International Journal of Forensic Mental Health 2002, Vol. 1, No. 1, pages 83-92 The Dutch Entrustment Act (TBS): Its Principles and Innovations Hjalmar J.C. van Marle Terbeschikkingstelling (TBS) is a provision in the Dutch criminal code that allows for a period of treatment following a prison sentence for mentally disordered offenders. This article describes the legal criteria as well as the actual treatment environment of the TBS. Discussion focuses on the selection of patients and the indications for treatment, quality improvement in treatment programs and their evaluation, and the exchange of knowledge about the TBS approach and its effectiveness. Terbeschikkingstelling (TBS)—translated literally, “at the discretion of the state”—is a judicial instrument embedded in the Criminal Code that works in combination with a prison sentence. The prison sentence is enforced first and then followed by TBS. TBS is not a punishment, it is an entrustment act for mentally disordered offenders. Its primary aim is not to seek retribution by depriving an individual of his or her freedom, but to protect society in the short term by detention, and in the long term, by treatment that reduces risk. TBS means that society can be shielded from a dangerous, mentally disordered individual for as long as is necessary. The TBS order remains in force as long as the person is considered dangerous. Hence it is crucial to establish that a person is dangerous whenever a TBS order is issued or renewed. If the person is wrongly assessed, he or she could be detained for longer than is necessary. Alternatively, he or she may be released while there is still a chance of recidivism. For many years the possibilities and impossibilities of establishing this point have led to discussions inside and outside the Netherlands. As the issue of dangerous personality disordered offenders is a generalized problem for many countries, the TBS is described here as the Dutch way to seclude these offenders out of the society as long as they are dangerous. TBS can be understood solely by clarification of the Dutch principle of diminished responsibility and the Court decision based upon that judicial criterion. Then aspects of the placement and incarceration in a TBS-maximum security hospital will be described in which treatment is voluntarily. The relations between security, care, and treatment must be coordinated to create a positive environment for delivering the therapeutic services. After a review of these judicial and the forensic psychiatric paradigms, the policy discussion of the last 10 years will be brought to the fore. The number of TBS detainees has increased so much that cooperation with the community mental health care is necessary. When the Psychopath Act came into force in 1928, people were adjudged dangerous if they were considered a threat to public order. In those days, TBS (or TBR as it was then called, “at the discretion of the government”) could be imposed on persons for any type of deviant behavior such as theft, exhibitionism, or violence. In 1988, under the influence of social change and the peak in the number of persons detained under TBS (van Marle, 1998b), this criterion was narrowed to “a danger to others and/or to the general safety of persons and property” (Art. 37a CC). Hence, an offense that leads to a TBS sentence must be highly serious. At present, 96% of the TBS population has been convicted of serious violence against persons or serious sexual offenses combined with violence (van Emmerik, 1999). This change came about after years of protracted debate in the Lower Chamber of the Dutch Parliament. TBS used to be called TBR because the Minister of Justice not only played a key role in allocating cases to a hospital but also could take independent decisions on provisional release. Since Prof. dr. Hjalmar J. C. van Marle is Professor of Forensic Psychiatry at the University of Nijmegen and psychiatric advisor to the Ministry of Justice. He is also a psychoanalytic psychotherapist at the Dr. H. van der Hoeven Clinic in Utrecht. Mailing address: Department of Forensic Psychiatry, Catholic University Nijmegen, Thomas van Aquinostraat 6, 6525 GD Nijmegen, the Netherlands (E-mail: VanMarle.HJC@best-dep.minjust.nl). ©2002 International Association of Forensic Mental Health Services 84 van Marle 1988, the Ministry of Justice has still regulated the placements and the parole-based release policy but it is the full court alone that decides whether the TBS is to be lifted. The Minister of Justice is, however, responsible for enforcement by means of adequate legislation and funding for TBS maximum security hospitals. Originally, TBR was deemed necessary by legal experts because a gap had appeared in the criminal legislation around the turn of the 20th century. On the one hand, prison sentences were passed on offenders who were fully responsible when committing a crime. On the other hand, people who committed a crime because they had a serious mental illness were considered unfit to plead. They were then forcibly incarcerated in the state asylum under the Lunacy Act of 1884. It turned out that there was also a middle group who fell outside this system: people who suffered from mental disorders that impaired their volitional control but not to the extent that rendered them non-culpable. This applied to, among others, people with personality disorder or mental retardation. This group presented the courts with a dilemma, for although they did not have full volitional control when they broke the law, they were only partially under the influence of the mental disorder. The first case implied a shorter prison sentence because