SELECTION OF REACTIONS ON SAAR ROELOFS' BOOKS 
ABOUT THE DUTCH OUTPATIENT MENTAL HEALTH CARE

This website is selected as digital heritage for inclusion in the Dutch Royal Library, the national library.

In my Dutch E-document No talent for docility ( Geen talent voor volgzaamheid) I describe my experiences as a Dutch psychologist: as a scientific reseacher at the universities of Utrecht and Amsterdam, as a clinical psychologist/behavior therapist in a clinic for alcohol addiction, as an independent therapist and as a manager in the outpatient mental health care. 

In all jobs I found it important to remain true to my own insights. In my 
E-document I explain what in that case happens in the workplace. 

In the Dutch text all my work experiences pass the review. Below I summarize only my experience in the outpatient mental health care, with an emphasis on the events after the Bijlmer Disaster of October 4 1992.

CONTENT

Malpractice in the Dutch oupatient mental health care

Observer

After the Bijlmer Airplane Crash

Outright racial discrimination

Censorhip, publication ban and dismissal

The fate of the victims of the Bijlmer Airplane Crash

Conformism and rigidity in the organisation

Publication of books on the Dutch outpatient mental health care

Malpractice in the Dutch outpatient mental health care

In 1992, at the time of the Bijlmer Disaster, 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 was 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." 

See summary in Dutch of this organisation report.

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.

See summary Dutch article: Riagg's onder druk: naar een nieuw kwaliteitsbesef? / Riagg's under pressure. Towards a new quality awarenes? (1987).

Focus on inner conflicts and reluctance against treatment of black patients. My department focused on Prevention, Innovation and Research and did not treat patients. Whereas coworkers in the treatment departments preferred treatment of intrapsychic conflicts, my department stressed the necessity to focus on the world in which the patient 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 patients. 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 patients with social problems, trauma, black patients and refugees. They preferred to treat young, white, well educated patients with vague complaints. My department was - as similar departments in the Dutch outpatient mental health care - considered inferior. 

See also quote from an interview in Dutch with a university professor Prevention who speaks of contempt for the Prevention, Innovation and Research Departments.

Personality disorder instead of trauma. In the Dutch outpatient mental health care were special treatment teams for women to which mainly patients 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 patients. 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 patient and unilatterally determined the therapeutic proces. They sometimes even made their patients object of ridicule.
Nevertheless the therapists were not aware of any wrongdoings.

For the malpractices in the outpatient mental health care see also a summary of a Dutch scientific report: Vraag en aanbod in the Riagg / Supply and  demand in the outpatient mental health care (1992). 

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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. 

"Therapeutic immunity". The consultant, however, did'nt allow me to show the cartoons on the treatment because that would cause the outrage of the therapists. I didn't agree with this selection: 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. As if the therapists between de four walls behind the closed doors with the signs Do not disturb - like diplomats and Heads of States and Governments - enjoyed immunity.* Therefore I decided to show none of the cartoons. I included the cartoons in my later books together with new drawings.

* Government officials who represent their country abroad enjoy diplomatic immunity. This protects them against prosecution in the host nation for the entire period in which they hold their diplomatic post.

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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.

Policy paper on black patients. 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 patients 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. 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.

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 patients, remained in the background.

Shocking patient files. A few months after the disaster the management team asked me to write an article on the treatment of the disaster victims for a journal on mental health. In this context I read many patient 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 patients needs, patients were often labeled in a condescending way, there were no treatment plans or evaluations and the files testified not infrequently of therapeutic inabilty. 

See also summary in Dutch of a scientific study on patient files: Riagg-dossiers nader bekeken / A closer look at files in the outpatient mental health care (1995) about the deplorable status of the patient files.

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 patients (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 patients 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.

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Outright racial discrimination

In the meeting of the management team of March 23 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. Furthermore, at the insistence of the same department head the director withdrew the policy paper on the treatment of black patients during that meeting: the conservative Psychotherapy Department did not in any way tolerate black people as patients or collegues. As a therapist in the Psychotherapy Department phrased it: 
"Or else hell breaks loose". 
My objections where ignored by all those present.
Whereas before the reluctance to treat black people was more or less implicit, now there was actual evidence of outright racial discrimination. 

See records of the management meeting of March 23 1993 in annex 2 of the e-Document Achter gesloten deuren / Behind closed doors, included in the Dutch Royal Library. Click on Open de publicatie.

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Censorhip, publication ban and dismissal

"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 patients 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. Having previously removed the contribution of my department in a official report on the activities the after the Bijlmer Disaster, 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. 

See selection of interviews (1992-2000) with V.K., head Pyschotherapy Department annex censor of the Riagg Zuidoost. 

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.

See letter in Dutch of the chief editor of the journal annex 2 of the e-Document Achter gesloten deuren / Behind closed doors, included in the Dutch Royal Library. Click on Open de publicatie.

Dismissal on the basis of false accusations. The director forced me to withdraw the manuscript under threat of dismissal through the court. Four weeks after submission I realised that the copyright of the manuscript was vested in the organisation (because I wrote it in working time). Despite the irrational publishing ban I did'nt want to violate the copyright so I withdrew my manuscript. The director nevertheless sticked to the dismissal procedure. To discredit me she used improvable false accusations such as irresponsable behavior toward patients. The hidden rationale behind the dismissal was of course my commitment to the improvement of the mental health care in the organisation, in particular for black people. 
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. Because of blockages in the communication she considered a continuation of my appointment not opportune, 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.

Conformism and rigidity in the organisation

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 patients were treated inadequately, including the victims of the Bijlmer Disaster (see below). 

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The fate of the victims of the Bijlmer Airplane Crash 

Publication books on the Dutch outpatient mental health care

During an exhibition of cartoons in 1996 in the Academic Medical Center (AMC) in Amsterdam, a publisher asked me to provide them with a text. This resulted in my (Dutch) book Do not disturb (1997). Later I wrote Who is crazy, actually? (2008), which was also illustrated with cartoons. In both books I recorded my professional knowledge and my observations of and insight into the Dutch outpatient mental health care in detail. The books received mostly positive reviews.

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