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Dutch lessonsin forensicpsychiatryA senior registrar tours the Pieter Baan Centre and othersecure facilities in The Netherlands*

Jeyabctla Balakrishna

Dutch forensic psychiatry provides services for mentallydisordered offenders which centre around a legalmeasure called the TBS order. Specialised units dealseparately with assessment and treatment. The systemappears to work in the context of a small and wealthycountry and a criminal justice system which differs fromthe English system. This paper describes the keyfeatures of the secure units, examines the conceptualissues and complications of the Dutch system, andconsiders lessons for psychiatric and legal approachesto the problem of psychopathy in Britain, in particularthe new hybrid order.

The Ministry of Justice in The Netherlandsoperates a collection of therapeutic units formentally disordered offenders. The court remands particular offenders to an assessmentunit, the Pieter Baan Centre, which recommendsthe need for a TBS order - terbeschikkingstelling('to dispose of). If this order is imposed uponconviction, a selection unit will determine allocation to one of the many TBS clinics.

The TBS order is imposed by court on a personwho commits a serious crime while sufferingfrom 'defective development or pathological disorder of his mental faculties' (i.e. 'defectivedevelopment' of personality or intellect; 'pathological disorder' includes psychosis). Its functionis to protect society from unacceptably high risksof recidivism, through detention in a TBS clinic.It is usually of indefinite duration, imposed fortwo years in the first instance, extended onyearly or two-yearly periods, and subject tospecified rules, psychiatric review and right ofappeal.The Dutch Government's Memorandum (Ministry of Justice, 1994) clarifies the position ofTBS:

*J.B. visited The Netherlands on the John HamiltonFellowship awarded by the Royal College ofPsychiatrists.

"It is distinguished from confinement in a psychiatrichospital by a restriction of the danger criterion to theconcrete threat to others, the seriousness of the crimecommitted. ... [it is) distinguished from long-termimprisonment in that the offender is deemed to be notresponsible or to have ' 'ly diminished responsibility. . . and in that its primary objective is to reduce thefuture threat by treatment seeking to effect astructural change in behaviour".

Dutch law determines criminal responsibilityon a five-point scale rather than the British all-or-nothing approach.

The TBS order is aimed at motivating theperson to undergo treatment during custodialcare. Typically, a convicted prisoner serves one-third of his penal sentence before moving to aTBS clinic, but the order can be imposed withouta penal component. Assessment and treatmentare strictly separated in the TBS system.

Assessment - at the Pieter BaanCentreThe Pieter Baan Centre (PBC) in Utrecht isnamed after the psychiatrist who founded theCentre in 1949. Professor Baan was one of a trioof influential academics in the 1950s - the othertwo being Kempe. a criminologist and Pompe, alawyer - who promoted the so-called UtrechtSchool, which emphasised an individualisingapproach to the mentally disordered offender inthe criminal justice system (Moedikdo, 1976).

The assessment of the remanded prisoner isconducted by a multi-disciplinary team ofpsychiatrist, psychologist, social worker, socio-therapist and jurist. This remand for assessmentoccurs if the offence is serious or unusual innature, if there is continuing recidivism or ifthere are particular psycho-social issues.

The seven-week assessment seeks to answertwo key questions:

(a) Did the remanded prisoner suffer frommental disturbance at the time of the

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offence which diminished his responsibility for his actions?

(b) Does the remanded prisoner present witha degree of dangerousness and risk of re-offending which would require a TBS orderto protect others from him?

The PBC has four departments (wards), eachhousing up to eight remanded prisoners. Theremanded prisoner is called observandus - 'hewho is being observed'. Emphasis is on apsychodynamic understanding of the observandus. Behaviour is observed in groups, in informalinteractions, in occupational therapy and inrecreational activities. The medical model doesnot predominate, assessment does not aim toreach a psychiatric diagnosis, and treatability isnot a key issue.The group leaders, 'sociotherapists', are theunique discipline in the PBC, who work in shiftson the departments. There are three groupleaders to eight observandi. They undergo formaltraining in 'institutional work', involving sociology and psychology. Their backgrounds vary -probation officers, prison officers, social workersand nurses.

The jurists are lawyers who collate andsummarise all information pertaining to the legalprocess (i.e. facts of the case, witness statements, previous convictions, probation report,etc.). This will then assist the investigations ofthe other professionals.

