May 27, 2026 · 7 min read
When the kindest treatment lands as the coldest
Autonomy-promoting policy (autonomiebevorderend beleid, also called hoogrisicobeleid) is a deliberately designed treatment for a very small group, on the order of 0.5 to 3 people per 100,000 residents a year (Michiels et al., 2024), living with complex, chronic suicidality for whom repeated forced crisis admissions can escalate harm rather than contain it. In the summer of 2024 the Dutch patient platform MIND opened a meldpunt about how that policy is carried out and collected 126 reports across 25 institutions, analysed by Bureau Lenz and published 4 December 2024. The reports describe, as lived experience, care that landed as cold, as over-demanding, as confirmation of feeling worthless, and that in cases did not reduce suicidality and was felt to intensify it. This is not how GGZ treats everyone and it is not what therapists do. It is one specific policy, and the people it was built for are the ones who described the cold. The article holds both truths: a treatment can be evidence-reasoned on paper and felt as abandonment in the room.
May 27, 2026 · 6 min read
The patient did not leave. The system let go.
In Dutch mental health care, an ending is not always the patient drifting off. The system terminates the relationship through structurally different mechanisms: a patient refused entry for being "too complex" after a long wait; a short-term trajectory that closes at a by-design 8 to 12 sessions; a financing ceiling that, while it was live, stopped treatment for 33% of affected people in the GGZ and blocked new care for 69%; and disputed discharges a tribunal sometimes judged careless, including one referral made without asking the patient. The financing cutoff is now being dismantled for independent practices. What stays is the question of how an ending is done, because a cold ending compounds the wound and a warm one does not.
May 27, 2026 · 6 min read
For an expat, finding therapy in the Netherlands is a lottery, not a referral
For an internationally-mobile patient in the Netherlands, getting into therapy is structured less like a referral than like a lottery. Three draws stack up before care begins: which huisarts you register with, since reimbursed GGZ care needs a written GP referral (Rijksoverheid); whether your language is ever treated as a matching field, which it usually is not; and whether you can read a credential system where the generic title psycholoog has not been protected since 1993, while gezondheidszorgpsycholoog and psychotherapeut are protected and registered under the Wet BIG (Psychologen Amsterdam; BIG-register, 350,000+ professionals). On 1 January 2025, 16.8% of the population, more than 3 million people, were born abroad (CBS). The lived expat wait runs anywhere from about six weeks to over a year, as expats report it, never a measured national average. And the evidence that documents the barrier comes from English-language forums and expat press, which over-represent higher-resource expats, so the people hit hardest are the least visible in it. "We offer English" is the most misleading promise in the system, because offering English at intake and providing continuous English-language care are two different things.
May 27, 2026 · 6 min read
A therapist may always listen. The wall families hit is a habit wearing a legal costume
A relative calls about a loved one in care and hears "I can't tell you anything, it's confidential." Confidentiality is real, but it is a one-way duty: it governs what a clinician may share with a family, and says nothing about what a clinician may hear from one. The sector's own bodies say so plainly. Ypsilon: much more is permitted than what you often hear in the ggz. The Akwa quality standard treats involving relatives as the recommended norm. Roughly one in six Dutch informal carers now looks after someone with a psychological problem, up from one in eight five years earlier (SCP, 2020), and carers of people with mental-health problems are far likelier to feel heavily overburdened, 34% against 19% for carers overall. The only statutory family advocate exists solely for compulsory care, so the relatives of the voluntary majority have none.
May 27, 2026 · 5 min read
The first contact that never happens
The unanswered phone, the email that goes nowhere, "van het kastje naar de muur." That layer is real, but there is no Dutch figure for it; it lives as testimony, not statistic. The hard number sits one notch up, at the first conversation that never gets booked. The NZa shows 67% of intake-appointment waits breach the four-week norm, and 72,443 of 108,878 ggz waiting positions are people still waiting to be seen for the first time (NZa, 2025). The regulator has said plainly that during that wait no one owns the patient (IGJ, 2023), and the GP becomes the holding pen, with 93% reporting few or no options to refer (LHV, 2025). For someone who took weeks to work up the courage to ask, an unanswered first contact is not a delay. It is the door closing at the moment of most need.
May 27, 2026 · 5 min read
The molecule was probably right. The conversation was missing.
A patient who says they were "drugged into silence" sounds like they are arguing against the medication. The Dutch evidence reads it differently. In primary care, 94.6% of antidepressant use was in line with the NHG guideline (Piek et al., 2011), which forecloses the over-prescription story before it starts. What is documented as the problem sits around the prescription, not inside it: in a 326,025-patient cohort, of those on four or more prescriptions in the first year, 42% were still being prescribed antidepressants in every one of the five years studied (Verhaak et al., 2019), with the authors noting that proactive medication reviews grow sparser the longer the prescription runs; an institute monitoring prescribing found antidepressants used longer than recommended in 40 to 50% of users and called on prescribers to discuss the intended duration at the start (IVM); and a patient panel of more than 750 people found roughly two of three do not co-decide on their own diagnosis and treatment (MIND), against a standard of care that names the patient as the expert on their own experience. The complaint is rarely about the molecule. It is about being prescribed instead of being heard.
May 27, 2026 · 6 min read
Every room belongs to someone. The space between them belongs to no one.
