Restrictiveness in long-term forensic psychiatric care – report of a STSM in the Netherlands

Written by Jack Tomlin – PhD student at Nottingham University

This STSM was undertaken with the aim of developing over the coming years a tool to measure restrictiveness in (long-term) forensic psychiatric care. In December of 2015, I was fortunate enough to receive COST Action funding to undertake an STSM in the Netherlands and I welcomed gladly the opportunity to visit several Dutch forensic institutions and the Expertisecentrum Forensische Psychiatrie.

The ‘Dutch approach’ seems to have become quite en mode in discussions of forensic psychiatric care in the UK. I recently attended an end of project conference on Long-term forensic psychiatric care (LFPC) wherein comparisons of British and Dutch secure settings provoked fruitful discussion. Typically, the Dutch are seen as being less restrictive, more liberal and QoL-focused in their care approach than the British. This is evidenced most strongly in patients’ rights of sexual expression. In the UK, although not codified in any national policy, sexual relationships between patients are prohibited – in the Netherlands, this is not the case. Indeed, a week prior to my arrival in December, two individuals; one from a secure care ward in Nijmegen, another from the long-stay centre in Zeeland, wed in the latter’s chapel.

I visited centres in Vught, Nijmegen and Zeeland, decreasing in level of security respectively, to ask patients and staff what they found most restrictive about long-term forensic care, and to learn about the policy framework around this. The answers I received varied widely and can be sorted into three broad themes – individual, institutional, and systemic elements of restrictiveness.

One patient highlighted his lack of access to an internet-ready computer to read medical journals, another, the opportunity to interact with a pet dog. In Vught, a patient described to me the process through which one can purchase goods such as videogames and clothes through a committee of staff members. The Pompestichting, the umbrella organization managing the centres, remunerates patients 2.35euro an hour for occupational work. A patient recounted to me how he was currently working two hours per week, but after some time and consistency, this would increase. The individual in Vught and member of staff described the forensic mental health system (terbeschikkingstelling (TBS) (translated as: “at the discretion of the state”)) itself as the most restrictive element of care. Patients can reside in the TBS system indefinitely, subject to review through tribunal. This individual felt that one disagreeable tribunal member many years ago has prejudiced his chances of ever leaving secure forensic care.

These responses mirror the regulatory framework operating within and around forensic psychiatric care. For instance, the “Beginselenwet verpleging ter beschikking gestelden” is a Dutch Act stipulating the process for admittance of patients into the TBS system, paralleling the Mental Health Act 1983 (as amended) in the U.K. Below this, the Pompestichting has policies affected within or across all its centres. This is true in the U.K. too. Rampton Hospital, for instance, has a list of internal policies; however, its regulatory framework is peppered with CQC (Care Quality Commission), NHS-national and NHS-trust policies, too. Finally, in Nijmegen, blanket rules for what each patient may or may not do are being rejected in favour of a “Ja, tenzij” approach. “Ja, tenzij” (“yes, unless”) aims to offer all patients equal access to services and opportunities (leave, work, picking up visitors, etc.) unless their particular characteristics suggest it would be unwise to do so. This in contrast to the approach in the U.K., where blanket policies are, unfortunately, the norm, and discussions questioning the rationales of each patient’s restrictions are seldom held.

Visiting the Netherlands allowed me to broaden my definition of ‘restrictiveness’ beyond seclusion, walled areas, locks and curfews etc. Restrictiveness of care is perhaps better described as any subtraction from individual autonomy, which is known to have negative effects of QoL, self-confidence, treatment-engagement, personal growth, etc. It is therefore important to understand what elements of care patients find most restrictive, and which policies/decision-making processes are directing this. Hopefully, this will better our understanding of to what extent the multi-faceted restrictive nature of forensic care affects patient recovery, and in what ways.

For more information about the PhD project on restrictiveness in long-term forensic psychiatric care, please click here.