Forensic psychiatry Rekem (Belgium)

1. Forensic psychiatry Rekem(Belgium)

2. Medium security units: 2007 “contract concerning the partial creation of a care path for mentally-disturbed offendersmedium risk within the target group of adults in the region of Antwerp and Limburg” • Historical background • Hospital • Contract • Organisation • Challenges Forensic psychiatry Rekem

3. Historical background • New law 1964: psychiatric disordered offendersreceive treatment (intention !!!!) • Increasing domestic criticism • European Committee for the Prevention of Torture • Case Dutroux 1996 • Case Ait Oud 2006 Forensic psychiatry Rekem

4. Historical background 19th C psychiatric institutions belong to the department of justice 20th C psychiatric hospitals Rekem up to 1964 department ‘social defense’ 1995 forensic department tradition – familiar low risk patients OPZC Rekem // U.P.C. Bierbeek, P.C. Zelzate  historical background Forensic psychiatry Rekem

5. Historical background • Problems: complexity– multiple handicaps offer >> capacity re-integration: almost inexisting • Consequence: Psychiatric nursing home Rekem (15/90) Psychiatric nursing home MIN Antwerp: 24 Halfway house MIN Antwerp: 50 Halfway house ‘t Veer Lanaken: 20 • 2001: projects Department of Justice and Health Care n = 40 T-beds + support MIN Antwerpen Forensic psychiatry Rekem

6. Hospital Serious Minor Psychopathology Risk of relapse Escape risk Offence/act + alcohol substance abuse sexual deviancy Forensic psychiatry Rekem

7. Disturbed perception Destructive aggression Impulsivity Disturbed conscience Disturbed expression of emotions and empathy High emotional tension Cross-border and disturbed autonomy Lack of practical skills Crimes Traumas Lack of social skills ….. • Hospital • Target group: specific features Forensic psychiatry Rekem

8. C.P.S. Nesessity of residential treatment Prison Mid Security/Care Low Security/Care Halfway House Nursing home Home care Ambulatory follow up Impulscontrol HospitalCare network Forensic psychiatry Rekem

9. Contract • Hospital: 40 beds • Psychiatric Nursing Home: 60 (4 x 15) beds • Halfway house (rehabilitation): 20 (2 x 10) places ‘t Veer Rekem • Halfway house (rehabilitation): 20 (2 x 10) places MIN Antwerpen • Support for the network MIN Antwerp Forensic psychiatry Rekem

10. Contract: modular structure • Hospital: total stay 2 years • Crisis and relapse: 3 beds; max. 14 days • Observation: 1 – 3 months • Intensive treatment; 6 – 12 months • Continued treatment; 6 – 12 months • Outreaching • Training, advice, coaching • Reporting CPS (committee protection of society – “parole board” • Psychiatric nursing home: rehabilitation (2 years) and care • Halfway house: rehabilitation, e.g. on campus • Joint medical committee • Joint management Forensic psychiatry Rekem

11. Contract • Therapeutic project • Cross-sectional consultation Forensic psychiatry Rekem

12. ContractForensic care network: 2007 Forensic psychiatry Rekem

13. Organisation • Staff: 110 FTE’s / 214 patients -> 0,51 FTE / patient Norm: T, Nursing Home, (HH) Supplement contract: Hospital, Nursing home (rehabilitation) network M.I.N. Stewards: security cf. other Psychiatric Hospitals10% of 51,2 FTE: not assigned to a specific department • Working budget: max. 3,95% /budget Forensic psychiatry Rekem

14. Organisation • Network: not a legal entity4 seperate managements: Hospital,Psychiatric Nursing Home en 2 non-profit associations3 types of employment contracts • Partially whithin regular programme/ reconversionrecognised by the Flemish CommunityPartially outside regularprogramme recognition sui generis? • Specific supplementary security measures Forensic psychiatry Rekem

15. Challenges • Medium risk + intensive treatment-> low risk ?Therapeutically naive (?) optimismPrognoses : silt up psychiatric nursing home ,limited ability to learn patientsLimited possibility to work towards rehabilitation within the psychiatric nursing home setting Both in quantity as in quality weaker staff Severe pathology: negative selection Specific problems: mourning, giving meaning to life, learning to accept oneself, limited perspectives Forensic psychiatry Rekem

16. Challenges • Joint staffing policyNeed for a joint management: Hospital, Psychiatric Nursing Home, Halfway HousePublic servants versus private contracts Medical responsabilityNot specifically forensic, typically for a network without legal entity • Financial managementNo unity in accounting Hospital and psychiatric nursing home analytical bookkeeping non-profit organisations not an analytical bookkeeping Forensic psychiatry Rekem

17. Challenges • Implementation new Internment act –max date of coming into operation : 2012 ... • “Court for execution of sentences” allocates patients to an authorized institution; each alteration to the stay requires a new verdict • Care coordinator: Key figure in allocation of new patientsTo be appointed by Federal department of Justice (temporary)Experience in mental health sector • Required administration (reporting, …) • Royal Decree safety standards: Content? Supervision? Finance? Forensic psychiatry Rekem

18. Challenges • Care network is incomplete without high risk facilitiesInstitutions in Gent / Antwerp: Federal department of Justice?Importance of cooperation – owner – structure ? • Mental health care for mentally disturbed offenders: outreach?Hospitals should not become prisons • Expansion of capacity40 beds for treatment is insufficient to provide for the diverse and complex problemsIncrease of financial means: specialisation > fragmentation Forensic psychiatry Rekem

19. Challenges • Consultation between different departments and ministers :FOD Health, FOD Justice, Communities • Safety Standards • Financing building projects • Administrative requirements new “Internment Act” • Socialization: involving other aspects education, housing, culture, work, …… • Scientific monitoringJoint registration of target group and methodDefining medium risk: multidimentionalForeign experiences: good practices • Knowledge centre 2008-2009 Forensic psychiatry Rekem