Dr. Saar Roelofs

NO TALENT FOR CONFORMIsm

My experiences as a CLINICAL psychologist in the 

Dutch outpatient mental health care

Around THE BIJLMER  AIRPLANE CRASH

RACIAL DISCRIMINATION

INTRO

The Bijlmer airplane crash
On October 4 1992, an El Al Boeing crashes into two flats in the Bijlmermeer, a region in the heart of Amsterdam Southeast. 43 people die. Many eyewitnesses and surviving relatives are traumatized. The nearby outpatient mental health care organization (Riagg Southeast) is helping the disaster victims. 84% of the victims have a migration background, mainly coming from Suriname and the nearby Antilles.

After the disaster, the Riagg Southeast temporarily changes from a closed and bureaucratic organization into an open and efficient institution in which the clients' requests for help are central. The socio-cultural background of the many clients with a migration background was better taken in account.

However, this metamorphosis is short-lived. Whereas before the Bijlmer disaster the reluctance to treat black people was more or less implicit, now there is evidence of outright racial discrimination. Moreover, censorship was instituted.

My personal experiences
In the E-document No talent for conformism I look back on my personal experiences in the Riagg Southeast around the crash, where I worked as a department manager.

Following an introduction on the Dutch outpatient mental health care in general I descibe my experiences in the Riagg Southeast after the crash. In short, after the temporary metamorphosis I was the only one in the organization to openly oppose the overt racial discrimination and the censuring, which resulted in a character assassination and attempts to restrict my freedom of speech permanently.

Within such a work enviroment it was unavoidable that the clients were treated inadequately, including the victims of the Bijlmer Disaster.

For an extended retrospect on my career as scientific researcher,
therapist and manager (in Dutch) see Geen talent voor volgzaamheid.

Content

The Dutch outpatient mental health care in general

After the Bijlmer airplane crash

Court hearing

"A minority of one"

The fate of the disaster victims

A critical, still relevant triptych on the Duch mental health care

the Dutch outpatient mental health carE in general 

In 1992, at the time of the Bijlmer air plane crash, in the Netherlands existed 59 outpatient mental health care organisations, called Regional Institutions for Ambulatory Mental Health Care (abbreviated as 'Riagg').

Indifference towards quality control. In March 1991 I was apointed as a department manager in an outpatient mental health care setting in Amsterdam Southeast (Riagg Zuidoost). Soon after my apointment I noticed that there existed a culture of fear, sexism and abuse of power in the organisation. In July, a few months after my appointment, a management consultant who worked in the organisation published his report, in which he wrote amongst other: "The dominant culture in this setting is a total individualisation, bitterness towards each other, indifference towards innovation and quality control, and disbelief in any possible improvement." 
The management consultant, a specialist in mental health care, worked in many other mental health care organisations where also severe organisational problems prevailed. In 1987 he had written a critical article on the 59 outpatient mental health care organisations (Riagg's), in which I recognized much of what I saw around me.

Focus on inner conflicts and reluctance against treatment of black clients. My department focused on Prevention, Innovation and Research and did not treat patients. Whereas colleagues in the treatment departments preferred treatment of intrapsychic conflicts with little regard for the social context in which complaints can develop, my department stressed the necessity to focus on the world in which the client lives, for example on discrimination of women and black people, identity crises of immigrants and trauma (Post Traumamatic Stress Disorder, PTSD). On the basis of research it developed prevention and treatment programs for women, elderly and coloured clients. Around 1992 50% of the inhabitants in Amsterdam Southeast was black. 

Superior and inferior. As everywhere in the Dutch outpatient mental health care focus on inner psychological conflicts had a high status, not only in de Psychotherapy Departments (aimed at growth and insight) but also in the Social-Psychiatric Departments (aimed at concrete social problems). Most therapists were reluctant to treat clients with social problems, trauma, black clients and refugees. They preferred to treat young, white, well educated clients with vague complaints. My department was - as similar departments in the Dutch outpatient mental health care - considered inferior. 

