Belgium is a federal state composed of three communities (French, Flemish, and German-speaking) and three regions (Walloon, Flemish, and Brussels-Capital). The Ministry of Justice is responsible for prison administration (DGEPI) and prison healthcare. The regions are autonomous in the management of mental healthcare in prisons and in the psychiatric units of certain general hospitals.

People suffering from mental illness who commit a crime are subject to a psychiatric assessment to determine their criminal responsibility. While awaiting this assessment, they are placed in a special unit of a correctional facility: “psychiatric annexes”.
Persons declared criminally irresponsible are subject to treatment order known as “internment measure.” They can be placed in specific psychiatric facilities for people who have committed a crime: social defence units and sections or forensic psychiatric centres. General psychiatric hospitals may conclude agreements with the Ministry of Justice to admit individuals subjected to an internment measure.
Those found criminally responsible are placed in correctional facilities. Prison psychiatric annexes temporarily house prisoners who require care. In fact, the latter may be held there for long periods. Many people suffering from mental illness are held under the ordinary prison regime.

The European Court of Human Rights (ECHR) regularly condemns Belgium for its management of psychiatric annexes and lengths of internment measures. The ECHR considers the following structural problems: the lack of separation between prisoners subjected to an internment measure and ordinary prisoners, overcrowding, insufficient staff, and lack of care. It calls for the reorganisation of the forensic mental healthcare system.

In April 2019, a study estimated that 37% of Flanders prisoners suffered from severe mental illness. In 2016, psychotropic drug prescriptions accounted for over 43% of prescriptions.

Designated units called “psychiatric annexes” receive remand prisoners awaiting their psychiatric assessment, persons declared not criminally responsible awaiting their transfer to a specific facility, and prisoners who require mental health care. Even though these annexes are designed to accommodate people temporarily, the average length of stay is two to four years. Some individuals subjected to an internment measure are placed there permanently if no specific facility can accommodate them.

A psychiatric annex system is like that of ordinary detention. The same disciplinary procedure applies. The European Committee for the Prevention of Torture (CPT) reported the placement of prisoners in solitary confinement or “punishment cells” for medical and disciplinary reasons. The CPT “has serious reservations about the use of isolation as disciplinary protocol against people with mental illness” and finds no therapeutic justification for it. The ECHR has repeatedly condemned Belgium¹ for its management of psychiatric annexes. It considers overcrowding and the lack of care inhumane and degrading. Some people under an internment measure are held under ordinary prison regime due to lack of space. Cohabitation between them and other prisoners has been described as difficult.
Female prisoners do not have access to psychiatric annexes; they must remain in ordinary prison regimes. The Social Defence Section (section de défense sociale, SDS) of the Bruges prison, intended for people under internment measure, can accommodate women with mental illness.  

Access to mental healthcare  ¶

A medical examination must be carried out no later than 24 hours after prison admission. The doctor must inform the prison psychiatrist if they detect mental illness. The CPT noted that nurses often take care of the examination, and the consultation with a general practitioner is organised a few days later. The interview consists of a quick visual check and some questions.
Delays to medical consultation vary between facilities. People detained at Lantin prison wait three months for psychological care. In Ittre, this timeline is at least eight to nine months.

Provision of mental health treatment¶

Psychological care is generally limited to medication. The provision of psychotherapeutic care has been deemed insufficient. Psychiatric care at the correctional facility in Ittre is limited to the most severe cases. Prisoners with mild mental illness are only followed up through rehabilitation projects. Some facilities offer programmes to improve prisoners’ mental health. Some associations offer psychotherapeutic activities.

Prisoners in psychiatric annexes have access to therapy, medication, and crisis support. They also receive individual and group therapy and socio-administrative support. Care is generally limited to pharmacology treatment, and psychotherapy is rare. The CPT noted the inadequate support and care provided to individuals under an internment measure and pointed out the lack of individual treatment plans for these patients. The CPT observed the suspension of psychotherapeutic activities at the psychiatric annex in Lantin due to a lack of healthcare and supervision staff.

The CPT reported that psychologists and care teams cannot access the psychiatric annex of Jamioulx prison when strikes occur. It expressed its concerns about the increased dosage of medication during such events. This protocol, determined by doctors, aims to compensate for the absence of healthcare professionals.

