Special Workshop Peter Peerdeman & Bernadette Schomaker
Where care and safety meet
Presenters:
Bernadette Schomaker, Centre for Crime Prevention and Safety, Utrecht, the Netherlands
Peter Peerdeman, CAOP, Den Haag, the Netherlands
In this workshop, it is explained how care and safety are related to each other in the Netherlands. Especially, with regard to persons with psychotic disorders public safety and psychiatric treatment are not always well balanced. In this paper it is explained how care and safety meet each other in the Netherlands.
Safety incidents
On the 9th of April 2011, a young man entered a shopping mall in a small Dutch city. He shot 5 visitors of the shopping mall, wounded another 17 persons and, finally, committed suicide. The young guy had a permission to possess three guns, as a member of a shooting club. After analysis, it was found that the young guy was also suffering from psychotic disorders.
On Monday the 10th of February 2014, the former minister of Welfare and Care of the Netherlands was found dead in her garage. Almost one year later, the police announced that an arrest has been made. It appears that the offender suffered from psychotic disorders. He also murdered his sister and due to this event, a DNA match was found. A large research took place why the psychotic patient was not treated well and why the prosecutor did not react properly on all kind of signals. It was found that psychiatric care and the criminal justice system did not work well together.
The two incidents represent only a small part of all safety incidents with offenders with a psychiatric background. Recently, they got a lot of political and societal attention in the Netherlands.
In the Netherlands these offenders with psychotic disorders are called ‘confused persons’. These confused persons have their ‘good periods’ and their ‘bad periods’. As other countries, we have the possibility of civil law of enforced mental health care for people who are a risk to themselves or to society. There are also a lot of possibilities for forensic care when psychiatric patients commit a crime. However, there are still a lot of confused people avoiding care, due to their mental health illness.
The number of incidents with so called confused persons has augmented enormously: from 40.000 in 2011 to 52.000 in 2013. E.g. between 2013 and 2014 the number of incidents in the region of Rotterdam augmented with 28%.
Let us start with defining the concept of ‘confused persons’: it concerns persons who have lost or might lose the control of their lives, which might cause damage to themselves or to others.
It is about people who have different psychiatric diseases or restrictions (psychiatric, addictions, slightly mentally disabled or dementia), often in combination with social and financial problems (like huge debts, loss of beloved ones, homelessness, lack of participation, uninsured, illegal and so on). Through all kind of circumstances, they may not recover and it can occur that their problems become chronic. Consequently, they avoid care and lose the control of their lives. They can become victims of criminal activities or commit criminal activities themselves.
The general idea is that incidents can be prevented if signaled earlier, and therefore around every patient a closed network of “care and love” has to be arranged. However, through rules and regulations and through high “fences” within and between organizations these networks do not function properly. Nevertheless, due to the above mentioned and to other incidents the need to change this became more and more urgent.
In September 2015 the ministries of Welfare and Care, Safety and Justice and the Association of Dutch Municipalities (VNG) formed a task force. The aim of this task force is to develop tools and guidelines for local governments to signal psychiatric problems earlier and prevent incidents. It also develops tools for supporting people with psychiatric problems and their families. The recommendations are based on the knowledge and experiences of about 60 organizations involved, like mental health organizations, organizations of psychiatric patients and their families, knowledge institutes, housing corporations, primary health care and so on. In September 2016 this Taskforce will present its final conclusions. But whatever the recommendations will be, probably the best result of this Taskforce is that it succeeds in gathering all involved parties around one table. The sense of urgency is felt now and all noses are directed towards the same direction.
In the following section, we explain more about the ways in which safety and care are organized in the Netherlands.
The organization of safety
• Local governments
In the Netherlands the final responsibility for safety issues is given to municipalities. Municipalities are managed by a mayor who is also the chairman of the municipal council.
In safety issues, the mayor has a special role, as the head of the police at local level. He bears responsibility for the public order. Every four years a safety plan is made up, in which the local priorities are worked out. At the local level, the mayor is one of the main actors to connect safety and care as he has special legal authority with regard to enforced treatment of confused persons, suffering from psychotic orders and being an acute risk to society or themselves.
