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No talent for conformism: experience as a psychologist in the mental health care |
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REVIEWS
"Balanced
distribution between in-depth and lighthearted items."
"Roelofs'
objections "A book that doesn't mince words. A vivid description of how things work in the Riaggs. Well worth reading." Opzij, June 1997, Margot Minjon. "Sounds familiar. Roelofs describes not only what is wrong, but also how it can be improved." Nederlands Tijdschrift voor Geneeskunde, November 1997, JH Hoogeveen. "Do Not Disturb shows incisively how therapists get trapped in the snare of consultation, speak Orwellian language, and leave the patient out in the cold. Yet it is not a heavy-handed book because the criticism is phrased with a wink and a witty remark. An eye-opener for everyone working in mental healthcare." Modern Medicine, August 1997.
" A
varied and engaging work
that asks important questions." " An
uplifting book, required reading for all mental healthcare
providers, clients, funders, and auditors." "Hopefully,
clients will now start asking their therpists difficult
questions about their diagnosis." Amsterdamse
Patiënten Krant, October 1997.
The TV
current affairs program EenVandaag "The Riaggs': are they really that healthy for the mind?" Sandra van der Werd & Lucia Kooiman, Clients' Union in Mental Health Care, March 1999.
"The manner
in which practice is conducted in the mental health care is very
alarming. Do not disturb describes
these processes
in minute detail." "Just look how surprisingly relevant Saar Roelofs' descriptions are of the problems with the Riaggs in the 90s" Frits Bosch, psychologist and author of Help, the Psychologist Is Drowning, on X, June 21, 2022.
"As you
write, that is how it is! The cartoons dot the i's and cross
the t's."
"I read Do
not
disturben
with a
stream of moments of recognition. Mental health care needs
people like you who have the courage to openly and without
beating around the bush expose processes of sham care." "A wonderful book." From a letter by Dr. Ad Beenackers. (scientific researcher into Riagg files, employee of Riagg Gooi- en Vechtstraat)
"I enjoyed
the book." Comments by mental health care workers revealed that Do not disturb also held the status of 'samizdad', the Russian word for literature banned in the communist Soviet Union that circulated underground. The workers endorsed the criticism in Do not disturb but did not dare to express it openly. REACTIONS FROM (FORMER) CLIENTS Even at least ten years after the publication of Do not disturb, the author continues to receive letters and emails from (former) clients in mental healthcare who recognize themselves in the book and feel supported by it. Below is a selection.
"After
seeing an interview with you on TV, I purchased your book and
read it in one sitting. This book means a lot to me, because
as a client in the mental health care, I encountered exactly the
things you describe. Every time I
voiced my criticism of the way things were being handled, it
was (as you also describe) reduced by the care providers to
part of my problem. All problems were traced back to the
relationship with my parents (tunnel vision). Time and again,
I hit a wall of dogmatism, ignorance, and tactless remarks. At
a certain point, I grew tired of fighting. I quit. By then, I
had almost truly come to believe that what I thought about
things was part of my problem (the pressure being exerted was
immense). After reading your book, I knew for certain that I
can indeed trust
my own perceptions, perspective, and judgment. Thank you for
the book. Despite the anger that resurfaced, I laughed a lot
while reading. It helped me to process a number of experiences
better. I have been able to hold on to the idea
that I really wasn't crazy for finding certain things that
happened during the treatment ridiculous. "I have experienced many desperate moments under the "wings" of therapists who treated me inhumanely. Your book has done me so much good! Finally, someone who says it!" "I have had very bad experiences with the Riagg. It only made me feel worse. When I read an interview with you, I thought: if only I could talk to her" "The content of your book is a faithful representation of how chaotic things are regarding the quality of treatment and files." "My therapist mistook my PTSD for a Personality disorder. She was very stubborn about that. I became -as you write -entangled in the therapy. Your book helped me a great deal to break free from her." "Very recognizable books Who's Crazy Now and Don't Disturb! Years later, unfortunately still very relevant!
