THE DUTCH MENTAL HEALTH CARE

AFTER THE BIJLMER AIRPLANE CRASH

Metamorfosis, racial discrimination & censorship

From her book Do not disturb (1997)

 

CONTENT

Introduction

The Dutch mental health care after the Bijlmer airplane crash:
- The organization: from inside out
- The mental health care: from diagnosis to story
- Return to the old way of working
- Hopeful

Sources

The fate of the victims of the Bijlmer airplane crash

 

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INTRODUCTION

The Bijlmer airplane crash. On October 4, 1992, an El Al Boeing crashed into the Groeneveen and Klein-Kruitberg apartment buildings in the heart of the Amsterdam Southeast region Bijlmermeer. 43 people were killed. Many eyewitnesses and surviving relatives were severely traumatized. The nearby mental healt care organization, called Riagg Southeast ,provides mental help to the victims. 84% of the victims have a migration background. They are primarily of Surinamese and Antillean descent. 

Saar Roelofs was working as a department head at Riagg Southeast at the time of the Bijlmer air disaster.

The Riagg prior to the disaster: resistance to help for black clients and clients with current traumas. As in other Riaggs, in the adult care at Riagg Zuidoost in 1992, the focus was not on the client's request for help, but on the preference of therapists for treating relatively young, well-educated, white clients with vague complaints. Treatment was primarily aimed at the client's intrapsychic problems, i.e., at the world within the client. There was resistance to providing assistance to both clients with a migration background (over 50% of the population in the Amsterdam Zuidoost region around the time of the Bijlmer disaster) and clients with current traumas and socio-economic problems.

After the disaster: more and better help for black clients and clients with current traumas. After the disaster, the client's request for help is central: help regarding his or her concrete needs, feelings, and cultural background. A policy memorandum is unanimously adopted recommending improving 
assistance to clients with a migration background and appointing more black therapists. Within the organisation a true metamorphosis takes place. This metamorphosis demonstrates what the mental health care could look like if it were truly aligned with the needs of its clients.  

The temporary metamorphosis is followed by blatant racial discrimination. However, the metamorphosis is short-lived. A few months after the disaster, the innovations are brutally crushed. Whereas previously there was tacit resistance to the treatment of clients with a migration background, there is now blatant racial discrimination: at the insistence of dominant therapists in one of the organization departments who do not tolerate people with a migration background as clients or colleagues, the migrant policy that was in effect for a short time is withdrawn, because, as one of the therapist frased it: "Otherwise all hell will break loose".  

Request for publication. At the request of the entire management of mental health care organisation, Saar Roelofs wrote an article for the Dutch Monthly Journal of Mental Public Health about the the help for the disaster victims. In it, she describes, among other things, the aforementioned policy change at the Riagg: more support for and by people with a migration background in all departments.

Censorship. After the disaster, the director had appointed the head of the department who absolutely did not want any black colleagues or clients, as a censor. If he were to approve the text, he would jeopardize his position as head of his discriminatory department. He therefore rejected the text. At the same time, he urged the director to reverse  the policy change regarding the help for people with a migration background. Consequently, the director withdrew the new migrant policy and  prohibited the publication of the manuscript. Saar Roelofs opposed this mismanagement. This was followed by a restriction of freedom of speech and a character assasination. 

The fate of the victims of the Bijlmer disaster. The racial discrimination and censorship by the Riagg Southeast is obvious harmful for the clients, including the many black victims of the Bijlmer disaster. For instance, the Parliamentary Inquiry Committee into the Bijlmer Disaster noted in 1999 that six years after the disaster, at least 100 victims were still suffering from PTSD. Nothing is known about their fate. Read more about the fate of the disaster victims

 

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Below Saar Roelofs' observations of the developments in the Dutch mental healt care organization Riagg Southeast after the Bijlner ariplane crash as described in her book
Do not disturb

 

The mental health care after the Bijlmer airplane crash

 

