Do money and bureaucratism make the world go around?

Written by Erik Bulten, PhD,
Head assessment, research and professional development of Forensic Psychiatric Hospital the Pompefoundation


The Dutch forensic psychiatric system is influenced by several different cultural developments. Some of them are positive while some are, perhaps not too helpful for improving quality. Anxiety in society, strong emotions and reactions to repression by isolated incidents, shaming and blaming do also affect forensic psychiatry and the patients who are treated using this line of treatment. We have to deal with such influences. We like to deal with them as forensic psychiatry works for and with the society and is of course part of it.

Variation in budgets is, at all times, directly related to increasing and decreasing the number of beds. We have to deal with these cycles as well; we want to deal with them because forensic psychiatry is part of economic systems, governmental budgets and economical fluctuations.

Guided by mistrust, and perhaps, based on obsessive compulsive attitudes, forensic psychiatry in the Netherlands is forced to produce multiple reviews, involving a lot of paper work and file information and follow intensive procedures, in order to put in place huge amounts of so called benchmark statistic, measures of achievement etc.

The evil of ‘Bureaucratism’ is widespread. A lot of our well-trained professionals spend most of their time (even as I as I am writing this Blog) in front of a computer. They have to account for every movement they make and every minute they spend, in order to get financed at the end. In the process, they have to pass through several tedious bureaucratic legal procedures. We have to deal with it; we want to deal with it if all of this would improve the effectiveness and quality of the forensic care offered to the patients. We want to have this responsibility and do not want to step away from it.

But cutting down budgets and at the same time increasing all the meaningless tedious administrational and bureaucratic work doesn’t make sense. Instead of spending the money on these claptrap administrative procedures if we would spend the same amount on real treatment and superior research on areas such as what intervention is effective for what type of patient, we could easily take the responsibility for the effects of our work, improve our treatment and bring in the professionals from the PC to the patient, without needing additional funds.

But why is such intensive accounting necessary? This is an interesting question! It seems basic mistrust is an important reason behind it. Distrust is in some way specific for forensic psychiatry. The patient, who is being treated, involuntarily distrusts the system, possibly based on a paranoid personality. The patient distrusts the system because his previous experiences with authorities created this mistrust. Professionals too have to distrust the patients to a certain level. Is he/she manipulating me? Does he/she speak the truth? Is he able to give the proper information based on his or her pathology and criminal background? Mistrust in the society, the government, the patient and the therapist: an interesting combination. Is it enough to terminate a treatment? Is society willing to accept and support the patient? Interestingly, other professionals such as lawyers, judges can also have such a critical attitude of mistrust. We have to deal with it; we want to deal with it because it is part of our complex yet interesting job to communicate with these key professionals. Getting the patient to undergo treatment is a way to assure the society that we do our best to reduce risk to a realistic minimum. We have to deal with it; we want to deal with it because it is also part of our responsibility to see that money is spent in a proper way.

Nonetheless, we don’t want to deal with mistrust by adapting a ‘big brother is watching you’ system in which every movement is accounted for and monitored, registering every second etc. Not just for our own sake, but for the sake of the patient. We lose significant amount of time in – monitoring, being monitored and monitoring the way we monitor and we write an awful lot or reports. Unfortunately, the time so lost will not make patients better, will not improve treatment, but will create a vicious cycle – time lost in monitoring and documenting would lead to treatment getting worse, decrease effectiveness of treatment and more monitoring would therefore be needed, according to society and the government, thus completing the cycle. We want to improve treatment. We want to make it more effective, making sure that patients get the essential treatment but spend no more time in forensic hospitals than necessary. This in why we work together in the COST IS1302 action. Learning from each other, combining and stimulating research on long-term forensic psychiatric care, developing best practices, improving quality of life for patients and exploring the reasons why patients sometimes get stuck in the system. Do patients get stuck in the system because of bureaucratic reasons? We do need clinical data and scientific information for the purpose of providing better treatment, but collection critical data has to be linked to reaching important targets and not just for the sake of it.

We need to stand up for our results based on proper scientific research, improve the treatment based on this research and not be trapped in a impeding administrative, self reinforcing superficial system of pseudo-accountability.

Is this development typical Dutch? What kind of solutions are there to terminate this cycle of mistrust and exploding bureaucratism? Please, respond!!!!!