Although the mayor is responsible for local safety issues, the implementation of safety policy is in the hands of different organizations.
• The police
Since 2014 the National Police Force of the Netherlands is in a reorganization. Nowadays the Dutch national police force consists of ten Regional Units, the Central Unit and the Police Services Centre. Each regional Unit is managed by a Chief Constable. Within one regional unit there are several municipalities, depending on the number of inhabitants.
The reorganization has a large effect on the daily work of police officers. Work processes have changed and a lot of functions have been shuffled. Primarily the police is responsible for maintaining laws and regulations. Police officers prevent people from committing offences and crimes by being visible present on the street, on foot, by bike of in a marked car. They perform detective work and investigate mayor crimes, give advice on prevention of crimes, provide assistance, deal with traffic issues and so on. The Dutch government is keen to put more and more police "on the street".
• Public Prosecution Service
The second major organization involved is the Public Prosecution Service. Its highest authority, the board of Procurators General, lays down policy on investigations and prosecutions. The board and its staff form the service’s national office. The Public Prosecution service has offices – the public prosecutor’s office – in ten districts (in accordance with the ten Regional Police Units). Each of these district courts is under the authority of a chief public prosecutor.
Since 2011 the Public Prosecution Service has introduced the so called ZSM-method. The ZSM-method is a co-operation between Public Prosecution Service, the police, Rehabilitation Service, the Child Care and Protection Board and Victim Support. Light cases – like smaller aggression incidents - will be evaluated within six hours. If there are no special circumstances the Public Prosecution Office will offer the delinquent an adequate punishment. If accepted the case will be closed. More severe incidents will be treated through regular legal procedures.
Triangle
In each of the ten Regional Police Units decisions about the principal law enforcement policies are made by a regional board, the so-called Triangle. The chairman usually is the mayor of the largest municipality in the region. The other board members of the Triangle are the chief constable and the (chief) prosecutor.
The organization of mental health care
In the Netherlands the primary care acts as a gatekeeper for all health services, including mental health care. Family doctors, nurses and psychologists identify, treat and offer care for people with mental problems. The specialist mental care services (secondary and tertiary care) is provided by regionally integrated service provider organizations and by a small number of stand-alone community services and mental hospitals. Together these organizations offer about 85% of all mental health services, from ambulatory specialist care, acute inpatient care to community based services.
Since 2015, national government has shifted the responsibility for the provision of care facilities to municipalities, local communities and family. People in need of help are stimulated to stay at home as long as possible, with help from family, friends and care officers. Municipalities are made responsible for decisions regarding the type and amount of care. The idea behind this is that at local level governments have better insight in the care needs. They are able to provide the right care quicker and more cost efficiently. Moreover it is meant to concentrate help.
Where care and safety meet
As you have noticed, in the Netherlands safety and care come together in municipalities. At local level policies and implementation are arranged. In practice however, this often does not go as smoothly as it is supposed to be. Especially on the field of safety and care much has gone wrong. However, interesting initiatives to overcome this have been taken. Like the following initiatives:
1. Legislation
In the Netherlands the Psychiatric Hospitals Compulsory Admissions Act (Wet Bijzondere Opnemingen in Psychiatrische Ziekenhuizen, BOPZ) regulates the circumstances involved in involuntary hospitalization and treatment in psychiatric institutions. Before involuntary placement can take place a few conditions have to be met:
- There has to be serious harm to oneself, to others or to society as a whole;
- Which is caused by psychiatric disorder;
- As assessed by a psychiatrist;
- That there must be no alternative that detainment to avert the danger;
- And that the patient is refusing voluntary hospitalization.
If all of these conditions are met a judge can decide to detain the patient. It can be enforced through two procedures: an Acute Involuntary Admission (AIA) or a court order (CO). An AIA is used in case of imminent danger. Anyone can request an AIA, but a psychiatrist has to determine if the aforementioned conditions are met. If so, a medical report is submitted to the mayor, who decides whether or not an AIA is issued. If so, the patient is detained within 24 hours. Within one workday of the detainment a public prosecutor decides whether further detainment is necessary. A court order is used to the same conditions, but when there is no emergency.
