Presentation text: Forensic Psychiatry Netherlands

Here you will find the text of my presentation on forensic psychiatry in the Netherlands, which I delivered at 26 July 2015 in Tokyo, at a conference organized by the Japan National Group of Mentally Disabled People (http://www.jngmdp.org/ )

Several laws in the Netherlands allow for forced psychiatric treatments by a court order. Under current Dutch laws, both for children as for adults, the practice of forced treatments is legally connected to forced hospitalization to a (specialized) mental health institution. Inside these mental health care institutions there is basically a structural lack of social attention for the life of users, and in many occasions there are no adequate services to deal with mental health crisis situations. Once hospitalized, the psychiatrist and/or nurses have the power to decide to use forced interventions. Their job is basically “to intervene” with pre-defined interventions and they have too little time for contact with the persons involved. The dominating medical model has caused a narrow mind-set and neglect of the social dimension. Coercion is traumatizing and doesn’t help to bring safety or wellbeing, even on contrary.

The State of the Netherlands has not been playing a key role in banning coercion from mental health care in the Netherlands.
In 2008, a law reform process on forced psychiatric treatments started, for which 3 law proposals were designed:
1.a law proposal on “Mandatory mental health care”
2.a law proposal on “Care and Coercion”.
3.a law proposal on “Forensic psychiatric care”

The goal of this reform is to harmonize the laws to enable flowing of persons with psychosocial or intellectual disabilities from one system to the other. In these laws, the court will decide the scope of forced treatment, although the judges are not doctors.
The place or location of the treatment can vary, depending on the conditions of the treatment order and the so-called “need for protection” of the person during the treatment, so the person can be transferred to higher or lower security settings on the judgement of the psychiatric staff, and the treatment order is portable. This also applies to persons who haven’t had a sentence for crimes. They can also be transferred to high secured settings. The judge decides on a treatment plan and indicates the scope of treatment. For various steps of treatment there are conditions to the level of security, which is called “stepped care”.

One would expect that in the Netherlands, a progressive law proposal would be made, taking into account the CRPD (Convention on the Rights of Persons with Disabilities) and the Good Practices to avoid forced interventions that were identified in various Dutch projects, but unfortunately the law-makers in the Netherlands proposed to expand the options of forced psychiatric treatments, and allow for “any intervention that is considered necessary”, by which they aim to allow for individualized forced treatments, depending on the so-called individual needs of the person. So it is no longer only the standard practice of institutionalization and seclusion, medication, restraints, food or fluid, but allowing for individualized plans, including Community Treatment Orders with conditions and sanctions when these conditions are not met. In the law proposals, the scope of interventions is not defined or limited, and is described as : “any intervention in the care-field”, so for example a court order for forced abortion would be legal under this law. The law-makers claim that this system of “Stepped care”-orders are less invasive and more sensitive to individual needs than the standard practice of forced institutionalization and forced treatments. But there is no limit, anything can be done to the person according to the law.

Shockingly, the law-makers also claim that the use of forced treatments, such as physical restraints in the community is less invasive than in a hospital, such as tying a person with intellectual disability or dementia up in a chair in their own home at moments of distress, which is amongst the most primitive practices in the world. Obviously, the mental health care system was in fact established with the goal to prevent these primitive practices of restraining persons with psychosocial or intellectual disabilities in the home situation.

The language in the law proposals is, like many State-supported documents, generally smoothing, substitutive and misleading, covering up the real practices, reaffirming stigma and based on an outdated medical model.

If more efforts were made by the State of the Netherlands, forced treatments and substitute decision making could probably have been already banned from mental health care in the Netherlands, but somehow the sense of priority seems to be lacking at the policy levels.


Forensic mental health care in the Netherlands is in Dutch called: TBS, and it is clinical mental health care combined with detention, which is generally taking place in a specialized secured mental health care setting, often a forensic psychiatric clinic. A court order for forensic psychiatric treatment is a severe measure in Dutch justice. The measure is meant for someone “who cannot be accounted to the crime, because he or she suffers from a personality disorder or a severe mental disorder, and whose disorder has contributed to committing the crime” The person is then found “irresponsible”, either partially of fully.

The official governmental descriptions of Forensic psychiatry mention that the goal of Forensic psychiatry is to provide a “combination of care and protection for persons with psychiatric disorder”. This suggests it is about providing “care”, but that is not really true. It is mainly about “protection of the society” by detaining the person for what they call “as long as necessary”.

Forensic psychiatric treatment-orders are in theory sentenced for a period of 2 years, and as a rule it can be prolonged every time with 1 or 2 years. The judge will prolong the measure when he considers that necessary, on advice of the treatment-coordinators, according to the expected danger of severe relapse.

Forensic psychiatric treatment can replace detention in prison.
But in case the crime can be partially accounted to the subjected person, the judge can sentence him or her to imprisonment for that part of the sentence. These are “combination-sentences”. After completing the detention, commonly the subjected person will be institutionalized in a specialized institution for treatment after the detention.