culpability was diminished (according to the Dutch legal principle, “punishment to match the level of guilt”). The second case implied placement in an asylum, which was virtually incapable of treating such individuals, given the treatment available at that time. A compromise was found in the form of TBR. DIMINISHED RESPONSIBILITY The area between total culpability versus nonculpability is referred to as diminished responsibility (similar to the concept of diminished capacity in Anglo-American law). This term does not appear in the Statute Book, but comes from Article 37a of the Criminal Code, which states that a person may be sentenced to TBS when he or she commits an offense while suffering from “developmental deficiencies and pathological mental disturbance.” The Supreme Court has also decided that some kind of causal connection should exist between the disturbance and the offense. Hence, in a TBS case, the disorder— which must be ascertained by experts—must be one of the factors that led to the offense. This necessary connection between the disturbance and the offense means that an extensive examination must be carried out by two experts (including a psychiatrist) before the court can pass sentence. The behavioral experts submit their assessments on how far the court can hold a suspect responsible for his or her acts. The stronger the connection between the disorder and the offense—that is, the greater the influence of the disorder on the offense—the lower the responsibility. There are five levels of responsibility ranging from fully responsible to not responsible (unfit to plead). At the fifth level the offense is believed to have been caused entirely by the mental condition of the perpetrator. A distinction is drawn in the gradations of diminished responsibility in relation to the role played by the mental disorder in the offense. A prison sentence is imposed for the part for which the perpetrator is deemed culpable. The greater the culpability imputed by the court, the longer the prison sentence. TBS is always enforced after the prison sentence has been served. This need not, however, be served in full. The provisions of September 26, 1997 for prison sentences and TBS (Gazette, St crt 1997, 185) state that only 1/3 of the prison sentence need, in principle, be served and that this period may even be shortened due to unsuitability for detention or a serious medical need for treatment. COURT REVIEW The court may renew the TBS by a period of one or two years. The director of the TBS-hospital must submit well-substantiated recommendations to the court on the behavior and the progress of the patient when the TBS is due for review. Renewals must then be requested by a Public Prosecutor who has given due consideration to these recommendations. Otherwise, the TBS will be automatically terminated. Usually, the Public Prosecution Service acts in accordance with the director’s recommendations. The court reaches a decision after hearing the detainee in the presence of his or her lawyer. Often, the hospital that submits the recommendations is asked to elaborate on the report at the hearing. The Dutch Entrustment Act (TBS) The court may also decide on a provisional termination of the TBS (Art. 38g CC). This may not last longer than three years. Each year, the court must be advised on the desirability of renewal by another year. The responsibility for this decision rests with the court. In that case, the Probation Services (Stichting Reclassering Nederland) in the Netherlands supervises the detainee after conditions have been drawn up in consultation with the hospital and the probation services and approved by the court. If the detainee breaches these conditions or is at risk of doing so, the probation officer may apply to the Public Prosecution Service, who will assess whether the detainee should be removed from society and placed in custody. The provisional termination may be lifted and the TBS resumed after a court hearing. Given the seriousness of these decisions, the court can take extra time to reach a conclusion by deferring its decision on termination or renewal for a maximum of three months. The session is then adjourned for this period. In the meantime, mental health professionals from the hospital and the resettlement services can consider ways of arranging aftercare. In 1997, “Conditional TBS” was introduced (Art. 38 CC), which made it possible to sentence people to TBS without necessitating direct admittance to a maximum-security hospital. This obviously creates certain tensions, because a person needs to commit a serious crime before being sentenced to TBS and there must be strong reasons to suspect there is substantial likelihood of recidivism. The legal criteria are the same for a conditional TBS as for a TBS with a care order. The number of conditional and unconditional TBS sentences has grown (to 26 and 23 in 1998 and 1999, respectively), especially since the introduction of the new TBS legislation in 1997. This outpatient or ambulatory version of TBS makes it possible to put pressure on an offender to undergo certain treatment without having to lock him up. The offender must be personally motivated to undergo this treatment. Supervision is carried out by the resettlement services, but the treatment is placed in the hands of experts in the mental healthcare sector or in the forensic outpatient departments of TBS hospitals. A conditional TBS order may be imposed for, say, non-violent sex offenders, perpetrators of domestic violence, and seriously disturbed psychiatric patients who can get the best treatment in a 85 mainstream psychiatric hospital as long as they do not abscond. PROBATION