Psychiatric patient Edwin V. took his own life in his prison cell in early April. He was waiting for a place in an institution for secure and sheltered housing. It was, for the umpteenth time in his life, unavailable. Before he was imprisoned, the mental health institution Dimence Groep refused to admit him, despite his confused condition. “We also have our backs against the wall in mental health care,” says medical director Josephine Lenssen (41). “The entire system fails with people like Edwin.”
NRC followed Edwin for the past three years and described in several articles how he repeatedly did not receive the care he needed, but instead deteriorated on the streets and became trapped in the criminal justice system. Due to medical confidentiality, Dimence cannot discuss Edwin’s individual case, but it can discuss the major problems underlying it. “There are really a lot of Edwins. Here problems within healthcare, criminal law, money, housing and social unwillingness come together,” says Josephine Lenssen.
As medical director, she is ultimately responsible for the implementation of mandatory care within the Dimence Group – psychiatric care for people who have been given a care authorization by the court, which makes mandatory admission possible. Lenssen also monitors the quality of care within the Dimence Group, which offers both regular mental health care (Dimence) and forensic care (Transfore). She is also a psychiatrist and a PhD philosopher.
Lenssen: “If matter is complex, we as humans find it difficult to understand and we break it up into smaller parts. But because of this division, which is what politicians have done with the care of complex patients, there is no one left who has an overview of the whole. The fragmentation makes cooperation between parties difficult. And that is a major problem.”
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Care without bars for ‘repeat offender’ Edwin V: everyone wanted it, but it didn’t happen. Now he’s dead
Edwin was released from prison for the last time last summer. Homeless, addicted, bipolar and soon psychotic, things immediately went wrong. In three weeks he was arrested ten times for nuisance and petty shoplifting. Despite his confused, psychotic state, he was put back on the street after each arrest. To the frustration of the police, the Public Prosecution Service, judges and the probation service, mental health institution Dimence repeatedly refused to use the option of forcibly admitting Edwin, to protect himself and those around him. This could be done at any time, the judge had granted Dimence a care authorization to impose mandatory care on Edwin. According to lawyer Jan Vlug, his client Edwin would still have been alive if he had been forcibly admitted and had not been in a prison cell.
Lenssen thinks that is an unfair accusation. “We really do our best to help as many people as possible within a failing system. Sometimes we have to say: admitting this person now makes no sense, it does not meet the legal requirements for mandatory admission to mental health care, or there is simply no suitable place to be found. That is different from saying: we do not treat at all.”
But the reality is: Edwin was not admitted and now he is dead.
“Yes. He is dead. That is horrible. That has also had a huge impact here.” She continues with a sigh: “I cannot comment on this because of professional secrecy. In a general sense: when things go wrong, mental health care is very easy to point out as the culprit. But pointing fingers will never lead to a solution, there is a system problem underlying this.”
The problem also seems clear in a general sense: you take in people with a healthcare authorization who are seriously disrupted.
“No. With a care authorization you may only provide mandatory care if it is effective and can be performed safely. Those requirements are laid down in the law. That is not my invention. A care authorization is intended to treat a psychiatric condition with the prospect of improvement. It is not a security measure.”
Josephine Lenssen: “Perhaps unfortunately, it is also true that we desperately need criminal law to limit these people.”
Photo Kees van de Veen
Due to the far-reaching interference with personal freedom, a care authorization can only be imposed by a judge. Not as a punishment, but as a measure to treat people who refuse help but do need it. But the fact that treatment is mandatory does not necessarily make it successful, says Lenssen. According to her, trying to help a complex psychiatric patient who has been involuntarily admitted to get rid of his addiction rarely makes sense.
“Then, so to speak, you might have to admit a hundred people for a long period of time to help one person sustainably. And don’t forget that compulsory admission is very drastic for the individual. You affect their autonomy. Sometimes compulsory admission makes someone so angry or sad that the danger to themselves or others within the walls of the clinic is greater than outside. Even with all the beds in the world, you wouldn’t use them for that.”
What should happen if there is an acute danger and admission is not appropriate in your opinion?
“That requires a highly coordinated approach by different parties, each with their own role: mental health care is for treatment, the police for safety, criminal law for limiting behavior. So it is, perhaps unfortunately, also true that we really need criminal law to limit these people. For example, you can offer someone from mental health care addiction treatment and medication against psychosis. But if they have no roof over their heads and have to rely on a drug-rich homeless shelter, you cannot treat them as mental health care. The police also encounter the problem that they receive repeated reports about the same people, and arresting those people does not solve anything. This causes frustration in the cooperation.”
So the criminal justice system is called in because there are not enough beds?