The end-date of detention/institutionalization is unknown at the start or during forensic psychiatric treatment. Prolonged forensic care can become imprisonment for life-time.
The combination sentences are therefore generally used for the most severe crimes that have a high social impact. There are several cases of sexual crimes where a person get sentenced to for example 6 years detention plus Forensic psychiatric treatment afterwards. During the first part of the sentence, which is the detention, the person will not get the treatment, but this will come only after the set time of detention.
This construction of “combination sentences” for high impact crimes is highly stigmatizing the entire system of Forensic psychiatric care, and the public perception is that persons in forensic psychiatry are a kind of monsters.

About all crimes who lead to sentences of Forensic psychiatry have a component of violence, sexual crime, fire or property crime.
In official recidivism studies on Forensic psychiatry, the category “crimes worthy of Forensic psychiatry” are suggested as the worst category of relapse, additional to severe crimes and very severe crimes. This language and attitude is again highly stigmatizing and hardly has anything to do with mental health care.

Of people currently placed in forensic psychiatric facilities in the Netherlands:
95% is male.
The average age is between 30-40.
60-70% has a Dutch nationality, and about 30-40% has another nationality.
The average stay in Forensic psychiatry is about 9-10 years.
“In 2011 less than 50% of the population whose forensic psychiatric detention started in 2002 had flowed out”.
Averagely, about 14% of forensic psychiatric treatments is ended because of death of the person concerned. (which means that over 1 out of each 10 persons does not survive forensic psychiatry)


The laws state that a forensic psychiatric treatment should be completed after 6 years. - When after 6 years the risk for relapse (recidivism) has not been reduced sufficiently according to the judge, the care budget of the clinic will be cut down and the emphasis will shift from care to stay. - When treatment in 2 different clinics does not have sufficient effects (and the risk for relapse has not or not enough been reduced and there is no perspective on improvement) then the subjected person is marked as “long-stay-patient”.

This decision is taken by the Ministry of Justice, after getting an advice and being informed by LAP, a board consisting of psychologists and psychiatrists. And although also during long-stay the measure is evaluated at least once per 2 years, this can lead to a life-time imprisonment in prison settings, institutions or forensic psychiatry. The longest forensic psychiatric detention in the Netherlands was over 50 years continuous detention in a forensic psychiatric-clinic, from 1960 to 2011. (while in the regular prison system there is no such life-time imprisonment in the Netherlands)

The number of persons in longstay-forensic psychiatry is on the rise. In a period of 6 years, between 2004 and 2010 there was an increase in the number of persons in longstay-forensic psychiatry of over 330 %.

Forced treatments and forced interventions in forensic care settings are comparable to general mental health care, although generally executed with more force.

Experts with lived experiences tell us that inside forensic psychiatric settings there is too little attention for the mental wellbeing of the person, because the focus lays on preventing danger and exercising control, which leads to a lack of chances for personal development.
Forensic psychiatric institutions itself are very disabling to live in, by the huge amount of bureaucracy and a full focus on control which is rooted in every daily activity (locks, checks, rules, procedures, protocols, registration and so on). Sometimes ‘collective punishments’ are used, for example when one detainee escapes, it happens that all other leaves are put on a hold to be reconsidered. Collectively reconsidering all supposedly individually taken decisions on freedoms, when a small segment of the population shows rule-breaking behaviour is not an accepted form of punishment, and is certainly not a good care practice.

Persons with psychosocial or intellectual disabilities in detention, are often excluded from getting access to various evidence-based and experience-based care-resources, such as user movements, self help initiatives, peer support, complementary care, wellness, education, research and consultancy, and even access to general understandable information about mental health, care, rights and options is often hard to reach, due to structural limitations in communication (limited or prohibited internet access, limited freedom of movement, and so on). This seriously reduces the chances on recovery.

The legal position of persons placed in forensic psychiatry is much weaker than other persons with disabilities, while persons with psychosocial and/or intellectual problems in detention are an extremely vulnerable group at high risk of suicide, and facing a reduced chance on recovery.
The Forensic care system is currently solely coordinated by the Ministry of Justice (without the Ministry of Health, which partially explains why the care-component is falling more and more off the scope.


Detention always creates a risk for mental health, due to power imbalances, social exclusion, sensory deprivation, detachment and dehumanization.
Recidivism (or relapse) is higher for persons who have been detained (almost twice as high). So the original goal of Forensic psychiatric treatment to prevent relapse and recidivism is not met, but even on contrary, it creates more risks for society.

It is clear that the Forensic psychiatric system fails to bring relief, either for the persons subjected, and for the community as a whole.

A more social approach, with a focus on social chances and investments in a “crime-free future” by supporting recovery and future autonomy such as by education, mental health care and social restoration, is proven to be more effective and contributes to a lower rate of crime and detention.


PS
For footnotes and references to data, also see CAT-report 2013 “Torture and ill-treatment in mental health care in the Netherlands” written by Stichting Mind Rights. (Chapter 3. Forensic psychiatry, page 45 and up)
http://www2.ohchr.org/english/bodies/cat/docs/ngos/StichtingMindRights_Netherlands_CAT50.pdf