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Forensic Psychiatry in the Netherlands

Dutch psychiatry and law meet in several places: in the laws and regulations concerning patients in general psychiatric hospitals, psychiatric wards of general hospitals and psychiatric outpatients. Not-voluntary admissions, not-voluntary treatment, M & M (means and measures), competence of will, guardianship etc. This part of psychiatry & law I will not discuss in this letter.

A second place where psychiatry and law meet is the forensic psychiatry, the subject of this paper.

To explain what the system looks like and how it works I will fabricate a case.

The story of Mr. A.

On a rainy November day in 1994 the police arrests Mr. A., suspecting him of the murder of his wife, two days before in their apartment in Rotterdam. He is arrested in the house of his mother where he turned his old room in a complete mess and his mother in a very nervous and upset old lady.

He immediately admits the murder of his wife, although he claims she isn't his wife; she is a messenger of Satan who overtook the body of his wife and was sent to kill him. He can show the officers proof of that and hands them two grocery-bills and an empty chocolate-box, which he says contains "devil-traces". By this and his looks, -the man wears torn and dirty clothes and hasn't combed or cut his hair and beard for several weeks and has big, wild and angry looking eyes- the arresting officers realize that he isn't an ordinary criminal and needs to see a psychiatrist soon. After quite a struggle, because the man recognizes the police-van as one of Satan's private cars, they get him to the police station, where he is examined by the district-psychiatrist the same day.

The district-psychiatrist concludes the man is psychotic and dangerous and a more elaborate multi-disciplinary psychiatric evaluation and clinical observation could give important extra information.

The judge follows this advice and 3 months later Mr. A. is placed in the forensic-psychiatric-examination-clinic. During the waiting-period the patient stayed in a specialized unit for psychiatric patients (FOBA) in a prison, which has psychiatric-trained employees.

The clinical examination takes 7 weeks and the conclusions are that Mr.A. suffers from paranoid schizophrenia, which was not treated for the last 3 years, and that he committed the crime in a psychotic state, which lead directly to the crime committed and therefore they conclude he was entirely-not-responsible for the murder he committed. But if he would be released from custody untreated the chances would be very high that he would commit a related crime in a short time, therefore they advise the judge to give him a forced clinical treatment in a TBS-clinic. As expected the judge follows this advice too and after the trial on May 6th 1996, at which was proven without doubt that he had killed his wife, Mr. A. is sent to the TBS-selection-institute to select the most suited TBS-clinic concerning treatment possibilities and security level. Finally in October 1997 Mr. A. is placed in a TBS-clinic.

In May 1998, 2 years after the verdict he has to stand trial again and the judge has at that moment to decide whether the treatment has to be prolonged.



PERSONAL COMMENTS

In general the Dutch forensic psychiatric system in my opnion is reasonably good.

People who are arrested for a crime are thoroughly examined if a psychiatric disorder is suspected.

Clear cut cases, like Mr. A. in my imaginary story, are well-diagnosed and well-treated. A problem arises for some of them when the treatment has reached its final result and the patient is ready to leave the hospital, but not able to function independently. These, mostly schizophrenic, patients are not very welcome in the existing facilities for chronic psychiatric patients without a violent history. Discussions about this topic between general psychiatric caretakers and the forensic psychiatry are being held broadly in our country and specialized forensic-psychiatric policlinics, half-way-houses and other facilities are being started "around" most TBS-clinics.

Another difficult problem, but probably not just in the Netherlands, is the treatment of people with very severe personality disorders who committed a violent crime. There is a tendency to move from psycho-analytical-oriented treatment plans to plans that focus on a disability-model. But a small but seemingly growing group stays in the TBS-clinics for long periods (6 years and up) without improving enough to return to the society safely. Some of these patients have psychotic disorders too.

About this problem a discussion has risen about opening long-stay-units in TBS-clinics, not merely treatment-oriented but designed to live there for life.

Again another problem area is the long prison time with all its unwanted effects many patients have before they can start therapy.

Last but not least: we are suffering from major capacity problems in our treatment-clinics: patients have to wait for one or sometimes nearly two years before they can start treatment, during that time they stay in prisons. To solve this problem the capacity is raised by building new clinics and allowing or ordering the other clinics to treat more patients at the same time. The clinic where I work raised its capacity from 67 to 176 (!) patients in about 5 years! Just imagine such big changes in a forensic-psychiatric hospital.

I will never get bored!

I hope you got an impression of the forensic psychiatry in the Netherlands through this comments.

Although I work as a psychiatrist in a forensic-psychiatric hospital this piece is written entirely as a personal opinion for which my employer is in no way responsible.

Annette J. M. van Zeist, M.D., November, 6th, 1997.