People with substance abuse problems can access substitution treatment and benefit from psychological consultations provided by external organisations. ”Drug-free sections” exist in Hasselt’s and Bruges’ prisons, where prisoners are placed at their request. There, they receive psychological support. Therapeutic group activities and individual follow-ups are provided in Hasselt’s facility. People with severe mental illness are not eligible.

Medical staff¶

Each correctional facility has a “psychosocial service.” It must consist of psychiatrists, psychologists, and social workers.
The CPT observed a lack of care staff. At Leuze-en-Hainaut’s and Arlon’s facilities, psychiatric consultations are limited to six hours per week. The Arlon Prison psychologist is rarely present and there is no associated psychiatrist. A psychiatrist from another facility visits occasionally.

No doctors are on call at night. This is also the case for the medical staff in most facilities. Doctors can sometimes be reached by phone.

All correctional facilities with a psychiatric annex must have a healthcare team. In theory, it consists of a psychiatrist, a psychologist, and psychiatric nurses. Social workers, occupational therapists, and educators are also involved. The CPT reported that care teams in each visited facility are incomplete. For 12 hours a week, only one psychiatrist provides consultations for all prisoners in Lantin prison. Every position for psychologist, educator, and occupational therapist is vacant.

Medical confidentiality ¶

Prisoners can file written consultation requests and post them in closed mailboxes. The healthcare staff is in charge of treating those demands. Incarcerated people can also express their wish to see a physician orally to the prison staff. It is mandatory to provide a reason for the request in some facilities.
Prison guards are not expected to be present during consultations unless the patient is very aggressive. In most cases, however, psychiatrists require their presence.

The CPT reported that medical examinations carried out in solitary confinement or punishment cells are systematically conducted in the presence of the prison staff. Some interviews are carried out through the entrance gate or the cell door. Other breaches of medical confidentiality were reported, particularly during consultations outside the prison and in the multi-bed medical rooms.

External pharmacies usually prepare the medication. Healthcare staff and prison officers complete this in the evenings and on weekends. In almost half of the correctional facilities, guards distribute the medication. This is also the case in psychiatric annexes.
Nearly 60 % of incarcerated people were prescribed at least one psychotropic drug in 2016. Some guards do not comply with medical prescriptions.

Emergency measures ¶

People in a state of mental crisis may be subject to a doctor-ordered “security measure.” They are usually placed in isolation in a security cell or under mechanical or chemical restraint. The prison administration may also place the person in crisis in solitary confinement or in a “punishment” cell. The CPT reported the case of one prisoner who was kept completely naked for several days in a “punishment” cell.
Prisoners in crisis are transferred to a psychiatric hospital when the prison cannot provide the necessary care. Psychiatric hospitals generally refuse to accept people from psychiatric annexes.

Non-consensual care protocols should only be applied in emergencies and must be in the best interest of patients. Medication without consent is possible when the person is in a state of psychological crisis, with the authorisation of two doctors. Sometimes, a “special intervention team,” equipped with helmets and protective shields, intervene to restrain the patient. The CPT observed the case of a team immobilising a patient on his back in the Saint-Gilles prison so that the nursing staff could carry out a forced injection. It considered these means of restraint as inappropriate.

Prison officer training¶

Prison officers) must undergo a six-day training course on mental illness. Those in the psychiatric annexes must follow specific training. The CPT reported that none of them have benefited from such training.
In September 2017, the ECHR criticised the lack of prison officer training in the case of Tekin v. Belgium. One of the officers involved in the case had not received any training in working with mentally ill persons.

Continuity of treatment¶

The prison’s “psychosocial service” must draw up a reintegration plan, and the patient’s medical file is sent to the facility that provides the treatment. Psychiatrists from different facilities can exchange information about patients.
Psychiatric hospitals are generally reluctant to the idea of receiving individuals subjected to an internment measure.
The Flemish region’s service “Guidance and Registration after Detention and More” (Orientation et enregistrement après la détention et plus encore, TANDEM) provides a reintegration plan for prisoners with mental illness. Liaison services in some facilities refer released prisoners to external care services with the aim to facilitate their reintegration.

Admission¶

The “Social Protection Chamber” (Chambre de protection sociale, CPS) places some individuals subjected to an internment measure in psychiatric hospitals. Their consent is required. Psychiatric hospitals that do not have a placement agreement can refuse them; this is generally the case, as these patients are considered too dangerous.
Prisoners usually wait a long time for their transfer to a psychiatric hospital in the psychiatric annex of a correctional facility.
Psychiatric hospitals admit individuals subjected to an internment measure in the event of a release on probation (libération à l’essai). Transfers to psychiatric facilities are also possible in the case of a particularly severe psychological crisis.