Antipsychiatry in
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What happens within the four walls of the treatment rooms behind the closed doors with the DO NOT DISTURB signs? Do not disturb (1997) offers accessible insight into the 59 Dutch outpatient mental health care organizations in the last decennium of the 20th century called Riagg. The book provides information on the excessive bureaucracy, the inadequate diagnostics, the often ineffective treatments, and the undervaluation of preventive care. It also gives examples of the largely futile attempts at innovation in mental health care. Do not disturb is accompanied by analyses and background information. The book is based on scientific research, research into client files, and personal observations as head of the Prevention, Innovation & Research Department in the Riagg in the Bijlmer district of Amsterdam, called Riagg Southeast. Do not disturb is richly illustrated with practical examples and quotes from the press and professional literature and 80 previously exhibited cartoons by the author created on the request of a management consultant as an intervention to bring about organizational changes; furthermored with parodies and quotes from world literature. The book consists of three parts:
1.
The
organization Do not disturb concludes with the temporary metamorphosis in the Riagg southeast following the Bijlmer air plane crash of October 4 1992.
summary of DO NOT DISTURB CONTENT
The organization
More
and more rules, regulations,
procedures and protocols.
Part
I subsequently discusses the
meeting culture, the convoluted
language, the frequent
skirmishes between colleagues,
and the group pressure that
prevents the expression of one's
own vision. It addresses how
organizations are establishing
increasingly numerous and
stricter rules, regulations,
procedures, protocols and codes
of conduct in order to keep
conflicts and boundary
skirmishes between colleagues
and departments in check.
Opaque language. Part I also addresses Riagg language: it is convoluted, opaque, impersonal, and riddled with abbreviations; in short, far removed from concrete topics that matter in care provision. The language camouflages the lack of communication and vision within the Riaggs. "Doublethink". Furthermore, the fact that employees often simultaneously hold multiple positions with conflicting interests is discussed, as well as the unrest this causes within the organization. Like George Orwell in his famous novel 1984 the author speaks of "doublethink".
The
DSM is not suitable as a
diagnostic instrument. In
Part II, adult care in outpatient
mental health services is
examined. A
major point of criticism is the
use of the Diagnostic
and Statistical Manual of Mental
Disorders (DSM) in
making a diagnosis. The 'D' and the 'S' of the Manual. The DSM was designed in the 1950s to collect statistical information about population groups: which mental disorders occur in this country, in this region, in this city? That is what the 'S' in DSM stands for. The manual assists with a quick screening: in this province, so many percent of anxiety disorders occur; in that province, so many. Although the manual claims to be Statistical (S) and Diagnostic (D), the DSM is only useful for registration purposes. The 'D' for 'Diagnostic' means little: a 'diagnosis' according to the DSM is merely a classification, a rough division into categories based on a description of complaints and symptoms, and says nothing about their causes. To make a 'diagnosis', the therapist works, among other things, with a so-called decision tree: via a technical protocol - based on complicated routes of yes-no choices like on a tax form - he or she categorizes people's complaints and problems into categories. A major objection is also the psychiatric terminology for problems caused by mistreatment, sexual abuse, and oppression.
Exception: PTSD. The
DSM offers one category that
does provide a cause for the
psychological problems, and
that is Post-Traumatic
Stress Disorder, or PTSD. In
this diagnosis, the cause of
the problem is already
inherent in the name: the
disorder arises post -
that
is after
- a
trauma. Moreover, there are
widely known and effective
treatment methods for PTSD
that address the problems of
traumatized individuals.
The DSM enjoys considerable prestige as a diagnostic instrument in mental health care. Nevertheless, therapists generally do not adhere strictly to careful classification according to the DSM guidelines. They use the handbook as a sort of catalog of labels. Furthermore, in the Riaggs psychiatric labels were sometimes used that have long been removed from the DSM and other psychiatric handbooks, such as hysteria and masochism. Additionally, threapists referred to their clients as 'a theatrical aunt' or called someone's personal account 'a narcissistic story'. Because there is no diagnosis in mental health care in the sense of 'knowing through' or 'seeing through' what is wrong with a client, these were cases of a pseudodiagnosis.
"THE CLINICAL EYE" After the first, usually brief, registration interview and the slightly longer intake, the client is assigned a therapist. Usually, the therapist conducting the intake is different from the one who conducted the registration interview. The treating therapist is often, in turn, different from the intake interviewer. Clients must start all over again each time in building a relationship of trust and must also tell their entire story over and over again. For every therapist wants to form their own judgment. Whether that also contributes to refining the diagnosis is questionable. The intaker is already familiar with the initial diagnosis provided by the clinician, even though he or she has never spoken to the client. In many cases, that initial diagnosis is a pseudodiagnosis. The intake worker will notice precisely those things that are consistent with his or her colleague's diagnosis. The same applies to the treating therapist. He or she has already seen a complete report containing all the details from the intaker without ever having met the client. He or she, too, will be inclined to see what his or her colleague saw earlier. A pseudodiagnosis is confirmed time and again. The client cannot escape it.