Regular multi-disciplinary staff meetings review the progress of each assessment. The finalmeeting delivers the recommendations of thePBC and the voluminous report to the court. Theteam decides by consensus on the degree ofresponsibility of the observandus and the risk ofharm to persons or property.

The PBC produces some 200 reports a year.The majority of observandi are male, a third arefirst offenders, and about three-quarters haveprevious psychiatric admissions (Koenraadt,1992).

Selection and treatmentThe convicted prisoner who receives a TBS orderis assessed in the Selection Institute (which sitsadjacent to the PBC in Utrecht). The Instituteallocates the prisoner according to the emphasised modalities of treatment in the different TBSclinics and the nature of mental disorder. Forexample, the van der Hoeven Clinic in Utrechthas a therapeutic community, the van MesdagClinic in Groningen is run on analytical lines,while the Pompe Clinic in Nijmegen emphasises abehavioural regime. (There are six TBS clinics inThe Netherlands.) The TBS clinics are spacious,with state-of-the-art physical security, modernoccupational and recreational facilities (includ

ing gymnasia and swimming pools), and goodstaffing across the disciplines.

The FOBA (Forensische Observatie en Begeleid-ings Afdeling) in the prison service is a psychiatric intensive care unit, located in the maximumsecurity prison in Over-Amstel. The FOBA dealswith acute psychosis and severe behaviouralproblems referred from the prisons and TBSclinics.

In the health service, there are forensicpsychiatric clinics (similar to British mediumsecure units), and forensic psychiatric departments (similar to close supervision units) situated on psychiatric hospital sites. The clinicsdeal primarily with organic and functionalmental disorders. Some TBS prisoners, usuallywith dual diagnoses, are treated here. Thedepartments are typically small wards withlimited security. They do not usually acceptTBS prisoners. However, they contain a mixtureof people with psychosis and personality disorders with significant forensic histories.

Lessons to learnStrachan (1982) comments on the assessmentprocess in the PBC: "the pressures to find someabnormality after seven weeks of observation forthe court is an interesting complication of theDutch approach". Strachan says that someobservers see this process as "elaborate andextravagant", and he wonders whether a shorterperiod of observation with the same professionalresources might work equally well. The TBSsystem promotes the independent and impartialposition of the forensic mental health professional. Hence assessment and treatment arekept apart. Mooij (1991) emphasises assessmentand reporting as the essence of forensic psychiatry, where legal questions lead to answerswhich have judicial consequences. The ReedWorking Group on Psychopathic Disorder (Department of Health. 1994) were attracted to thestructured assessment model of the Dutchsystem. They proposed "hospital assessmentcentres" and "prison selection centres" to dealwith offenders who might have serious personality problems.

I would argue that the Dutch model worksbecause it operates in a system where there isgreater compatibility between legal and psychiatric functions, where the mental state at thetime of offence is focused upon, and where adiscussive rather than adversarial legal processdetermines disposal. These circumstances donot exist in Britain, where hospital-based forensic psychiatrists who have responsibility for thetreatment of mentally disordered offenders needto be able to also assess, in order to ensureappropriate use of hospital services.

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The Dutch have difficulty describing the TBSclinics as either prisons or hospitals, implying aunique blend of the two models. Is this possible?Peay (1993) argues against the labels of 'treatment' and 'punishment', and supports pluralism. In examining three models of criminaljustice - crime control through punishment,due process to ensure safeguards in fairness,and the medical model of rehabilitation - Peayproposes "balancing the peculiar merits of eachmodel to provide one cohesive system capable ofdealing with the particular conditions of all".

One might see TBS clinics as an attempt to'treat' criminal behaviour in the hope of reducingrisk of re-offending. This is invariably a long-term commitment. The need to find meaningfulmeasures of efficacy in treatment is a questionwhich continues to be addressed.

The TBS system is expensive. Strachan (1982)points to the cost implications of adopting thismodel in Britain. Koenraadt (1993) states thatthe system probably works because of "the smallpopulation size and the relative wealth of thecountry, and could not be replicated in larger,more heavily urbanised countries with lesscommitment to public spending".

The Dutch system is landed with the burden ofgrowing numbers of convicted prisoners waitingto 'receive treatment'. The courts, faced withlimits on punitive sentencing, appear to use theTBS order as a means of detaining dangerousoffenders for as long as possible.

A further concern is the growing numbers ofoffenders with functional disorders ending up onTBS clinics designated for psychopaths, a probable consequence of psychiatric hospital closures and deinstitutionalisation. There arelimited hospital-based forensic psychiatric services for TBS prisoners who are psychotic. Onemight argue that the extensive investment inaddressing psychopathy has created an assessment and treatment environment which thementally ill cannot fit into.