Resettlement plays a key social role in the conditional forms of TBS. The probation officer is not the treatment provider but the case manager. He or she must not only monitor the potential risks to the environment but also adherence to the treatment. The treatment provider reports on the progress and the completion of the treatment insofar as this is necessary for the safety of others (see also van Marle, 1998a). If the resettlement officer is to fulfill effectively a role as case manager, he or she must consult the compilers of the court recommendations long before the TBS conditions are formulated. This way, a form of treatment can be decided on the basis of consensus and a specific provider can implement the treatment. The probation officer arranges for the detainee to report regularly to his office so that progress can be monitored. In this it is very important that he or she has an immediate connection with the Prosecution Counsel, who orders detention when rules or conditions are trespassed. MATERIAL AND RELATIONAL SECURITY TBS is enforced in nine TBS hospitals, some with an outpatient department and day centre. These hospitals are the Dr. S. van Mesdag Hospital in Groningen, Veldzicht Forensic Psychiatric Centre in Balkbrug, Oldenkotte Forensic Psychiatric Institute in Rekken, the Prof. mr. W. P. J. Pompe Hospital in Nijmegen, the Dr. H. van der Hoeven Hospital in Utrecht, the F. S. Meijers Hospital in Utrecht, the Singel TBS Hospital in Amsterdam, the Kijvelanden in Portugaal near Rotterdam, and the Rooyse Wissel in Venray. There are also two forensic psychiatric hospitals (FPKs), which are part of a larger mainstream mental hospital: the FPK of the Psychiatric Centre in Drenthe and of the GGzE (Mental Healthcare Services of Eindhoven and de Kempen). Detainees who are retarded or mentally handicapped are admitted to Hoeve Boschoord in Vledder. Together these institutions provide a total of 1200 beds. 86 van Marle Security is high in all TBS hospitals, both internally and between the hospital and the outside world. Once the detainee has been admitted he or she may not leave the hospital without permission. There must be no chance to abscond. The security record in this respect is positive. Each year sees, on average, one escape, sometimes involving several persons. The number of detainees who fail to report back after parole is, of course, higher. In almost every case, the absconders are back in the hospital within two weeks. The security of the peripheral ring between the hospital and the outside world is controlled by mechanical systems, secured gatehouses, sliding entrance gates, reinforced glass, and the necessary electronics. The security in the hospital is based on two components: mechanical security and relational security. The detention units are usually closed, but some may be semi-open if the hospital has a policy of internal differentiation. In principle, the whereabouts of each detainee should always been known in the hospital, and closed-circuit surveillance is used when certain doors are opened. Relational security implies that the personnel are a crucially important part of all security arrangements in the hospital. The relationships that the personnel enjoy among themselves and with the detainees make them feel responsible for one another and for the patients. This facilitates early detection of stress and tension and enables prompt intervention. Frequent contact between the personnel and the patients is therefore an important prerequisite for a sense of safety in the hospital. It is for this reason that it is essential to have permanent teams in the treatment units. Too many personnel changes have a negative effect on the treatment climate. Anyone who refuses a treatment program will receive only nursing care. Nursing care differs from treatment (van Marle, 1995) in that it is geared to short-term security through ensuring that the patient does not deteriorate. The nursing climate is also preventive with regard to aggression, as the trained personnel can de-escalate potentially violent situations because of their continuous presence on the ward. The patients are given full support in any positive initiatives. The aim is not to change personality but to stabilize disorder in an optimal living climate whereby the personnel provide and control all activities of patients. The personnel involved in this type of care should by then offer treatment to patients treatment and try to persuade them to accept it. The nursing care must therefore incorporate implicit motivational factors such as social learning, tolerance, and safety. The treatment aims to bring about changes in the person in the expectation that this will greatly reduce the risk of a repeat offense; however, patients are also a threat due to mental disorder. This is the safety function in the long term: successful treatment will greatly reduce the risk of recidivism in society. Though the aim was initially to change the personality or cure the psychological disorder, it is now generally accepted that the primary aim of the treatment is to prevent recidivism. Priority is therefore given to aspects of mental disorder that present a direct threat of recidivism. Each of these indicates a specific program of treatment. The risk factors can be divided into four categories (Steadman et al., 1994): • NURSING CARE AND TREATMENT • TBS is a judicial measure that is imposed on offenders whether they want it or not. This does not, however, imply that people can be compulsorily treated under TBS, as constitutional rights protect the detainee against this. As a rule, compulsory treatment is only possible if patients are a threat