LITLE INTEREST IN THE OUTSIDE WORLD AS A SOURCE OF PSYCOLOGICAL SUFFERING The world within the client versus the world in which the client lives. Most therapist have an aversion to helping with socio-economic problems and concrete traumas sustained in the outside world. They are primarily interested in the world inside the client and have little or no interest in the world in which the client lives. Scientific research: the client is not central. Studies by the Trimbos Institute, a Dutch national institute for mental health, also show that the focus is not on the client's request for help, but rather on the therapists preference for assisting relatively young, well-educated, white clients with vague complaints who can express themselves well verbally. When concrete socio-economic problems are at the forefront, therapists believe there are insufficient starting points for treatment. Consequently, treatment becomes unfocused, and clients drop out at an early stage. The researchers conclude that the request for help cannot be viewed in isolation from the socio-economic context and the client's living situation. They see it as an explicit task of the Riagg to develop a range of services that also focuses on that living situation. Below more about the treatment preference of many healthcare providers.
""PUZZLING":
AN INTELECTUAL GAME Of the many forms of therapy, insight-oriented psychotherapy focusing on growth and awareness is the favorite. This is a treatment in which the therapist helps the clients discover their feelings and make connections between current issues and the past with a view to personal growth and insight. In principle, this form of therapy can be beneficial for a client who needs it, provided that the client is in good hands. Support aimed at growth and insight is primarily provided in Psychotherapy departments. Do Not Disturb describes what such therapy might look like in principle. In practice, however, this form of therapy often degenerates into a form of conversational support that the author calls "puzzling." "Puzzling" is a method that meets to the therapist's need to distinguish themselves with a quasi-Freudian depth psychology. Thus, therapists turn therapy into a purely intellectual affair, in search of a supposedly repressed childhood trauma of the client that could shed light on their current issues and simultaneously satisfy the therapist's curiosity about the client's personal life. In doing so, the therapist is inclined to ignore the client's direct request for help. As a rule, that request relates to current psychological and/or social problems. Following in the footsteps of psychotherapists, most Riagg care providers in the Social Psychiatry department, which is tasked with dealing with concrete societal problems, regardless of their discipline—social work, social psychiatric nursing, psychology, or psychiatry—also prefer to focus on the client's inner world and have little interest in the external world as a source of psychological problems. Why is "puzzling" so popular?
1.
Status.
Differences in
treatment methods appear to be
accompanied by differences
in status. As an unwritten rule,
a therapist enjoys high prestige when his or
her approach focuses on inner
psychological conflicts and the
client's past; when his or her
role as an expert carries
significant weight; and when his
or her client is white, young,
and well-educated, and has vague
problems without striking
socio-economic or current
complaints. In American
professional literature, the
term YAVIS clients is used.
YAVIS stands for Young,
Attractive, Verbal, Intelligent,
and Successful. Of all the staff
at the Riaggs, psychotherapists
with their traditional, in-depth
verbal therapies for young,
well-educated white clients with
vague complaints therefore enjoy
the most prestige. A therapy
that - as mentioned
before - often
degenerates into "puzzling." 2. Descending into the subconscious is fun; complaint-oriented, methodical help is boring. The therapists in the Social Psychiatry department do not want to be merely the doers who have to roll up their sleeves for concrete problems when psychotherapists fail to deliver. They also want to descend into their client's subconscious. Just like the psychotherapists, they want to "puzzle." They have such a strong preference for this that they would prefer to do it with every client. Consequently, in all treatment departments, there is rarely any question of concrete, complaint-oriented treatments that could get clients back on their feet relatively quickly. In the treatment of PTSD, for example, the therapist must gradually confront the client with the traumatic memories. This requires patience, a methodical approach in which the therapist systematically guides the client, step by step, to transform his or her psychological problems into healthier behavior. That does not sufficiently pique the care therapists curiosity. It does not interest them enough. 3. The Power of Secrecy. A third reason why therpists prefer "puzzle therapy" over treatment focused on the client's concrete, current problems is the need for power. By emphasizing intangible inner processes - inner conflicts and unconscious connections - therapists create a distance between themselves and the client and turn the mental health care into something mysterious. They turn themselves into authoritative experts with power who 'see right through' the client, and into clients who are dependent on their knowledge, insight, and willingness to provide explanations.