The organization: from the inside out

In the immediate period following the disaster, the Riagg is in turmoil. Care providers, managers, secretarial staff—everyone rushes through the corridors looking for one another, for stability, for order in the chaos. The dozens of treatment rooms in the main building, annex, and emergency barracks are connected by a maze of corridors within the entirely single-level Riagg. In the center of this conglomerate of structures, two main corridors form a crossroads. Here, the most important decisions are made; here, everyone consults with everyone; here, people ask one another for advice without distinction as to department, discipline, or treatment team.
Clients come and go constantly. They ask for help processing the shocking event and for advice on numerous practical problems. Immediate availability for clients is now considered more important than bureaucratic regulations. In the first week after the disaster, the Riagg is open until eleven o'clock at night and also on weekends. On new registration forms, only the most essential information is entered. Representatives from diverse disciplines and methods are working intensively together to create appropriate support as quickly as possible. 
Due to the enormous influx of clients from ethnic minority backgrounds, migrant policy is now also gaining momentum. Shortly after the disaster, a memorandum is adopted tightening the existing migrant policy regarding personnel matters, care provision, professional development, registration, and research. To bridge language and cultural barriers, additional care providers from ethnic minority backgrounds are recruited.
The attitude towards the outside world is unprecedentedly open. The scale of the disaster forces all mental health institutions in the region to collaborate intensively and flexibly. Within two weeks of the disaster, a joint policy plan is on the table. The Riagg travels into the region to provide information. An information leaflet is distributed in seven languages. Riagg Zuidoost, also known as The Bunker in the region due to its closed nature and abominable facilities, breaks open.

The disaster reveals that the organization harbors a potential for creativity, flexibility, and inspiration that runs counter to the conventional system. The qualities of individual employees are now being utilized to the fullest. At the same time, a collective goal is being pursued. Individual responsibility, initiative, and a personal vision are no longer at odds with the organizational structure. On the contrary, these qualities are now at the service of a higher purpose. The air disaster creates a paradoxical situation: the disintegration of the conventional care and organizational model means that Riagg employees can function as integrated individuals. It is no coincidence that the expression the Chinese use for 'crisis'—wei-ji—is composed of the characters for 'danger' and 'favorable opportunity'.

 

The mental health care: from diagnosis to story

The clients. On the evening of the plane crash, the lives of numerous people in the Bijlmermeer were completely disrupted in one fell swoop. People saw their neighbors jump from balconies, lost their children in panic, and searched through the wreckage for family, loved ones, or friends. Still others saw the plane fly straight into their neighbors across the street from their flats. They sleep hardly anything, eat poorly. Feel nothing anymore. Or perhaps too much: "Even my hair and nails hurt." They are terrified with every plane flying overhead. They have nightmares. They no longer leave the house and survive on leftovers from their refrigerator. They wander around the scene of the disaster in a daze. People arrive at the Riagg completely distraught. For instance, an elderly woman suddenly stands dejected in the hall one evening: she saw two of her daughters burn to death and cannot shake off the images. 84% of the clients have a migration background.

The care offered. In the face of the immense suffering with which they are now directly confronted, the care providers relinquish their attitude of authority. Advice is sought from external trauma specialists who point out the necessity of an event-oriented approach in which the client's story takes center stage and in which there is no place for fixating psychiatric classifications. Within four weeks of the disaster, a support program for eyewitnesses and local residents is ready. This program is aimed at preventing disorders in the processing of the traumatic event. The key features of this support program are as follows. 

The client's request for help is central. Recounting the traumatic experiences forms the core process of the support.

In some cases, earlier painful or traumatic events that were typically 'covered up' prior to the disaster are now also coming to light for the first time. 

Attention is paid to both the social and societal situation and the client's body perception. 

For the client, the diagnosis is clear: his complaints constitute normal reactions to abnormal events; they are adequate attempts to cope with stress accumulated in the outside world and are not signs of an intrapsychic conflict.

In the relationship between care provider and client, power is minimized. The care provider is emotionally affected and recognizes something of themselves in the client. He or she shares their knowledge and is not the sound and authoritative expert facing a sick and dependent client. 

The Therapist emphasizes the healthy and strong part of the client.

 

Return to the old way of working

As pointed out in de ntroduction the metamorphosis is short-lived. The Riagg views the developments following the disaster as a danger rather than a favorable opportunity to break new ground.

 

Hopeful

In 1992, with the organization of the support services for the victims of the Bijlmervliegramp, Riagg Zuidoost spontaneously anticipated the widely recommended developments in mental health care , in which the needs of the client take center stage rather than those of the care provider or organization. It involved a collective effort by Riagg staff, without any regulations, strategy, or quality assurance system. In doing so, Riagg Zuidoost temporarily served as a model for other Riaggs. Even though the innovations at the Riagg were nipped in the bud, the fact that these developments actually got off the ground is nevertheless hopeful. Love for the profession, passion, creativity, and respect for the client's perspective are evidently present within the organization, albeit only tapped into under extreme circumstances.