A court order can be requested by people near to the patient of by the patient himself. An independent psychiatrist assesses the client and presents his medical report to a public prosecutor. If the public prosecutor agrees that detainment is necessary he passes the request to the court, which makes the final decision.
However in the near future the BOPZ will be replaced by the Compulsory Mental Health Care Act (WVGGZ). This new act will only apply for patients with a psychiatric disorder. No longer will admission be central to the law, but the care itself, and it can also be applied outside the walls of the treatment setting. Compulsory care will become obligatory care, and can be given based on care warrants of a care professional. Care warrants will substitute the current law admissions. The risk criterion of the BOPZ law will be replaced by a damage criterion. Also in the WVGGZ the engagement of the family will be enlarged. And there will be some organization changes in the complaints and reporting procedures.
2. Community Teams
In almost all municipalities community teams have been formed. These are teams consisting of different disciplines working in local communities or neighborhoods.
The community teams are formed to:
- Stimulate the participation of citizens, and enhance social bonding and help at community level
- Support citizens to take the responsibility themselves for all kind of life issues;
- Be a contact point for questions and ideas;
- Support the own strength and self-supporting capabilities of citizens;
- Be the portal to more intensive, more specialist care
The power of these teams lies in stimulating civil participation. Through their close relationships with the inhabitants of a certain area they are able to pick up the first signals of problems with certain individuals or families. E.q. psychiatric problems but also feelings of loneliness or alienation.
3. Safety Houses
The first Safety House started in 2002 and nowadays there is a nationwide network of regionally operating Safety Houses. Safety Houses are networks of local organizations working together to reduce crime. Criminal Justice Organizations cooperate with municipalities, social sector and care organizations to combine and integrate penal and rehabilitative interventions for offenders. They do not only collaborate, the partners in Safety Houses also share the same office. This allows them to learn a lot about each other but also to learn how to trust each other. As organizational and physical distances are shorter, actions are taken earlier.
In Safety Houses the partners make specific agreements as to who will do what and when on the basis of a joint analysis of the problem, so that punishment and care are not opposed but rather reinforce each other. They have selected a number of categories of offenders who are systematically discussed at the Safety House: frequent offenders, robbers, members of delinquent gangs and criminal groups, systematic violent offenders, young recidivists, perpetrators of domestic violence and former prisoners with multiple problems. Often the Safety Houses are oriented towards certain families with multiple problems. Safety Houses have arranged that care is much more concentrated. This is also reflected in the slogan of Safety Houses: One Family, One Plan, One Director.
4. Covenant Police and Mental Health Care
Operational police staff regularly come into contact with civilians with psychological and/or addiction issues who cause inconvenience and (feelings of) insecurity. These are considered to be ‘confused persons’ who cause inconvenience, require assistance, languish, act dangerously or commit offences. The police estimates that they spend a considerable part of their capacity- that is about 13% - on this group of ‘confused persons’. A reason for this is that the police are available 24 hours a day and therefore can be called upon at all times. In the police always chooses to act independently, or to (also) appeal to mental health care services (in Dutch: GGZ). Mental health care services can also call the police for assistance. In view of this reciprocal dependence, a good collaboration between the police and mental health care institutions is important. In order to facilitate this, cooperative agreements have been made in a covenant with police and mental health care.
The covenant is a national framework that is brought into practice regionally, so the execution of the covenant can differ regionally. In 2003 the police and mental health care services entered into the first national covenant. In 2012, a second police – mental health care covenant was drawn up.
In 2016 these covenants were evaluated. Among others this resulted in the agreement to pay more attention to prevention and signaling. Moreover they agreed to co-operate more closely in the emergency rooms by having psychiatric care officers working there too. These officers can select the need to offer psychiatric help more quickly. And there will be made arrangements to adapt the detention of psychiatric offenders to their specific needs.
E.g. in city of The Hague the police has arranged special cell units with staff from a mental health care institute providing for the needed care. After a person with psychiatric problems has been detained a public prosecutor decides on the criminal consequences while mental health staff assess the health situation. Together they start up an action plan for the person involved.