The Crime (Sentences) Act 1997 contains theso-called hybrid order which combines a 'hospitaldirection' with a prison sentence based on publicprotection criteria, rather similar to the TBSorder. In my view, the ethical, legal and healthservice cost implications, as described by Eastman (1997), arise partly as a result of thesituation of parallel models of prison andhospital.

CommentsThe Dutch forensic psychiatry services appear towork well in the context ofThe Netherlands's sizeand economic situation, and the interface between its judicio-legal framework and psychiatry.These circumstances differ in Britain, and a

replication of the Dutch model cannot easilyoccur.

We should examine the possibility of a pluralistic approach to mentally disordered offenders - not isolating this group, avoidingcategorisation into 'treatment' or 'punishment'and considering provisions for the "partly mad"and "partly bad" in both prison and hospitalservices (Peay, 1993).

Should Britain adopt the Dutch system of TBSclinics, which appear to sit between the prisonand hospital models? This might work with theoriginal proposal of the hybrid order applyingonly to psychopathic disorder as recommendedby the Reed Working Group (1994). If the hybridorder is extended to all categories of mentaldisorder, the Dutch experience suggests thatjudicial response to such sentencing optionswould overwhelm the health services.

Our health services will have to consider if theyshould have primary responsibility for providingtreatment for psychopathic offenders. In considering specialised units for these individuals,we must guard against hospital-based servicesfor the mentally ill offenders becoming poorcousins.

Finally, if we do set up such specialised units,these units should provide both assessment andtreatment. We should consider the opportunityfor a naturalistic approach to researching outcome, as advised by Dolan & Coid (1993): "toconsider which patients benefit from whichsetting at which time in their recovery". Theyadd that this approach could build on existingresources and identify resources for expansion,towards greater efficiency in and better understanding of dealing with the problem of psychopathy.

AcknowledgementsI am greatly indebted to Jan Scheffer, Director ofObservations and Reporting at the PBC, for hisconstant support and profound inspiration.Thanks also to Professor Mooij, Professor Raes,Dr Koenraadt, Jack Oudejans. Kess Lemke, allgroup leaders on Afdeling A, the efficientsecretaries. Els the librarian and officials fromthe Ministry of Justice.

ReferencesDEPARTMENTOF HEALTH(1994) Repon of the Working Group

on Psychopathic Disorder (Reed Report). London:HMSO.

DOLAN.B. & Com, J. (1993) Psychopathic and AntisocialPersonality Disorders: Treatment and Research Issues.London: Gaskell.

EASTMAN.N. L. G. (1997) Hybrid justice: proposals for thementally disordered In the Crime (Sentences) Bill. Theethical, legal and health service cost implications.Psychiatric Bulletin. 21. 129-131.

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KoENRAADT.F. (1992) The individualising function of forensicmultidisciplinary assessment in a Dutch residentialsetting: The Pieter Baan Centre experience.International Journal of Law and Psychiatry, 15. 195-203.

—¿�(1993) Forensic mental hospitals according to Dutchstandards. Criminal Behaviour and Mental Health. 3,322-334.

MINISTRYOFJUSTICE(1994) TBS: A Special Hospital Order ofthe Dutch Criminal Code. The Hague: Ministry ofJustice.

MOEDIKDO.P. (1976) De Utrechtse School van Pompe. Baanen Kempe. In Recht. Macht en Manipulate (ed. C. Kelk).pp. 90-154. Utrecht/Antwerp: Spectrum.

MooiJ. A. W. M. (1991) Forensic-psychiatric reporting in aresidential context. In Considering the Accused (eds A.Mooij. F. Koenraadt & J. Lommen-van Alphen), pp. 9-19. Amsterdam: Swets en Zeitungen.

PEAY.J. (1993) A criminológica! perspective - the influenceof fashion and theory on practice and disposal: lifechances in the criminological tombola. In The MentallyDisordered Offender in an Era of Community Care (edsW. Watson & A. Grounds). Cambridge: CambridgeUniversity Press.

STRACHAN.J. G. (1982) Psychiatric assessment of thedangerous offender in The Netherlands. Medicine.Science and the Law. 22. 16-20.

Jeyabala Balakrishna, Senior Registrar inForensic Psychiatry, Springfield UniversityHospital. London SW17 7DJ

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