Personality disorder instead of trauma. In the Dutch outpatient mental health care were special treatment teams for women to which mainly clients were referred who were raped, sexually absused or mistreated. I was an advisor at the case discussions in such a team. The treatment was not aimed at the trauma's, however, but mainly at the alleged personality disorders of the victims. I opposed those diagnoses. Though I was an experienced clinical psychologist and behavior therapist, as an "inferior" coworker of the Prevention, Innovation and Research Department I was often silenced.
Such was also the case with the clients. The team members did not take the remarks of their patients on the therapy seriously. When a patient was dissatisfied with a diagnosis or treatment, the therapists interpreted the complaint usually as part of the psychological problems with which the patient had signed up. Thus the therapists disregarded the client and determined the therapeutic proces unilatteral. They sometimes made their clients  evenobject of ridicule.
Nevertheless the therapists were not aware of any wrongdoings.

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Observer

Because of the resistance of therapists against the initiatives of my department, I usually didn't have a say, not only in the women's team (see above) but also in the management team of which I as a department head was a member. When I gave my opinion or opposed injustice I was usually ignored by the director and my co-managers. 
Thus my colleagues in the organisation forced me in the role of observer. I saw and heard a lot about the outpatient mental health care. From amazement I frequently put my observations on paper. 

Cartoons. Because of my detachment and the fact that I am also a visual artist the management consultant asked me to draw cartoons in an effort to bring about a cultural change. I made fourty cartoons on the bureaucracy and the treatment practice which were based on my direct observations. 
The consultant, however, did'nt allow me to show the cartoons on the treatment because that would cause the outrage of the therapists. I did not agree with this decision: I was allowed to expose the organisational structure but not the treatment practice, the ultimate goal of the organisation. As if organisation and treatment could be disconnected. As if "a total individualisation, bitterness towards each other, indifference towards innovation and quality control, and disbelief in any possible improvement" - words from the organisation report - didn't influence the quality of the treament. Therefore I decided to show none of the cartoons. I included the cartoons in my later books together with new drawings.

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AFTER THE BIJLMER AIRPLANE CRASH

Traumatic events. On october 4 1992 an El Al Boeing 747 cargo aircraft crashed on a residential area in the Amsterdam Southeast region called the Bijlmer. 43 people died. After the Bijlmer Disaster most of the victims (eye witnesses and local residents) were treated in the mental health care organisation where I worked. A trauma specialist of the Utrecht Institute for Psychotrauma was hired to train the therapists in PTSD prevention and treatment. The specialist stressed an approach which was focused on the traumatic event instead of intrapsychic or personality problems, that is on what happened to the victims in the outside world.
In the first months after the disaster the therapeutic focus was aimed at the prevention of a PTSD. When later nevertheless a PTSD developed, the PTSD would be treated.

Policy paper on black clients. 84% of the disaster victims were black. Months before the disaster my department had written a policy paper on the necessity to improve the treatment of black clients and to employ more black therapists in the organisation. This paper was continuously ignored by the management, but was adopted short after the disaster. Because only four of the 60 staff members were black coloured therapists from outside the organisation were temporarily hired to bridge cultural differences.

Fruitful collaboration. Immediately after the disaster there arose a fruitful collaboration between the usually disrespected Prevention, Innovation and Research Department and the Social-Psychiatric Department. Because of its expertise in the field of prevention, innovation and the problems of black people my department made an important contribution to the development of treatment programs for the disaster victims. The Pychotherapy Department, which was mainly focused on the treatment of inner psychic conflicts and had no experience with coloured clients, remained in the background.

Shocking client files. A few months after the disaster the management team asked me as an experienced publicist to write an article on the treatment of the disaster victims for a journal on mental health. In this context I read many client files and was shocked by the poor treatment prior to the Bijlmer Disaster: therapists used their own preferred treatment methods at the expense of the clients needs, clients were often labeled in a condescending way, there were no treatment plans or evaluations and the files testified not infrequently of therapeutic inabilty. 

Back to the usual routine. In February 1993 when the temporarily appointed black therapists had left the organisation and the spotlights of the public attention had been extinguished, the new impulses in the treatment after the disaster were replaced by the usual routine: the therapists fell back on their preference to treat inner mental problems or conflicts and resisted the treatment of black clients (see above). 

Manuscript on the treatment of the disaster victims. In March 1993 I finished my manuscript. In spite of the inadequacies in the usual treatment practice I had choosen to emphasise the temporary improvements in the short period following the Bijlmer Disaster, that is: the increased attention for black clients and the focus on traumatic events, that is on what happens in the outside world, instead of intrapsychic problems. I closed the article with the recommendation to initiate a discussion on possible improvements in the Dutch outpatient mental health care with the Riagg Zuidoost after the Bijlmer Disaster as an concrete example of such improvements. 