5. Case Veldhoven: a safety and security mark
In a small town in the south of the Netherlands, called Veldhoven, a big care organization for mentally disabled persons called Severinus is situated in two neighborhoods. In 2015 Severinus took the initiative to formalize the co-operation with municipality and police in a safety network. A working group consisting of professionals of these three parties agreed to co-operate on three themes, that is safety issues (like aggression, burglary, traffic, and fire alarm), social issues (like signaling loneliness) and livability (like loud noise and waste). The process was guided by a consultant of the Centre for Crime Prevention and Safety (CCV). The whole procedure was audited externally by another care organization. After approval the CCV gave the official mark “Safety and Care in the Area”. Although co-operation was not new the success of it depended too much on the enthusiasm of individuals. And although a mark is not a guarantee for co-operation it has resulted in a better safety security awareness and policy within each organization.
6. Case Vught
In Vught the number of incidents with persons with a psychiatric background has reduced substantially due to two mental health nurses working in the community. The combination of their knowledge of the area and of the vulnerable people living there, and the knowledge of the operational police staff has resulted in early signaling and early care.
7. The Psycholance
People with psychiatric problems were often transported by force in police cars after incidents had taken place. Often this caused stress and aggression with patients as well as police staff. Since a few years there is the so called Psycholance. The Psycholance is a special ambulance for transporting people with psychiatric problems. From the outside it looks like a normal ambulance, but inside the design is more open and calming. The Psycholance has several advantages for patients as well as for staff: patients need less restrictions and arrive more relaxed and more cooperative at the care institute while staff feels much safer.
8. Forensic psychiatry in the neighborhood
As more and more confused persons live in non-residential facilities, the organization of care and treatment has become outreached. Many so-called functional assertive community treatment teams have emerged that offer special intensive treatment at home for persons who have been of might become a risk to themselves or to others. They offer outreaching care and visit persons at home, offering matched care. These teams co-operate with other professionals working in the area, like police, neighborhood team and primary health care. In practice, cooperation in the chain of care is still difficult to the exchange of information about patients. Care professionals have the obligation of secrecy on what is told to them in trust. Experience has shown that good results can be obtained if police and care workers exchange internships.
A few lessons learned
Reducing aggression by people with psychiatric problems is a complex problem with many parties involved. It is not just a matter of care and safety. It is a complex network of intertwining measures directed at patients, their families, the communities they live in, the safety and care organizations and so on. In the Netherlands a number of initiatives has been taken and proven to be successful. A few lessons learned:
- It is not only about care and safety. Also other organizations responsible for the basic needs of persons with psychiatric problems, like income and housing, have to be connected. Organize a closed network of care around every patient.
- Organize collaboration at local level, but stimulate and facilitate this at national level. E.g. through a national taskforce that gathers all involved parties around the table;
- A better understanding of psychiatric problems by police staff through training and internships proved effective to reduce the use of force and to prevent aggression by psychiatric patients;
- Formalize the collaboration between care and safety in covenants and/or marks.
- Respect regulations but do not exaggerate. Encourage staff from care and safety organizations to find their common goals, that is to provide the right care to individuals and stimulate their and other persons’ safety, instead of “hiding” behind formal rules and regulations.
- Involve persons with psychiatric problems and their families at all times
- Bridge the different working cultures of care and safety, e.g. by stimulating the exchange of safety and care staff, or by letting them share a working place;
Conclusion
Some severe incidents in the Netherlands have been a wake up call for care and safety organizations to co-operate more closely and to take signals of persons and their family seriously. Several initiatives have been undertaken to bridge the gap between these two professions. Although co-operation often is complicated by different working cultures, privacy rules and high fences within and between organizations, safety and care find each other more easily. With municipalities functioning as the binding glue al local level.
- References
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- www.hetccv.nl
- www.movisie.nl
- www.veiligezorg.nl
- https://vng.nl/personen-met-verward-gedrag
- https://www.ypsilon.org/nieuws/05-07-2016/19201244/Eerste-meldpunt-verwarde-personen-in-Rotterdam
Wednesday 26 October 2016
Parrallel Session (2)
Executive Boardroom
16.30 – 18.00
© Oud Consultancy - Amsterdam - The Netherlands - 