to themselves or other people in the hospital. In such cases intervention is permitted in the form of, say, medication, if the threat is caused by a mental health condition. • • Dispositional (inherent) characteristics, especially personality factors, cognitive factors plus gender, environment, and hereditary defects; Previous history, especially the socialization, psychiatric and criminological history; Situational factors, especially subjectively experienced stress, the support from society and the means of violence; and, Psychiatric characteristics, such as the presence and seriousness of psychological symptoms (delusions, hallucinations, violent fantasies) substance use and degree of psychosocial function. Accordingly, there are treatment programs for patients suffering from addictions, personality The Dutch Entrustment Act (TBS) disorder, psychosis, and mental retardation, as well as patients with problems related to aggression and sexual deviation. These programs are provided in the hospital and the outpatient department. The success of the treatment depends, in large measure, on the patients. Patients must not only be motivated to start the treatment, but must also make an effort to change their behavior. To achieve this it is often necessary to present patients with their own ideas or behavior towards others and to get them to practice desired behavior. The aim is to help patients understand the nature of their offenses and how they came about, and to help them accept full responsibility for them. The steadily growing number of detainees who are in prison and waiting for a place in a TBS hospital has prompted the hospitals to focus more and more on improving the efficiency of treatment. It is difficult for hospitals to transfer patients to other hospitals who no longer need heavy security but still require psychiatric care. As a result, the treatment has become increasingly similar across the different units of the TBS hospitals. The extensions necessitated by the large numbers of detainees meant that each hospital could be equally secure. The external differentiation between the hospitals is therefore less than before whereas the internal differentiation between the units has increased into, for example, intensive care, closed, semi-open, and open departments and resocialization. At the present time each TBS hospital can admit all types of patients. This brings us to the next point: selection and detention in the TBS hospitals. 87 hospitals have found greater consensus in the treatment, each hospital can admit the detainees directly without mediation by the Meijers Institute. The role of the Meijers Institute was discontinued on July 1, 2000. Each hospital has a unit for patients with personality disorders and another for patients with psychosis. The specializations for psychotic and retarded patients have remained in the FPKs and in Hoeve Boschoord, but the other hospitals are also capable of treating people with these disorders. At present approximately 1/4 of all detainees have a psychotic disorder as the first diagnosis, and 1/3 are retarded or mentally handicapped (van Emmerik, 1999). The detainees at highest risk for violence or escape form a separate category. The Ministry feels acutely responsible for these persons, who are placed carefully in consultation with the hospital. Female detainees can be placed in the Van der Hoeven Hospital and in Oldenkotte. At the moment, the Department allocates patients for Individual TBS cases at the Ministry of Justice on the basis of the reports compiled by the multi-disciplinary teams of psychiatrists and psychologists for the court hearing. Selections are no longer made according to the hospital but according to the vacancies for the categories listed above. This allocation method makes a separate selection institute redundant. The hospitals are more dependent on one another than ever before for support and back up. This is stimulating cooperation. They must now collectively “re-select” difficult and untreatable patients to give them a new chance (of treatment) and to prevent themselves from becoming overstretched. PLACEMENT Originally, detainees were referred to a specific hospital after they had been examined at the Meijers Institute, the former Selection Institute, and the best treatment program for their needs had been decided. In this way data could be collected and used for further research. A diagnostic period was necessary to determine further treatment because each TBS hospital had its own theories in this respect. The Meijers Institute then submitted its recommendations to the Ministry of Justice because the Minister of Justice was—and still is—responsible for the placement of these patients. Now that the TBS TREATMENT METHODS TBS treatment has always been rooted in sociotherapy. People with a personality disorder or psychosis are particularly sensitive to stimuli from their environment (situational factors) when committing an offense. Socio-therapists provide all sorts of structured and less structured environmental stimuli in the here-and-now of the unit to shape the patient’s response. The socio-therapy enables patients to practice solving and avoiding risky situations. Within the structural community of the 88 van Marle unit the socio-therapists teach patients to relate to one another so that they can avoid a relapse after they return to society. The concept of the Therapeutic Community became widespread in TBS hospitals in the 1980s (Blankstein, 1979; Jongerius & Rylant, 1989; van Marle, 1995). Changes in the patient population, notably the arrival of psychotic patients, caused each unit to concentrate on its own treatment