The consequenceS OF "PUZZLING"
Undirectet treatment.
After the 'diagnosis' is
made, an usually undirected treatment follows, that is to
say, treatment without a clear treatment plan,
evaluations, and careful record-keeping.
Non-commital poking.
When push comes to shove, the depth-psychological
"puzzling" of the care providers amounts to very little:
that approach usually gets stuck in non-committal poking
into the client's past
Covering up traumas.
Therapists like to delve into their client's unconscious in
search of potential, deeply buried traumas. However,
traumas brought up by the client themselves
- such as sexual abuse, war experiences, or traffic
accidents - generally receive little attention. In such
cases, the therapist often switches to what is known as
'covering up.' By 'covering up,' he
or she attempts to keep the client's painful or shocking
experiences below the surface or banish them from
consciousness because the client's psychological capacity
to process the traumatic event is supposedly insufficient;
because the client would be unable to handle the memories
and would become depressed, suicidal, or psychotic.
No concrete exercises or training. If "puzzling" yields no results, care providers often turn to the support and structure method. When this method is applied correctly, the care provider brings clarity to the client's daily functioning, attempts to create order in their thoughts and feelings, and encourages the client to actively address the problems using complaint-oriented techniques and exercises. However, support and structure not infrequently degenerates into a stopgap measure, into providing all kinds of explanations, advice, and ready-made solutions without accompanying exercises or training. Clients and problems that receive less attention. The consequence of their preference for "puzzling" is that many therapists show little interest in the treatment of older and less well-educated clients, people with a migration background , and people with concrete traumas sustained in the outside world – whether these are refugees, abused and sexually assaulted people, or victims of disasters. There is also little attention paid to the relationship between body image and psychosocial functioning. Nor to sexuality and the excessive use of alcohol and/or sedatives. Personallity disorder: salt in the wound. When a client experiences problems resulting from explicit traumas sustained in the present or past, the DSM diagnosis of PTSD (a treatable disorder that arises after a trauma) is rarely given. Usually, it is the DSM diagnosis of Personality Disorder. In DSM terms, a personality disorder is a persistent, rigid pattern of behavior that is hardly susceptible to change and represents the client's 'personality' or 'character'. Thus, it can happen that sexually abused or raped people receive a 'diagnosis' of one of the DSM Personality Disorders. In this view, a person who is a victim of abuse or rape is abnormal. And for the client, that is salt in the wound.
"Unsuitable clients".
Scientific studies
study reveal that
almost all
therapists believe they are
regularly saddled with clients
with whom they cannot do
anything and do not want to do
anything either. They feel that
many clients are not suitable
for their treatment methods.
They are inclined to treat
so-called "difficult clients" in
such a way that the latter drop
out at an early stage. At
Riagg Southeast,
this was referred to as a "get-lost
contact" . "Ethnology desks". The preference for treatment of clients with a Dutch background leads to what the Dutch psychiatrist Sterman calls 'ethnology desks'; these are separate sections within the Riagg that deal with help for and by people with a migration background. Sterman warns of a new form of 'apartheid'.
NO ACCOUNTABILTY FOR THE TREATMENT In interdisciplinary team meetings, the progress of treatments should be discussed, and care providers should explain their working methods and consult with one another. In practice, such an exchange rarely takes place. Furthermore, team meetings quite often degenerate into gossip about a client's behavior and appearance.
Therapists consider themselves as indispesable. Therapists are inclined to attribute a central role to themselves in the client's life. They often view their clients as helpless and incapable of speaking for themselves. They sometimes find it difficult to imagine that the client has a life of their own, is autonomous, and makes their own decisions - separate from the care services. In her book Who is crazy, actually? (Scriptum, 2008), Saar Roelofs demonstrates, using various real-life examples, that people in psychological distress - even without the intervention of therapists - are capable of tapping into unsuspected inner strengths. When a client decides to discontinue treatment, this evokes quite a few emotions in the theraists. A quote from the study cited above (Dropping out as a solution): Clients who disengage without consultation and without consent do not meet the therapists expectations. Moreover, by severing it, they completely seize control of the care relationship. Consequently, protest against this shift in power is palpable when discussing it with therapists.
