When the kindest treatment lands as the coldest

A woman whose words ended up in a report once said that during her treatment she had never felt so alone in her life. Not alone the way you feel in an empty house. Alone the way you feel when someone is in the room with you, holding a plan, and the plan is to step back. She was not being neglected. She was being treated, carefully, by people who had thought hard about her, according to a policy with a name and a published rationale. And the treatment, as she lived it, felt like the cold.

I want to be careful here, because the easy version of this story is wrong, and the easy version hurts people. The easy version says a Dutch institution was cold to a suffering patient. The true version is harder, and it is the only one worth telling.

What the policy is, and who it is for

The policy is called autonomiebevorderend beleid, autonomy-promoting policy, sometimes hoogrisicobeleid. It is not how the GGZ treats everyone. It is not what therapists do in a normal week. It is a deliberately designed approach for a very small group of people, on the order of 0.5 to 3 per 100,000 residents a year, who live with complex, chronic suicidality and severe self-harm (Michiels et al., 2024). Hold that number for a second. In a country of seventeen million, that is a few hundred people. The clinicians who built this did not stumble into it. They published their reasoning in a peer-reviewed journal the same year the trouble surfaced.

And the reasoning has a logic you cannot wave away. For this particular group, the default playbook can backfire. Repeated forced admissions, the securing and the controlling, can escalate the harm rather than contain it. So the policy tries something that sounds almost paradoxical: it moves away from beveiligen en beheersen, securing and controlling, toward restoring the person's own agency. As part of that, a clinician may deliberately hand a help-request back to the patient, to break a self-harming pattern and appeal to the person's own capacity to carry it. On paper that is not coldness. On paper that is respect. It is treating someone as an adult who can hold their own life, when the alternative has demonstrably failed them.

So far this is a story about good intentions, well reasoned, aimed at exactly the people the system fails hardest. Why would anyone question it? Because intent is one thing and the felt experience is another, and the two were about to be put side by side. The same patients were asked what it felt like.

What it felt like in the room

In the summer of 2024, the patient platform MIND opened a meldpunt, a reporting point, about how this policy is carried out. It was open from the fifteenth of July to the fifteenth of September. Bureau Lenz analysed what came in and published the report on the fourth of December 2024. The headline number is plain and it is verified across multiple outlets: 126 reports about 25 GGZ institutions. The reports came from clients, from family, and from a few care providers.

Read what those reports describe, in the words the analysis uses. What did the care feel like? Cold? Demanding? Diminishing? Kille bejegening, cold treatment. Bevestiging van het gevoel niets waard te zijn, confirmation of the feeling of being worth nothing. Overvraging, being asked more than a person can carry. And trauma severe enough that some people needed separate therapy afterwards to process the treatment itself. These are not my conclusions. They are reported experience, collected by an advocacy organisation, attributed to the people who lived it. That distinction matters and I will keep it: this is a record of how care was felt, not an outcome study proving what care did.

The hardest finding has to be held the most carefully. The report states that for some, the policy did not reduce suicidality, and was experienced as intensifying it, and that it could not prevent the deaths of some clients. I am going to attribute that exactly: the report documents it as the reported experience of patients and families. Nobody has shown, and I am not saying, that a policy caused those deaths. What the report puts on the record is that the people inside the policy did not feel it working, and some felt it pressing the other way.

So here are two documents, both written in good faith. One explains, with peer-reviewed reasoning, why stepping back can be the kinder act for this small group. The other is the voice of that same small group, saying it landed as being left alone. Which one is true? They both are. That is the entire problem.

The gap nobody is standing in

How does that happen? How does a clinician do something meant as respect, and a patient receive it as abandonment, and both of them be telling the truth? Because intent is not the same thing as how care is received, and the two can drift apart without anyone noticing. The clinician knows the reasoning. The patient knows only the felt experience: the request handed back, the step away, the silence where help used to be. Autonomy and abandonment can look identical from the inside of a hard week. The only place that gap becomes visible is the relationship itself. And the relationship is exactly the thing that gets thin when a policy asks a clinician to step back.

This is not an argument that the policy is wrong, or that its authors were careless. They are named, published professionals working for the patients the rest of the system gave up on. It is an argument that intent does not travel by itself. Somebody has to notice, in time, when care meant as autonomy is being received as cold. If nobody is watching that seam, the gap just widens in the dark, one quiet session at a time, until a person sits across from someone holding a careful plan and thinks the words that anchor this whole report: never have I felt so alone.

What we built for the seam

This is the seam Freudche was built to sit beside, and only this one. Not the policy, not the risk, not the clinical decision. The relationship, where intent and felt experience either stay in contact or quietly come apart.

The feature is called Engagement. It looks back over a patient's own earlier sessions and may surface when their own pattern shifts: shorter answers, less feeling territory, a gentle trend held only against where that same person used to be. It is soft bands, not a score. There is no risk level, no verdict, nothing that reaches toward the clinical judgment that stays entirely with you. What it offers is a chance to notice the cold setting in a little sooner than you might have, while there is still a session left to ask about it. It surfaces what shifted. You read it, you decide what it means, and you carry it into the room. That is the whole of it, and it is enough: a small chance that the gap gets seen while someone is still in the chair.

Because the people this policy was designed for are the ones who described the cold. And how many of them are there? On the order of 0.5 to 3 per 100,000 a year, which means most clinicians will carry only a handful across a whole career. So picture yours. The one or two you will ever sit with. They are also the people for whom being seen, in time, is not a nicety. For them it is the treatment.

If you or someone you are sitting with is in crisis, you do not have to carry it alone. In the Netherlands, 113 Zelfmoordpreventie is free and reachable around the clock at 113.nl or 0800-0113. Anywhere else, findahelpline.com lists a service near you.

Researched by Freudche.