See a summary in Dutch of this text: De Riagg Zuidoost na de Bijlmervliegramp: een metamorfose.

Outright racial discrimination

In the meeting of the management team of March 23 1993 I was forced to hand my manuscript on the treatment of the disaster victims over to the head of the Psychotherapy Department, who was assigned by the director as the censor of the organisation. On the insistence of the same department head the director next withdrew the policy paper on the improvement of the treatment of black clients: the conservative Psychotherapy Department did not in any way tolerate black people as clients or collegues. As a therapist in this department phrased it: "Or else hell breaks loose". 
The director demanded that I adapted the text of the policy paper of my department to the wishes of the racist therapists. My objections to this unfair assignment were ignored and not recorded.

Censorhip, publication ban and false accusations

"Subversive". The next day I received the comments on my manuscript by the censor. He believed that after the disaster there was no mention of improvements in the organisation. According to him the treatment was always outstanding. Furthermore he claimed that there was usually enough expertise in his department to treat a PTSD. Finally, he brought up that there was not such a thing as a new policy regarding black clients because this policy was the previous day withdrawn. He considered my text not publishable. In line with this conclusion the director called the text "subversive" and "damaging", and forbade publication. She ignored my reasoned objections.

Hypocrisy. The head of the Psychotherapy Department annex censor now called the attention to himself in the public press as an important initiator of a succesfull treatment program for the victims - 84% of whom was black. 

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COURT HEARING

Nothing to lose but my self-respect. In this organisation all I had to lose was my self-respect. Therefore I refused to submit to this unreasonable publication ban and sent my manuscript to the jounal as intended. After a few weeks the editor of the journal informded me that he liked to publish the text.

Restriction of freedom of speech and a character assasination. Four weeks later I realised that the copyright of the manuscript belonged to the organisation and not to me (because I wrote it in working time) so I still withdrew it. As mentioned before, I had previously opposed the assignment to adapt the migrant policy paper of my department to therapists who did not tolerate black people as colleague or client. My dual resistance to the censorship and racial discrimination was for the director a reason to fire me. Under threat of dismissal through the court she submitted a settlement to dissolve the employment contract in which she tried to restrict my freedom of speech on the mental health care. When I rejected this settlement she went to court. To discredit me she used a series of improvable false accusations which together formed a character assasination.

Dictatorial. During the court session the Riagg Southeast argued among others that it was my duty to conform to the established policy, even if it was contrary to my sense of justice and responsibility. Because, according to the Riagg, "assignment is assignment". This gave me unpleasant associations. It reminded me of "Befehl ist Befehl", the platitude with which the Nazis justified their misconduct after World War II. In my view, doing injustice is also injustice if it has been enforced by the top.
I found this straightforward dictatorial position shocking, especially since it was honored by an institution that had to take care of people's mental well-being.

The court decision is in my favour. Though I didn't want to work in this detrimental setting anymore, I prepared a thorough defence to clear my name. The court decision was in my favour: the judge thought that the quality of my work was by no means subject of discussion. My freedom of speech was guaranteed. However, because of "a blockage in the communication" the judge considered a continuation of my appointment not opportune. She terminated the employment contract and obliged the mental health care organisation to pay me a considerable financial compensation.

Decision of the district judge Amsterdam, mr. M.L. Tan, case number EA-93/2170, August 11 1993.

"A minority of one"

Nobody in the organisation, not even my closest coworkers, opposed the racial discrimination, the censorship and the abuse of power. I was - in terms of George Orwells novel 1984 - "a minority of one".
Within such a work enviroment it was unavoidable that the malpractices continued to exist. In other words, in the organisation was evidence of a total rigidity. As a consequence the clients were treated inadequately, including the victims of the Bijlmer Disaster.

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The fate of the victims of the Bijlmer Airplane Crash 

A CRITICAL, still relevant TrIptYch
on the dutch mental health care

My books Do not disturb (on the Dutch outpatient mental health care, 1997) and Who is crazy, actually? (on the relationship between therapist and client, 2008) form together with this E-document No talent for conformism a critical, still relevant tryptich on the Dutch mental health care.

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