Dependent therapist
lack of self-reflection Part II also addresses the inability of many therapists and organizations to deal with feedback from colleagues, (client) organizations, and critical professional literature. In mental health care, there is a tendency to disregard or contradict this feedback. It is striking that in doing so, no substantive, professional arguments are used, but rather negative value judgments are expressed without substantiating them with arguments. For instance, Dr. Ad Beenackers, who conducted research into inadequate record-keeping in the Riaggs, was accused by the Dutch mental health umbrella organization, GGZ Nederland of “crooked reasoning and a lack of knowledge,” on the basis of which he attempted to “undermine the entire Riagg sector.” Such a lack of self-reflection is detrimental to mental health. This is especially true in a sector where one would actually expect mental health from the employees. Critical reports from client organizations show that many clients are disappointed with the care provided. However, not every disappointed client knows how to find their way to these organizations. They get stuck. In Do Not Disturb Saar Roelofs shows how a client can become entangled in the care system and what consequences that entails. See passage from Do Not Disturb elsewhere on this website: Entangled in the mental health care
Prevention, Innovation & Resarch Help for people with concrete socio-economic problems
Part III focuses on
innovations by
progressive departments
within the Riaggs: the
Prevention, Innovation &
Research departments. These
departments emphasize
that, in addition to
internal psychological
processes, attention
must also be paid to the
socio-societal factors
that have contributed to
the development and
persistence of
psychological problems;
that attention should be
paid not only to the
world living within the
client, but also to the
world in
which he
or she lives.
Their tasks include:
1) The
development of new care
programs aimed
at concrete,
socio-societal problems
of clients. For
instance, they design
programs for people with
work-related problems,
refugees, the elderly,
and traumatized women
and girls. Collaboration
with the treatment
departments is necessary
for this. Innovation of the mental health care and prevention is not taken seriously Due to resistance to this, the innovation and prevention projects of the staff from the Prevention, Innovation & Research departments do not get off the ground. Their work is usually not taken seriously. After all, therapist have a preference for clients with vague complaints and for "puzzling" as a method of care. Professor of Preventive Mental Health Care, Clemens Hosman, noted in 1996: "The established powers within mental healthcare unfortunately have little regard for prevention; they often view it with some disdain."
Consequently, there is a risk of an exodus of employees from the Prevention, Innovation & Research departments
DEVELOPMENTS IN THE MENTAL HEALTH CARE AFTER 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 Amsterdam's Bijlmermeer. 43 people were killed. Many eyewitnesses and surviving relatives were severely traumatized. Riagg Zuidoost is located a stone's throw from the crash site and provides assistance to the victims. 84% of the victims have a migration background.
Shortly after the
disaster: a
metamorphosis The director of the Institute for Psychotrauma, Carlo Mittendorff, is brought in to provide further training on the prevention and treatment of Post-Traumatic Stress Disorder (PTSD). A new migrant policy drafted by the Department of Prevention, Innovation & Research is unanimously adopted by management: more therapist with a migration background will be hired on a permanent basis in all treatment departments, and assistance to migrants will be improved. Therapists with a Surinamese or Antillean background are being temporarily employed in order to align with the culture of the predominantly Black disaster victims. Due to its expertise in information, prevention, and migrant assistance, the Prevention, Innovation & Research department makes a substantial contribution to the design and implementation of disaster care. This metamorphosis demonstrates what mental health care could look like if it were truly adapted to the clients needs.
Return to the old way of
working
Censorship
Racial discrimination
Nevertheless hopeful
In the years 1992 through 1996, one critical publication after another appeared regarding the Riaggs, including five research reports by the national Trimbos research institute. The publications address, among other things, the lack of enthusiasm among therapists to focus on the client's concrete problems, resistance to clients with a migration background, unfocused treatments, inadequate record-keeping, client dissatisfaction, the arrogance of care providers, far-reaching bureaucracy, and the dismissal of criticism. In the same years 1992 through 1996, national newspapers also regularly payed critical attention to the Riaggs.
See sources (all in
Dutch) on the Dutch
version of this webpage NB . © Copyright applies to text and cartoons The website www.saarroelofs.nl has been selected as digital heritage for inclusion in the web archive of the Royal Library (KB), the national library.
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No talent for conformism: experience as a psychologist in the mental health care |