Read more below about the fate of the victims of the Bijlmer airplane crash

 

SOURCES

Mental health institutions Amsterdam Southeast (16-10-1992). Aftercare plan Bijlmermeer aireplane crash.

Mittendorff, C. (1992-1993). Series of lectures held as part of a refresher course on trauma processing for care providers at Riagg Zuidoost following the Bijlmer airplane crash. Video recordings, Riagg Zuidoost.

Riagg Southeast (1990-1993). Client Files Adult Care 1990-1993.

Riagg Southeast (April 1990 - April 1993) Minutes & internal mailings.

Riagg Southeast (1992 . Immigrant policy gaining momentum. Policy memorandum of the Department of Prevention, Innovation & Research.

Riagg Southeast (October 1992 - January 1993). Preliminary advice and minutes of the project group on Assistance Offer for the Air Disaster.

Roelofs, Saar. (1992, October 20), on behalf of all mental health institutions in Amsterdam Zuidoost. After the disaster: information and advice for adults. Information leaflet for clients and other residents of Amsterdam Southeast . In seven languages.

Sande, R. van der, F. Hoof and G. Hutschemaekers (1992). Supply and demand in the Riagg. A practice-based study of Riagg care for adults. Utrecht: Netherlands Centre for Mental Public Health (now Trimbos Institute).

 

THE FATE OF THE VICTIMS OF THE BIJLMER AIR PLANE CRASH

The following is known about the fate of the victims of the Bijlmer airplane crash:

Professional knowledge of PTSD at Riagg Zuidoost was insufficient The Department of Psychiatry at the Academic Medical Center (AMC) wrote in a 1995 article that one and a half years after the Bijlmer disaster, 34% of the victims were still suffering from a processing disorder, even though the majority of those involved had been treated. The researchers concluded that the treatment expertise regarding Post-Traumatic Stress Disorder at Riagg Zuidoost was inadequate.  Carlier, IVE, JJ van Uchelen & BPR Gersons (1995b). The Bijlmermeer air disaster; a follow-up study into the long-term psychological consequences and aftercare for the affected persons. AMC, Department of Psychiatry.

Six years after the disaster, at least 100 victims still with PTSD. In 1999, the Parliamentary Inquiry Committee into the Bijlmer Disaster would conclude in its final report, *Een beladen vlucht* (A Charged Flight) , "that psychological aftercare fell short on a number of points" and "that in 1998, at least 100 people were still walking around with Post-Traumatic Stress Disorder and related complaints, which are a consequence of the Bijlmer disaster." * Een beladen vlucht. Final Report Bijlmer Inquiry . Sdu Publishers, The Hague 1999.

After 1999, more data became available regarding the fate of disaster victims with PTSD.  Following the Parliamentary Inquiry into the Bijlmer Disaster, the victims of the disaster were once again in the public spotlight. Riagg Zuidoost, which in 1998 administratively merged with the Frederik van Eeden psychiatric hospital under the name De Meren , sent a letter in May 1999 to all those involved in the Bijlmer Disaster.* In it, the institution stated that it intended to establish a treatment program for the disaster victims in collaboration with trauma specialists from the Department of Psychiatry at the Academic Medical Center, which would address Post-Traumatic Stress Disorder.  Following the disaster, the Psychiatry department of the AMC regularly published articles regarding the (evaluation of) assistance to the disaster victims (for a list, see the sources in the article below**). However, there is not a single publication regarding the intended collaboration between the Psychiatry department and Riagg Zuidoost (De Meren). Even in an article from 2000 concerning all events following the disaster, the trauma specialists at the AMC make no mention of collaboration with Riagg Zuidoost under the heading 'What next?'.** It is therefore doubtful whether the collaboration between the AMC and Riagg ever materialized . In an interview in 2012, twenty years after the disaster, the Professor of Psychiatry at the AMC stated that it is unknown how many victims are still suffering from symptoms resulting from the disaster.*** The fate of the 100 disaster victims who still had PTSD in 1999 therefore remains a matter of speculation.  *Letter dated 3 May 1999 from Ms. J. Meijer,  Operations Manager of De  Meren ,  to those involved in the Bijlmer disaster. ** Berthold Gersons, Ingrid Carlier, Joris IJzermans, 'In the mirror of emotions': Unforeseen long-term consequences of the Bijlmer plane crash. Monthly Journal of Mental Public Health , 2000, 55(10). p.876-888. *** Jaap Stam (2012, October 4). "The Bijlmer disaster has taught us a lot. De Volkskrant.