1. Forensic psychiatry Rekem (Belgium)

2. Forensic psychiatry Rekemslide 2 “contract concerning the partial creation of a care path for mentally-disturbed offenders medium risk within the target group of adults in the region of Antwerp and Limburg” 1.Historical background 2.Hospital 3.Contract 4.Organisation 5.Challenges Medium security units: 2007

3. Forensic psychiatry Rekemslide 3 1.Historical background New law 1964: psychiatric disordered offenders receive treatment (intention !!!!) Increasing domestic criticism European Committee for the Prevention of Torture Case Dutroux 1996 Case Ait Oud 2006

4. Forensic psychiatry Rekemslide 4 1.Historical background 19 th Cpsychiatric institutions belong to the department of justice 20 th Cpsychiatric hospitals Rekemup to 1964 department ‘social defense’ 1995forensic department tradition – familiar low risk patients OPZC Rekem // U.P.C. Bierbeek, P.C. Zelzate  historical background

5. Forensic psychiatry Rekemslide 5 1.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

6. Forensic psychiatry Rekemslide 6 2.Hospital Serious Minor Psychopathology Risk of relapse Escape risk Offence/act + alcohol substance abuse sexual deviancy

7. Forensic psychiatry Rekemslide 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 ….. 2.Hospital Target group: specific features

8. Forensic psychiatry Rekemslide 8 2.Hospital Care network C.P.S. Nesessity of residential treatment Nursing home Home care Low Security/Care Halfway House Mid Security/Care Prison Ambulatory follow up Impulscontrol

9. Forensic psychiatry Rekemslide 9 3.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

10. Forensic psychiatry Rekemslide 10 3.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

11. Forensic psychiatry Rekemslide 11 3.Contract Therapeutic project Cross-sectional consultation

12. Forensic psychiatry Rekemslide 12 3.Contract Forensic care network: 2007 HForensic department psychotic disorders21 HForensic department disturbed identity22 HDrug abuse Klimop3 NHForensic Psychiatric Nursing Home Rekem15 NHPsychiatric nursing home MIN22 HHHalfway House MIN60 HHHalfway House ‘t Veer20 PTZPsychiatric Homecare6 TOTAAL169

13. Forensic psychiatry Rekemslide 13 4.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 Hospitals 10% of 51,2 FTE: not assigned to a specific department Working budget:max. 3,95% /budget

14. Forensic psychiatry Rekemslide 14 4.Organisation Network: not a legal entity 4 seperate managements: Hospital,Psychiatric Nursing Home en 2 non-profit associations 3 types of employment contracts Partially whithin regular programme/ reconversion recognised by the Flemish Community Partially outside regular programme recognition sui generis? Specific supplementary security measures

15. Forensic psychiatry Rekemslide 15 5.Challenges Medium risk + intensive treatment-> low risk ? Therapeutically naive (?) optimism Prognoses : silt up psychiatric nursing home,limited ability to learn patients Limited 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

16. Forensic psychiatry Rekemslide 16 5.Challenges Joint staffing policy Need for a joint management: Hospital, Psychiatric Nursing Home, Halfway House Public servants versus private contracts Medical responsability Not specifically forensic, typically for a network without legal entity Financial management No unity in accounting Hospital and psychiatric nursing home analytical bookkeeping non-profit organisations not an analytical bookkeeping

17. Forensic psychiatry Rekemslide 17 5.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 patients To be appointed by Federal department of Justice (temporary) Experience in mental health sector Required administration (reporting, …) Royal Decree safety standards: Content? Supervision? Finance?

18. Forensic psychiatry Rekemslide 18 5.Challenges Care network is incomplete without high risk facilities Institutions 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 capacity 40 beds for treatment is insufficient to provide for the diverse and complex problems Increase of financial means: specialisation > fragmentation

19. Forensic psychiatry Rekemslide 19 5.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 monitoring Joint registration of target group and method Defining medium risk: multidimentional Foreign experiences: good practices Knowledge centre 2008-2009