Transfers from prison¶

Psychiatric hospitals receive prisoners suffering from a particularly severe mental crisis and people released on parole. Their consent is required.
Psychiatric hospitals set their admission criteria, and transfer delays to psychiatric hospitals for prisoners in crisis are generally long.

Daily life¶

Some hospitals have specific units for prisoners who suffer from mental illness or individuals subjected to an internment measure. “Medium risk” units are dedicated to people under an internment measure. The “forensic medium risk” unit of the Sint-Kamillus psychiatric hospital specialises in the treatment of personality and psychotic disorders. Incarcerated people can be placed with other patients. The “neuropsychiatric centre” (centre neuropsychiatrique, CNP) in Saint Martin has two designated beds for individuals subjected to an internment measure.

A psychiatric hospital that receives prisoners should be considered a “branch of the correctional facility.” Prison regime applies, except for those on release on probation (libération à l’essai).
The hospital care staff provide supervision. The CPT reported that prisoners are usually handcuffed to their hospital beds and calls for an end to this practice.

Continuity of treatment¶

Saint-Martin’s CNP offers daytime hospitalisation one to three times per week for prisoners leaving the psychiatric hospital.

Individuals who have committed offences and have been found not criminally responsible are subject to treatment order known as internment. This measure of “social defence” aims ─according to Article 2 of the 5 May 2014 law─ to “protect society and ensure that the interned person receives the care required by their condition with the aim of reintegration into society”. The safety of society takes, however, precedence over the reintegration perspective.
A court can impose an internment measure on a person declared not criminally responsible. The CPS is responsible for the placement of individuals subjected to this measure, which can be imposed at any time during the criminal justice process. The person’s consent is not required. The CPS can commute a prison sentence into a care measure at the request of the prison administration and after receiving the opinion of a psychiatrist. The CPS is responsible for the execution of this procedure.

Transfer. Transfer delays to specific facilities are usually long. People can wait up to two years to enter the Paifve Social Defence Facility (établissement de défense sociale, EDS). While awaiting transfer, prisoners remain in psychiatric annexes.

Placement duration. The length of placement depends on the facility. The Paifve EDS holds individuals subjected to an internment measure for an average of seven years. The CPT observed the case of one person placed in 1977, who was still present in 2017. It reported that interned patients stay longer due to the lack of space in other psychiatric facilities. This situation hinders the admission of new patients. The average duration of the placement at Tournai psychiatric hospital is eight years.

Measure review. The CPS is responsible for the measure review, which is done at the patient’s request or by court order. The CPS can adapt the execution conditions according to the patient’s health improvement. It may grant “limited detention” to allow the patient to leave the facility for up to 16 hours a day. Release on probation or early release may also be granted when the mental illness “is sufficiently stabilised so that there is no longer any risk of a recurrence of personal injury.” In general, the CPS grants few release measures to sexual offenders.

Individuals subjected to internment measure may appeal against it to the “Indictment Division” (Chambre des mises en accusation) within 30 days of the decision. If a prisoner is subject to an internment measure, they can appeal against it before the Court of Appeal within 15 days of being notified of the decision.

In principle, individuals subjected to an internment measure are placed in specific facilities. There are three types of facilities.

Social defence facilities and sections (EDS and SDS)¶

There are seven social defence facilities and sections. The Paifve EDS is exclusively reserved for individuals subjected to an internment measure and is under the responsibility of the prison administration. The correctional facilities of Antwerp, Merksplas, Turnhout, and Bruges each have an SDS on their premises. The SDS in Bruges is the only one designated for women.

Daily life¶

EDS function similarly to psychiatric annexes. Prison officers supervise most patients. The CPT reported that security logic marks their care. It observed the absence of any appropriate therapeutic or occupational activities at Paifve’s EDS. The high rate of officer absenteeism limits the activities offered. People placed in this facility have limited access to showers. Room doors are generally open during the day, except for patients considered difficult.

All patients are generally entitled to a one-hour walk per day. They may be placed in seclusion for disciplinary and medical reasons. Isolation for disciplinary reasons takes place in the patient’s room, whereas medical isolation takes place in solitary confinement. Medical isolation must be ordered by the psychiatrist. The CPT found no therapeutic justification for disciplinary isolation.