methods. The huge rise in the number of patients between 1990 and 1999, when the population of detainees doubled from 600 to 1200, pushed the TC concept farther into the background. Staff and inmates can cope with 60 to 80 patients spread over different units and with a collective treatment plan. A larger hospital tends to split into divisions, which then develop their own culture, especially when patient behavior calls for another approach. All the hospitals were assigned an intensive care unit; internal differentiation increased and has now become consolidated. The hospital-wide, sociotherapeutic environment is no longer part of the treatment program; but the socio-therapeutic environment is still important to good internal communication between all the treatment providers in a hospital. This has, as has already been noted, a beneficial effect on relational safety. Staff meetings in the form of, for example, a Clinical Board build cohesion between the decisions and the decisionmakers, particularly on the freedom policy in the hospital and towards society. The hospitals also have traditional social activities for all patients who want to participate. The emphasis now rests on the identity of the treatment of each unit. For instance, there are units for intensive care (as determined by law), group units where responsibility towards the group and the unit is paramount, development-oriented units where arrested personalities are re-stimulated, individualcare units for patients with excessive structural needs, semi-open and open (resocialization) units and detention units for chronically deviant and dangerous patients. A new development in recent years is transmuralization, the Dutch forensic version of community mental health care in the United States. This is an intensive, resocialization program whereby patients are placed in accommodation near the hospital as soon as they shows that they are following their treatment program in the hospital and cease to display mental disorder. An ambulatory team that pays frequent visits to the extra-mural detainee provides intensive guidance. This is not an option for every detainee as public safety comes first. The teams monitor and assist patients in their own accommodation and can have them re-admitted to the hospital as soon as there are any signs of becoming a threat to society. The Van der Hoeven Hospital in Utrecht and the Pompe Hospital in Nijmegen have made great strides in this respect, with 30 and 32 patients respectively in the transmuralization phase. It is normal in transmuralization for the patients to work part of the time in the hospital and part of the time outside, where the emphasis rests more and more on normal work in the society. They also continue to follow their therapy at the hospital. The hospital provides individual therapy and group therapy; the individual therapy may be verbal or non-verbal. These traditional forms of therapy are supplemented by treatment modules: well defined treatments programs with a start and an end point and variable content. There is an addiction program, an aggression management program, empathy training, recidivism prevention, programs for violent sex offenders, and specific modules for patients with borderline disorders and psychosis. The treatment is usually multi-method and multi-disciplinary. It is organized by treatment coordinators and experienced psychiatrists or psychologists. The treatment coordinators present their progress reports and treatment and probationary recommendations to the Board via the treatment manager. The Board then submits reasoned advice to the Ministry of Justice and the Court. Each TBS hospital also has support services. EVALUATION AND PERMANENT RISK As mentioned in the introduction, the main problem is how to predict a relapse by the detainee, not just in the hospital but also, and more importantly, on the outside. Assessments of dangerous behavior and the risks of a return to society are crucial to the whole process, as TBS is a security measure designed for the protection of society. This is why the recidivism statistics of the hospitals are always seen The Dutch Entrustment Act (TBS) as key indicator of effectiveness (Leuw, 1995, 1999; van Emmerik, 1985, 1989). These statistics are fairly consistent: Between 10 and 20% of all detainees recommit a TBS offense within five years. To date, these percentages have been a source of satisfaction to the hospitals, as well as to politicians. Other countries may, however, take a different view. It should be mentioned at this point that a recent evaluation (Leuw, 1999) revealed that the success was greater among detainees who had committed minor offenses, and that it was difficult to influence recidivism among a small group who had committed major offenses. The principle that the level of recidivism must remain at least the same was rigorously maintained for the interventions designed to create greater transparency in the costs, best practices, and throughflow of TBS. Recidivism rates of 10% to 20% are, in themselves, a sufficient inducement for improvement. A significant development has emerged in Canada and the USA in the form of risk assessment tools (Hare, 1991; Monahan & Steadman, 1994). The HCR-20, in particular, has acquired an important place in research on risk inventories in the Netherlands and has been translated into Dutch (Philipse, De Ruiter, Hildebrand, & Bouman, 1999). These tools consist of a list of predefined risk factors. It is still uncertain whether they can be automatically applied to the TBS population in the Netherlands (van Marle, 2001; Hildebrand & De Ruiter, 2000). This is why a specifically Dutch