Van het kastje naar de muur is not a service failure. It is the predictable output of a system where nobody is assigned to own the person between rooms. The Inspectorate found providers made insufficient agreements about who is responsible while a client is on a waiting list. The State 2025 IBO calls the system onhoudbaar and names versnippering across four separate laws as a core cause. And the GP, the one fixed point, has become an involuntary holding pen: 93% of GPs say they can barely refer to specialist GGZ, and they spend around 3.7 hours a week on bridge care outside their remit. Every hop restarts because every room belongs to someone else, and the seams belong to no one.
May 27, 2026 · 5 min read
The patient is the one person in the room with no vote on their own care
Shared decision-making is a defined, four-step clinical standard (Stiggelbout, 2015; Elwyn, 2017) and a decade-long national project in the Netherlands. The field's own senior researchers concluded in 2022 that the gains are real but uneven, and that the standard has not reached all patients. MIND's established position puts a number on who is left out: more than two in three ggz clients report no clear agreement on their own diagnosis and treatment, and more than 60% were never told a decision needed making. The patient is the one person in the room with no vote on their own care, and the data the field collects on itself says so.
May 27, 2026 · 5 min read
The five-star ghost
On the national client-experience index, the dimension closest to being treated as a person, bejegening en serieus nemen, scores 4.8 out of 5, near the ceiling. But the CQi is filled in after the treatment trajectory ends, so it surveys the finishers. The person who felt like a number and stopped showing up, the one never admitted, is structurally outside the frame. Satisfaction surveys over-represent the satisfied: in one peer-reviewed study only 16.5% responded, and responders differed systematically from those who stayed silent. So 4.8 and niet gehoord, niet gezien are not a contradiction. They are two instruments pointed at two different people.
May 26, 2026 · 8 min read
The waiting list is the part of the illness nobody counts
The wait between asking for help and receiving it is administered as a neutral queue, an "in progress" on a form. The evidence reads it differently. Longer waits for early psychosis care tracked worse 12-month outcomes (Reichert & Jacobs, 2018), and a network meta-analysis found being placed on a waitlist did worse than no treatment at all, with disappointment proposed as the mechanism (Furukawa et al., 2014). After referral, disengagement is a risk marker, not passivity: patients with mental-health conditions who missed more than two appointments a year had an 8.37-fold higher mortality (McQueenie et al., 2019), and reaching psychiatric care within seven days of a suicide attempt was associated with roughly half the reattempt risk (Kim et al., 2022). All of it observational, all caveated by its authors. In the Netherlands, 108,878 ggz waiting positions stood open in October 2024 (NZa, 2025). The wait is the least-counted stretch of the illness.
May 25, 2026 · 6 min read
The signal that tells you if your work is landing is the one you can't see
The therapeutic alliance predicts outcome at r = .278 across 295 studies, the strongest within-therapy signal we have for whether the work is reaching this particular patient. Yet 19.7% of patients leave early, and 93% have lied to their therapist at least once. The rupture in the alliance is detectable in principle, trained observers coding recordings agree on it at ICC .85 to .98, and invisible in the moment, where therapist and patient agree on the bond at only r = .36. The signal of whether your work is landing is the one you can least see while you are doing it.
May 25, 2026 · 7 min read
The hardest thing a therapist remembers is who everyone is
A patient says "and then Mark said..." and the therapist does a silent lookup: Mark, the brother or the manager? Working memory holds about three to five meaningful items at once, not the famous seven, and a single patient's relational cast routinely runs past that. Patients themselves recall only about a third of what a session covered, therapist caseload has a small but real effect on outcome across 18,322 clients, and Dutch mental health clinicians lose roughly a third of their time to administration. The cost of all that bookkeeping is presence, the active ingredient of the work. The field already solved the storage problem by hand, with the family map, decades ago.
May 25, 2026 · 6 min read
The therapist who holds everyone in her head
Dutch mental health care held 101,134 waiting spots in October 2025, with the average wait at 24 weeks, and the clinicians already inside carry the overflow. Working memory holds three to five things at once, while a full caseload is twenty or thirty people, each with a history to reload before the hour starts. The cost is not only the therapist's exhaustion. In one study, patients of burned-out therapists reached meaningful improvement 28.3% of the time against 36.8% for the rest, 37% lower odds. The load is invisible, and it reaches the chair across the desk.
May 25, 2026 · 6 min read
The therapist is the last to know the last session was the last
Of 100 people who contact a mental health clinic, fewer than 17 are still in therapy by session 10, and between 20% and 57% who attend a first session never come back for a second. The dropout research suggests therapists often feel the drift but stay silent. 76% sense a client is leaving; only 23% say a word. The patient walks out without a closing session, and the one window for repair shuts before anyone opens it.
May 25, 2026 · 6 min read
The gap between two therapists is where the patient is quietly lost
A referred patient waits weeks between one therapist and the next, and many do not arrive. Studies have long found that of 100 people who contact a clinic, only about 33 reach a first therapy session; baseline premature termination sits at 19.7%; and when the therapist changes, dropout in one inpatient sample rose from 7.1% to 40.4%. In the Netherlands, 108,878 waiting spots stood open in October 2024, with 67% past the intake norm and an average 28-week wait for personality disorders. The structured transfer leaves no lasting symptom mark, but the recovery window is real, and the dropout that happens inside it is the part nobody counts.