therapy and feel they are no longer “forced to rely on blind trust,” as the patient organizations have so aptly expressed it.

Martijne Rensen, MA, is director of the Netherlands Center for Chronic Early Childhood Traumatization (LCVT).