tool, known as the HKT-30, has been developed in the Netherlands. However, this instrument needs to be validated. What is so characteristic of this specifically Dutch riskinventory model is that it pays a great deal of attention to treatment factors and to factors that arise during the treatment that could have implications for later recidivism. A study is currently underway to test the application of the Dutch instrument in the various decisions taken in the criminal justice chain: the Pro Justitia report for the hearing, at entry, for parole, and at the end of the intramural TBS, and resocialization under the supervision of the resettlement services. The aim is also to apply it in the prison system, especially in the case of parole or conditional treatment. Applying risk assessment throughout the whole path of the TBS treatment detainees, who are a continuing risk of criminal behavior, can be detected. 89 Like in former days some TBS-detainees will not be released into the community, often due to several failed attempts at leave or at parole. Risk assessment though is able to point at some patients at risk in an earlier phase, and then a decision has to be made about further attempts for treatment or prolonged care. As the indefinite duration of the TBS has always been legitimized by constant attempts to persuade the patients to accept treatment, the idea that some are untreatable has raised a legal, medical and ethical problem. International acceptance of the assessment methods, validation for the TBS population, and continuing assessments at regular intervals during the stay legitimize on their part that TBS can be lifelong in certain cases. When someone is designated as a constant criminal threat, then treatment ceases within the current schools of thought (Rapport, 1998). Henceforth, he or she is provided with care in certain detention units. The sole aim is to prevent the disorder from degenerating further and to enable these patients to live (work, recreation and hobbies) as realistically as possible. This may then create a risk that such patients will start to display uniform behavior because no attempts are made to change it. Any change in the potential criminal tendencies could therefore pass unnoticed. The two-year renewal of the TBS could be undermined because the court receives no new (treatment) data. This creates the possibility of a self-fulfilling prophecy in which the permanent patient remains a permanent patient because there are no improvement activities to enable him to prove otherwise. The composition, background and criminal history of this group must be further analyzed; not enough is known about it to develop further means of intervention at this moment. FORENSIC MENTAL HEALTH POLICY All the discussions on the activities for the enforcement of TBS beg the question of whether TBS should be re-invented. Although some other countries have provisions for detaining offenders post-sentence (e.g., sexual predator laws in the United States), no other countries have adopted the TBS model to date, even though many foreign delegations pay regular visits to the Netherlands to study the workings of TBS. The positive aspects are attractive: It provides 90 van Marle a means whereby mentally disturbed and dangerous individuals can be removed from society for an indefinite period of time, while a judicial review is carried out by the criminal court every two years to determine whether the threat to society warrants further incarceration. It is immaterial to the court whether or not this person is treatable. What matters is the combination of dangerousness and a psychological or psychiatric disorder. But the increasing number of TBS orders and the declining outflow have created bottlenecks in the TBS hospitals. Hence, there are long waiting lists of persons waiting to be transferred from prison to hospital. The TBS sector may take it as a compliment that the courts have so much confidence in the system. This confidence is not, however, reflected in the teamwork between the TBS hospitals and the Mental Healthcare Authorities (GGz). At the moment, the GGz has no transitional treatment or accommodation for detainees who are no longer thought to need a secure clinical environment. These individuals are regarded with suspicion because of their previous history and the difficulties of assessing recidivism. Moreover, the GGz is not equipped to guide and assist these detainees, as their problems are totally different from those of the usual GGz patients. Just as the GGz can share its knowledge with forensic psychiatry, so can forensic psychiatry share its knowledge of how to deal with the problems of detainees (much more than at present). The Ministries of Justice and Health are currently collaborating closely on the integration of the TBS sector and the GGz organizations. Regional partnerships, joint indication bodies and quality development have a key role to play in this process. Hence, it is not only about treatment but also about custodial care. Public safety has to be guaranteed and so are the legal rights of detainees. The period is spent in a high-security TBS hospital where everything is done to treat the disorder so that there is no further risk of recidivism. This approach works for the benefit of all parties, but it also has a downside. The indefinite period that is determined solely by expert recommendations means uncertainty for the offender and contradicts any treatment optimism of the therapists. The possibility of recidivism after the TBS order has been lifted and the subsequent shock to the social order endangers an easy re-integration in society. Intensive and costly treatment