Semi state-led
rehabilitation of torture
survivors:
The Dutch experiences
B. Drožđek, psychiatrist
Psychotrauma Centrum Zuid Nederland/Reinier van Arkel
group
Den Bosch, The Netherlands
Torture survivors in the Netherlands
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Asylum seekers
Refugees
Illegal immigrants
Dutch Army UN soldiers (POW)
Survivors of Japanese concentration camps
(WW II)
Seeking asylum in the Netherlands?
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2002:
2005:
2013:
83.000
30.000
14.800
Due to restrictive governmemnt policy!
At the cost of human rights and international
standards and conventions?
Voices of survivors
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“I was tortured in my home country, but this is
worse! In the Netherlands, I am tortured with
documents, letters, and endless waiting for legal
recognition. They do not trust my story, they
want more and more proofs of what I have been
through in the past. As if I had time to plan my
departure!”
Voices of survivors
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“While I have been tortured in my home country, the
worst was waiting for physical torture to take place,
sitting in my prison cell and listening to sounds. Here, I
wait for years in my tiny room in a reception centre, I
can’t work, they do not allow me to learn the language,
I have nothing to do, but to wait …. for the next letter
by immigration authorities, next call for the court. On
Tuesdays, police enters the centre, and takes people
away to repatriate them. Noises again, crying, violence,
I can not stand this any more!”
Procedure of seeking asylum
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Lasts for many years
No right to work
No right to learn the Dutch language
Limited access to community
Social marginalization
Restricted access to medical services
Waiting in passivity!
Population of illegals is growing
Let’s shorten the length of an asylum
procedure!
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Shorter asylum procedure (8 days) – superficial?
Asylum seekers/torture victims disappear –
illegality, closed repatriation centres
Many doubts with regard to interview
techniques (suggestibility, insensitivity, rules of
conduct)
Commentary on the sixth periodic report on the implementation of
the UN Convention Against
Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment (May, 2013)
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Fast 8-days asylum procedure (6-days rest prior, lawyer
contact only once prior to hearing, hearings on days 1
and 3 – not enough for complex cases and children,
documentation must be presented within a week time,
submission of additional information restricted, initial
health check insufficient for determining torture
sequelae
No data on accepted asylum applications on grounds of
torture (not registered)
Illegal migrants detention limitless (de facto 18
months), and high rates for EU
Commentary on the sixth periodic report on the implementation of
the UN Convention Against
Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment (May, 2013)
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Lack of implementation of the Istanbul Protocol
(denying causality between torture and MH
problems)
Criminalization and humiliation in aliens’
detention – handcuffs, and strip search on
entering/re-entering, isolation of hunger strikers
No transfer of medical data upon
release/continuity of care endangered
Rehabilitation of torture survivors in
the Netherlands
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Screening by medical staff within reception centres(staff
employed by COA/immigration sevices), very limited
opportunities for psychosocial rehabilitation within
centres, legal services insured by government
Referral to standard Dutch mental health facility
Referral to specialized trauma treatment centres (3) for
outpatient and clinical treatment
Pitfalls of the current approach
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Lack of knowledge on torture sequelae, lack of trust in
“trauma narratives”, screening and recognition
compromised, limited resources for empowermentoriented activities in the centres and community
building
Restrictive criteria for referral from reception centres
(government and insurance company)
Policy of making the stay in the country as unpleasant
as possible, but within confines of international
regulations
Pitfalls of the current approach
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Medicalisation of problems (recognition based
on psychopathology, not on torture,
humanitarian vs. political solution)
Stepped care instead of matched care –
undertreatment
Holistic approach in a compartmentalized
overall system (communication between IND,
medical advisors to IND, mental health services)
Pitfalls of the current approach
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No care at all, and just a limited cure!
In the context of a country with highly
developed mental health services for PTSD and
related problems, and influential scientific
production
Paralysis of knowledge by policy!
New organization of mental health
services for asylum seekers
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3 specialized 3rd line mental health treatment centres
organize the system of care:
offer treatment for the most complex cases,
consultation to the 2nd line (culture-sensitive,
contextual diagnostics)
education of the 1st line – screening and signaling
choose a set of screening instruments
Limit number of 2nd line mental health partners, but
improve their knowledge
Focus on community care in reception centres (is there
a community? Can culture be changed?)
System of mental health care for asylum seekers in the Netherlands
Complexity
Specialization
Costs
3rd Line
*supraregional
*specialist care
referrals
educationcation
2nd Line
*regional MH care
referrals
1st Line
*within reception centres
*cure (diagnosis, medication, symptomatic treatment)
*prevention (psycho-education, courses, empowerment)
1st line and prevention
*easy access, outreaching
*cure (family doctor, social work)
*prevention (reception centre staff)
Universal prevention
*Material (money, food, housing)
*Social (activities, school, safety, social support)
*Legal (asylum procedure)
With regard to the implementation of
article 14 as of rehabilitation
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Torture victims are not adequately assessed and
recognized among asylum seekers
Medical professionals are employed by immigration
authorities
Social rehabilitation is marginalized
Legal system works against!
Compartmentalisation paralyses holistic rehabilitation
Efforts to make it comprehensive (holistic) only at the
top medical/psychological level in the chain of care
Refugees/torture victims have no right to use free
interpreters
The cross-cutting issues
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Availability: yes, but problems with adequate
identification and referrals
Appropriateness: comprehensive, but only at
the top level of national centres; enough choice,
needs not structurally evaluated
Accessibility: open, safe, but sometimes
unreachable; State agents disable recovery
environment