“Yes, sometimes. There is a huge lack of admission places for people who need extra security. Vulnerable people are therefore unnecessarily in a revolving door mode, in and out of the clinic, in and out of the cell complex without further prospects. The personal and social costs of this are very high. But psychologically vulnerable people are also, in principle, citizens who have to abide by the law.
“If delinquent behavior is related to a psychiatric disorder, it is the mental health care’s turn to treat that disorder if possible. But for some people it simply makes no sense to admit them. A mental health care institution like ours is not the place where anything will change in their situation. In addition to treatment and limitations, these people also need long-term guidance. The mental health care is there to treat. We are not set up to care for people for a long time in a secure and monitored location.”
Sometimes delinquent behavior has nothing to do with psychiatry. The outside world doesn’t understand that difference, but it makes a big difference to us
As an acute measure?
“We do this regularly, of course, when people are really lost. But there are also people who are simply angry, cause a nuisance or have a craving for drugs. If you have a psychiatric condition, that does not mean that everything you do is related to it. Sometimes delinquent behavior has nothing to do with psychiatry. The outside world does not understand that difference, but for us it makes quite a difference. We see many people who use substances, become psychotic for a short time and then, once the substances have worn off, there is nothing left to do. You don’t want to take those people in for short periods of time, that doesn’t change anything.”
Then you sit in the judge’s chair yourself. You ignore the judicial care authorization by stating: this person is now psychotic because he has used or wants to use substances, not because he is a psychiatric patient. And then the verdict is: find out on the street.
“You can usually only help people who are chronically addicted by giving them a long-term program in which they really kick the habit and receive help to get their lives on track.”
Why doesn’t that happen?
“That is also being attempted, very often in fact. But not everyone can be helped. And there I also run into another wall: the health insurers require me to have direct patient contact in order to receive care: I literally have to look them in the eye. But to provide good care to the Edwins of this world, 90 percent of the time is spent coordinating with all the different agencies to find a place, to coordinate who does what. We are not reimbursed for that time.”
If someone commits a crime and ends up in criminal law, he receives a so-called ‘forensic’ or criminal title. The care will then be fully paid for by the justice system as long as the criminal proceedings continue. Whether that care is in prison, in a TBS clinic, or in a secure sheltered housing location outside.
Lenssen: “No decent compensation has been arranged for people who occupy a high-security bed without a criminal title. It is therefore hardly commercially profitable to offer secure beds for people without a criminal title. In short, these people do not fit into the health insurers’ system.”
Which ultimately means that you are the one who, by not recording them, has to leave these people to waste on the street.
“Yes, but I cannot keep those people in my clinic if it is not efficient.”
Josephine Lenssen: “If you have a psychiatric condition, it does not mean that everything you do is related to it.”
Photo Kees van de Veen
What is the core of the problem?
“As a society, we have the problem that we are not serving a group of vulnerable people properly. But that is not just a mistake of the mental health care, that is a mistake of how the entire system is woven. Because those sheltered housing places that are needed have all been cut back. As a result, people cannot move on. The judicial system also suffers from this with all those people who are waiting for TBS treatment.”
If everyone accepts that lack of places as a given, the consequence is that people like Edwin, who wander around addicted and psychotic and are locked up in a police cell again, are actually written off.
“I do not accept that at all and that is why I do this work. These people are close to my heart, they deserve better. But at the moment they indeed have a poor prognosis.”
Where is the limit for you to accept that you have to solve increasingly larger problems with increasingly limited resources? When do you say: I am no longer part of the solution, I have become part of the problem?
“I am both at the same time. By working within this system at all, I am inextricably part of it. And at the same time, I am working against the odds to also be part of the solution. By making myself heard. By coming up with smart solutions. I try to do what I can. I have the confidence that I am doing that to the best of my knowledge. And I don’t think it will necessarily get better if I say: well guys, I will pull the plug and I will work as a gardener.”
What is the solution?
“I sometimes think: I’m going to start a political party myself to change it. But the things you have to say to get elected are different from the things you have to do to solve the problem. These people have almost no voice themselves. They are a small vulnerable group. People suffer from it on the streets, and they don’t want this group to cost even more money. We all have a ‘not in my backyard’ idea. So there is a large degree of intolerance in society.”
What would you do if you were ultimately politically responsible?
“Fortunately, that’s not me. But the solution is: create enough suitable sheltered housing places. Enable better cooperation between all parties involved. This breaks the revolving door cycle from street to cell to clinic. Then they will have a better quality of life and society will have less trouble with them. The bonus is that this also means cost savings, because a good sheltered place to live is much cheaper than a mental health care bed.”