The CPT reported that patients are handcuffed during their transfer to solitary confinement, and sometimes during the isolation measure at the Bruges’ SDS. It reported a lack of justification in some cases.

Treatment plans¶

Patients in Paifve’s EDS have access to a psychiatrist every four to six weeks. Psychiatrists intervene mainly in emergencies, and psychologists conduct most follow-ups. The nursing staff is absent in the evening and on weekends.

The CPT reported that the medical records included no individual treatment plans. Group and occupational therapy are held irregularly; medication remains the primary treatment. Families are not kept informed about the progress and follow-up of their relative at Paifve’s EDS. Little contact is possible with health professionals.

Three SDSs provide a “specific programme for individuals with mental illness subjected to an internment measure;” this is conducted by professionals external to the prison system. Three psychiatrists oversee the SDS in Bruges as well as the whole correctional facility.

Training¶

Prison guards at Paifve’s EDS receive no specific training. They do not have first aid training either.
The law provides for specific training for prison guards working in SDS. None of them have received this training.

Continuity of treatment¶

Continuity of treatment is similar for all individuals subjected to an internment measure, regardless of the facility.
Projects entitled “Care journeys for interned patients” (Trajets de soins pour patients internés, TSI) are being developed in Brussels and Wallonia to ensure continuity of care and promote reintegration. A care protocol is possible in psychiatric facilities or on an outpatient basis. The healthcare teams set up a “care network” with the designated facility, and a coordinator ensures continuity of relations in both medical and judicial terms.
A specialised “outreach” team at the Sint-Kamillus hospital follows up on discharged patients.

Forensic psychiatric centres (centres de psychiatrie légale, CPL)¶

There are two forensic psychiatric centres, in Ghent and Antwerp. This type of facility only accommodates individuals subjected to an internment measure. The prison administration manages security and infrastructure, and the Ministry of Health oversees healthcare.
Three new CPLs have been announced in Aalst, Wavre, and Paifve, with no planned date.

Daily life¶

The patient’s “care journey” determines the conditions of stay in Ghent’s CPL. The patient is first placed in the “intensive care” unit for observation, then transferred to the “resocialisation” unit, and finally to the “reintegration” unit. This gives the patient increasing autonomy and freedom. Patients in the “intensive care” unit are allowed one hour outside, while those in the “reintegration” unit may go out during the day.
Patients may be placed in solitary confinement or in a “hypostimulation room” as decided by the psychiatrist or psychologist. The CPT reported that the reasons for such placements were not clearly justified. A caregiver visits patients every hour. The CPT noted the consequent length of the placements: 22 days for the “hypostimulation rooms” and 44 days for solitary confinement.

Treatment plans¶

Pharmacological treatments and therapies are offered. The CPT reported cases of over-medication at Ghent’s CPL. It observed the case of one patient who was subjected to seven different medications with occasional very high dosages. Patients consult a psychiatrist at least once a month. Their situation is reassessed every six months.

Training¶

Healthcare staff training. The healthcare staff of Ghent’s CPL undergo a five-day training course on patient violence management. Some caregivers have special training in isolation placement.

Prison officer training. Ghent’s CPL surveillance staff is only responsible for external security.

General contractual psychiatric hospitals¶

The State concludes agreements with general psychiatric hospitals to accommodate individuals subjected to an internment measure; the CPS decides on such placement. Five psychiatric hospitals have a specific unit for these patients. The “Long Stay” unit in Aalst hospital is expected to open in 2022. All the facilities are under the authority of the Ministry of Health.

Daily life¶

In Tournai, patients remain in a secure unit of the psychiatric hospital. They are first received at the “admission” unit and then transferred to different units depending on their pathology. Patients can move around freely and usually have a key to their room. There is an activity room in each unit. Patients have access to artistic and outdoor activities and can work externally via company contracts.

Treatment plans¶

Tournai hospital’s therapy offer focuses on the prevention of recidivism. Talking groups on different themes are organised. The “Épicéa” project, intended for sexual offenders, is run by a multidisciplinary care team composed of two psychologists, an educator, an occupational therapist, a social worker, two nurses; a psychiatrist is in charge. The treatment of patients in the Sint-Kamillus hospital mainly centres on living conditions and environment.

Training¶

The Sint-Kamillus hospital does not hire any supervisory staff.