methods for offenders and their aim: prevention of re-offending has at this time only marginal affinity with the aims of the GGz. The long-standing aim of TBS is to remove dangerous individuals with a personality disorder from society. These individuals may then receive treatment in a TBS hospital. Admittance to TBS is not a question of whether the individual is treatable, but rather according to the Dutch criminal law he or she should be dangerous to other people. This dangerous, personality disordered individual needs a special nursing environment to prevent the disorder from degenerating further and to prevent or reduce the threat that he or she poses. In this way facilities can be created for dangerous persons that remove them from society for a long time and allow them to retain their dignity. In the co-operation between the Ministry of Justice and the Ministry of Health both can have their advantage. The option is to introduce the state of the art in psychiatric treatment into the TBS, and to supply the art of custodial care and treatment to patients in the Mental Health Care system who due to their behavioral disturbances are not suited for regular psychiatric inpatient care. The bottlenecks prompted the Ministry of Justice to appoint two inter-departmental working parties (IBO-1, 1996; IBO-2, 1998) to scan the TBS sector for expedience and results. These working parties submitted the following recommendations: 1) Admittance to TBS must be more functional, 2) The selection of patients for treatment must be clearer, 3) Circulation and outflow at TBS hospitals must improve, 4) Quality improvements are needed across the whole TBS spectrum to ascertain what is actually happening, and 5) The TBS should be funded more in accordance with treatment within the GGz. These recommendations were developed by working parties of experts from the TBS sector and the GGz. Further action will be taken in response to the results. A necessity is the further development and maintenance of a monitoring system that registers all patient movement inside and outside the TBS spectrum so that an overview can be obtained of parameters for effectiveness and expedience, such as the duration of stay per patient and patient category (personality disorders, psychosis, learning difficulties), the type of treatment for the different groups and indications for or against a return to society. This system will be placed in an expertise The Dutch Entrustment Act (TBS) centre that will monitor and boost the quality of TBS care as a whole. This centre will be independent of the TBS hospitals but will work in association with them. In addition to the managers, a board of all interested parties will need to be formed to define and evaluate the research. The current climate for change in the TBS hospitals is due partly to the fact that the treatment methods have failed to keep pace with those of the GGz. In addition, the background of the TBS population is so radically different from that of a mainstream mental hospital that knowledge sharing was not the most logical course of action. Another major problem is the lack of knowledge about adequate forms of treatment for personality disorders in combination with serious criminal offenses. The literature also indicates that there is no answer to the general question of whether personality disorders as such can be treated (Bateman & Fonagy, 2000; Dolan & Coid, 1993; Roth & Fonagy, 1996). The only treatment programs based on the criterion of evidence-based medicine are for borderline personality disorders (Linehan, Tutek, Heard, & Armstrong, 1994; Swenson, Sanderson, Dulit, & Linehan, 2001) and for psychosis (Liberman, 1992). A clearer description of the aim of therapy, a valid diagnosis and a description of the relevant problems should show, after scientific evaluation, which patients are treatable and which are not with a clearly defined treatment program. This is still an uncharted area in the TBS sector due to a shortage of systematic, longitudinal and prospective scientific research. A combination of risk inventories and risk management could be highly useful to structure this research as well as to provide the decision-makers with sufficient empirical data for structuring the appropriate provisions. TBS cannot be compared with the way other countries treat offenders with a personality disorder or a mental disorder. There, the vast (about 75%) majority of the TBS population, patients with personality disorders, end up serving long prison sentences and this not in a treatment environment. Exceptions are allowed only for those who show motivation for treatment. This is exactly what does not happen in the Dutch situation: motivation is not necessary for attending the treatment programs of the TBS. The first six years of treatment are offered to all TBS detainees within a secure environment so 91 they can demonstrate their responsivity and progress in therapy to the Courts. When they remain a severe risk for society, their TBS sentence will be prolonged as long as necessary. TBS as care in a maximum security hospital or intensive surveillance following discharge, then, is the basic condition for forensic mental health care. REFERENCES Bateman, A.W., & Fonagy, P. (2000), Effectiveness of psychotherapeutic treatment of personality disorder. British Journal of Psychiatry, 177, 138-143. Blankstein, J.H. (1979). De forensisch-psychiatrische kliniek als behandelingsinstrument. Tijdschrift voor psychiatrie, 21, 5-16. Emmerik, J.L. van (1985). TBR en recidive. Onderzoek en beleid, nr. 61. Den Haag, Staatsuitgeverij. Emmerik, J.L. van (1989). 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