WelcomeWorking with

criminal addicts in

different facilities:

From closed to open,

a Dutch experience.

Introduction

• Alexander Douwes Dekker, registered psychotherapist, specialized in

forensic addiction care

• Moniek van Koot, manager Piet Roorda Kliniek, Master Change & Culture

graduate

– Brief history of forensic addiction care in the Netherlands

– Course of treatment within the phases of the Piet Roorda Clinic

– Biopsychosocial model of forensic addiction treatment

Brief history of forensic addiction care in the

Netherlands (1)

• 1886: introduction of national penal code; “irresponsibility, of

unsound mind”

• 1891: first addiction clinic “Hoog Hullen”

• 1909: Amsterdam Consultancy for Alcoholism > Jellinek Clinic

• 1928: “Psychopaths Laws” beginning of theTBR system:

treatment of deliquents of unsound mind in specialized clinics

• 1948: Alcoholics Anonymous in the Netherlands > more alcohol

clinics & CAD’s in the 1950’s

• 1970’s: detoxification facilities for heroin addicts, introduction of

methadone; tolerance of cannabis > “coffeeshops”; increasing

consumption of alcohol, soft drugs & hard drugs

• 1988: “Psychopaths Laws” replaced by modern TBS laws:

“diminished resposibility”

Brief history of forensic addiction care in the

Netherlands (2)

• 1990’s: proliferation of hard drug use: base cocaine, XTC,

amphetamines; increase of hard drug related crime;

professionalisation of addiction care, public and private. Most

recently GHB

• 1998: Piet Roorda Clinic is founded, the first forensic addiction

clinic in the Netherlands; treatment of deliquents, addicted men

under a judge’s ruling, such as Art. 43.3, ISD, TBS, Art. 14a

• ISD since 2004: special ruling for repeated offenders; vast

majority are severely addicted; specialized ISD sections in

prisons, increase of treatment within prisons

Recent innovations in the field of (forensic)

addiction care

• More specialized professionals: psychiatrists, masters in

addiction medicine (specialized addiction physicians), clinical

psychologists, psychotherapists, health care psychologists,

nursing specialists, nurses, family/relation therapists,

psychomotor therapists, sociotherapists, (financial) social

workers, prevention workers, specialized probation officers

• Internet treatment (Tactus was first!); forensic addiction

policlinics (another first); double diagnosis clinics; modernization

of street work > social addiction care; supportive housing

facilities <> increase of outpatient treatment; Minnesota 12 step

treatment > self help & recovery groups

Piet Roordakliniek

• Facility at Zutphen

– psychological & psychiatric assessment

– individual treatment in a group setting

–2 closed units, 3 half-open units; 9 clients each

• Facility at Apeldoorn

– (continued) assessment & treatment; more training on leave

– 3 open units; 9 clients each

– next phase: living in a supportive housing facility

–

Client characteristics (1)

• Adult men (18>); repeated offenders

• At least one severe Substance-related and Addictive Disorder; usually

Antisocial Personality Disorder and/or Cluster B personality traits; often

Attention-Deficit/Hyperactivity Disorder; many cases with Posttraumatic

Stress Disorder; fairly often Autism Spectrum Disorder; sometimes

Psychopathy

• Intelligence below average; disharmonious profiles; cognitive problems

are common, usually inattention

• Almost all are impulsive in their behaviour; mood swings, leading to

fluctuations of motivation; frequent paranoid ideation; marked problems

with aggressiveness; quite deceitful; often out for kicks, thrill seekers;

lack of remorse to a certain degree; external attribution

Client characteristics (2)

• Patterns. Majority: substance abuse to begin with, followed by crime

to aquire money; large minority: substance abuse and crime go hand

in hand, more often agressive with cocaine; small minority: crime to

begin with, followed by substance abuse

• Related problems: low self esteem; health issues such as sleeping

problems/disorders; trust issues with partners and family; isolated from

society, lack of support; often troubled family background; low social

class and status; lack of education,unemployment; financial problems

and debts; frequent jail sentences are quite common

Exclusion criteria

• Gender: women are usually treated in double diagnosis clinics. Tactus

also provides treatment in a specialized unit, exclusively for women.

• Sexual delinquency

• Acute, major psychiatric disorders, such as psychotic disorders, bipolar

& depressive disorders and neurocognitive disorders, other than

substance/medication induced

• Intellectual disability (“IQ < 70”)

• Serious somatic problems and health issues

• Lack of behavioural control, leading to violence

Our approach

• an open group climate: a safe, structured and rehabilitative

environment in which there is a lot of support, clear

opportunities for growth and minimal repression

• group workers maintain a balance between therapeutic flexibility

and control.

– Therapeutic Flexibility: training alternative, constructive behaviour;

– Control: Urine testing; breath testing; room checks; etc.

– Written reprimand

Biological aspects; addiction as a brain disease:

• Genetic vulnerability + age onset substance use > lasting effects on neurotransmission

• Dopamine theory of addiction: craving & priming + Glutamate theory of addiction: neuroplasticity is affected; marked impairment of behaviouralcontrol + ?

• Cues, triggers > craving, priming > loss of control > relapse: substanceabuse, followed by deliquent behaviour

• Treatment: spotting early warning signs risk assessment; analysis of main functions: relief from craving, self medication > proscribedmedication

Biopsychosocial model of forensic addiction

treatment (1)

Biopsychosocial model of forensic addiction

treatment (2)Psychological aspects, addiction as harmful conditioning:

• Cognitive patterns: addictive, often obsessive criminogenic

reasoning; permissive, misleading, self indulgent thoughts; over-

and underestimation “One for the road” denial of craving;

suppression of painful, often traumatic memories

• Emotional patterns: key emotional states, associated with

craving; waves of craving, frustration tolerance, impulse control;

build up of agressive tension: irritation, anger, rage

• Behavioural patterns: inadequate coping styles, tendency to

react in passive and/or overactive way, bad timing; various

forms of impulsive behaviour, related to disorders; autonomous,

asocial and antisocial behaviour

• Treatment: (elementary) Cognitive Behavioural Therapy >

Schema Therapy; EMDR; Psychomotor Therapy;

• ADHD coaching

Biopsychosocial model of forensic addiction

treatment (3)

Social aspects, addiction as alienation from significant others and

society:

• Changing procriminal, substance abusers mentality and attitude;

involving significant others, “allies” (relatives and professionals);

learning to ask for and accept help on time; learning to look

before you leap, think before you act;

• Treatment: Early Warning Sign Plan, green, orange and red

phase, preventive actions > training during leave; Relaspe

Prevention Plan, individual preparation > presentation in the

group; presentation of actual relapses; Crime Prevention Group

• Rehabilitation: family therapy sessions; social skills training;

debt management; work in the clinic > work “outside”; leisure

and housekeeping skills; co-operating with authorities, such as

probation officers

What lies ahead for the Piet Roorda Clinic

and our course of treatment

• Integration of systematic risk assessment into the treatment of

our clients > systematic risk management of historic, current and

future factors

• Introduction of Schema Therapy Group and Crime Prevention

Training

• Introduction of self help programmes and recovery groups

during treatment; “ervaringsdeskundige” = “experiential expert”

who is trained to work with clients in treatment.

• Further specialization of the different units and integration of the

closed, half-open and open phases

a.douwesdekker@tactus.nl

m.vankoot@tactus.nl