clinical practice at the van der hoeven kliniek utrecht ... · relazione1.ppt author: gabree...
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Clinical Practice at the Van der Hoeven Kliniek Utrecht, The Netherlands
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Maximum Security Mental Hospital Patients: 225 Staff members: 350 Tbs: Court Order Measure Compulsary treatment under the Penal Code Ordered only for the most severe offences,
warrenting long prison sentences
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Murder Manslaughter Sexual offences (rape) Criminal assault Indecent assault Arson Ill-treatment / Maltreatment Blackmail Burglary Theft Imposture Embezzlement
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(attempted) murder/homicide
46.9% (69)
Sexual offences 29.3% (43)
(aggrevated) assault 11.6% (17)
Arson 9.5% (14)
Other 2.7% (4)
N 147
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Axis-I – Psychotic disorder: 20% – Autistic disorder: 10% – Paraphilia: 22% – And others, such as Depression and Substance-related Disorders
Axis-II – Cluster A: 31% – Cluster B : 73% – Cluster C: 30%
PCL-R – Cutoff point 30: 20%
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Main goal: succesful low risk re-entry into society for patients who have committed severe crimes
The Clinic advises The Court; The Court decides
On the one hand: Tool of Criminal Law On the other hand: Framework for
psychiatric treatment
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Recidivism Ex-prisoners N=19310 (2000)
Former offenders under mental court order measure n=354 (1999-2003)
Van der Hoeven Clinic N=79 (1999-2003)
General 71.2% 38.6% 22%
Serious 57.1% 29.8% 12%
Very serious 19.5% 12.1% 8.7%
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Highly professional, evidence-based and yet little hierarchy and common-sense
Safety first, not in materialised security, but by early warning in therapeutic relationships
A safe re-entry in society demands a treatment concept based on shared values in accordance with contemporary values in society
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Treatment Detainment
Treatment staff Prison guards
Psychological/medical interventions
Cells, fences, bars
Dynamic security Materialised security
Patients/staff move around freely
Security rules, protocol led behaviour
Symptom tolerance & long-term intervention
Symptom suppression: temporary & short-term
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Professional Structure – Evidence-based methods – Colleagues (professional) and patients – Treatment plans and programs
Social Structure – Atmosphere, persons, informal relations – Experiencing a sense of community
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The dynamics of a motivated and dedicated staff
Constructive collaboration between staff and patients
Common-sense and human experience are as important for organisational issues as professional guidelines and evidence-based methods
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Professional guidelines, treatment plans: – Highly focused goal-directed behaviour
Being together as human beings – Man and woman as persons subject to emotions
and irrational behaviour Both dimensions need an equal amount of
attention, especially in forensic settings
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Formal hierarchy – Keep it simple – Avoid excessive management layers – Enhance professional autonomy
Professional guidelines – Multidisciplinary use of monodisciplinary concepts – Interdisciplinary treatment – Interdisciplinary communication
Evidence-based methods – The Bio Psychosocial Model – No single-level approach, but multidisciplinary collaboration – A maximum impact strategy on all levels
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Informal relationships – Patients and professionals as human beings being together for long
periods of time – In a rather closed environment
Rational vs irrational behaviour – No professional and no patient is continuously goal-directed and
protocol-led – Much of what we do is not measurable and cannot be directly
influenced or managed A positive and sound atmosphere
– Little hierarchy, respect for all – Distributed leadership: professional decisions are not concentrated
at the top
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Both dimensions need an equal amount of attention
Distributed leadership enhances a sense of impact
A sense of impact enhances trust in treatment efficacy
Transparency is a key issue in treatment integrity
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‘Suppress Professional Narcissism’ ‘Suppress Managerial Narcissism’ Trust and support your employees Trust and support your patients Be a role model, both in individual and
organisational behaviour Be strict and consequent when trust is
broken
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A safe and open environment to work in Self-regulatory competencies and skills Collaboration and communication as
essential organisational process A positive and sound atmosphere Avoid too much bureaucracy and
management Financial management
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Scylla and Charybdis Thoughtfulness and respect for victims Managing expectations in the outside world Any re-entry in society comes with a certain
amount of risk of re-offending Be transparant, even when things go wrong Explain what you do
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