Therapie und Therapiebeurteilung als Grundlage juristischer Entscheidungen

The idiosyncratic focus of German legal politics on sexual crimes and the extension of preventive detention has led to an unhoped-for career of the juridical therapy expections of the penal system. The basic justification and necessity of an expansion of “treatment detention” particularly in the therapeutic form will be clarified. People detained under preventive detention are not sick but their disposition to undertake serious crimes can be considered as a condition in need of therapy and nursing. Even the “mental disorder” of the Therapy Detention Act (ThUG) is, according to the author, nothing more than this “disposition” to § 66 of the Penal Code. Of course therapy leads to obviously positive results in only some of the convicted felons but nevertheless it is worth it. The newer form of preventive detention takes over considerable tasks and responsibilies from the never realized social therapeutic mental institution (in the sense of a “reprimand solution”).     

Bedeutung des Intelligenzquotienten für die Feststellung des Eingangsmerkmals Schwachsinn im Sinne der §§ 20, 21 StGB

Disorders in cognitive capacity, as defined in § 20 of the German legal code, are responsible for a relevant proportion of the population sentenced to treatment in forensic psychiatry in Germany. Historically one of the first conditions for diminished culpability, it refers primarily to the level of cognitive functioning. In routine psychiatric treatment of people with intellectual disability other aspects, such as emotional and social development became more and more relevant. This article explains that these aspect should be more involved in the process of forensic assessment or at least give rise to discussion and makes proposals for a modification of exculpation criteria due to the German legal code.     

Die Entwicklung der Rechtsprechung zur nachträglichen Sicherungsverwahrung seit 2006

Since 2006, the development of the jurisdiction concerning the subsequent preventive detention has kept the continuity of the first decisions by the German Federal Supreme Court. An imprisonment according to the new law standards was decreed only in a few cases. The legislator’s attempts to enlarge its use by introduction of § 66b I 2 German penal code in substance were ineffective, because both the German Federal Supreme Court and the Federal Constitutional Court has viewed the law as constitutional, only, if its use is limited to a few “extreme cases”. Further difficulties appeared by the injunction of the subsequent preventive detention due to an acquittal statement of a hospital order treatment. At this some questions still remain unanswered.     

Entwicklung und Stand des psychiatrischen Maßregelvollzugs (§ 63 StGB)

Psychiatric forensic commitment is at the interface between psychiatry and criminal justice. Both fields are subject to societal and political influences, which are not to be underestimated and have undergone many changes since the introduction of the catalogue of penal measures in 1933. This article provides a summarizing overview of the development of psychiatric penal measures in the 8 decades since its inception. The various developmental phases are chonologically presented and analyzed, in some cases with reference to the international situation. The main transition is the change from custodial detention up to modern treatment enforcement, even if many different factors influence the certainly to be strived for further development. Finally, the complex topics of “forensic psychiatry and the public” as well as the influence of the media on this aspect are briefly discussed.     

Schematherapie bei antisozialem Verhalten und Psychopathie

In the Netherlands schema therapy is the first evidence-based treatment to be recommended for patients with personality disorders in forensic settings. Initial results show that schema therapy can even be effective in cases of “psychopathy”. The central concept in schema therapy are schema modes which can also be seen as emotional states or “parts of the personality”, which dominate temporary thoughts, emotions and behavior. Schema modes are the basis of individual mode models, which guide understanding and treatment of the disorder throughout the complete therapy. The schema therapeutic analysis of delinquency is part of the schema mode model and connects the sequences of the crime with the offender’s schema modes. With respect to the mode treatment, emotion-focused techniques and the therapeutic relationship are of special importance. The schema therapeutic treatment plan combines short-term behavior-related therapeutic goals with the underlying themes (needs and modes) in order to plan concrete interventions based on this. This has to be embedded into the individual structure of therapeutic options in the respective institutions (e.?g. individual psychotherapy, nursing staff, occupational therapy). This article demonstrates the practice of the schema therapeutic approach with a forensic case study and discusses resources and limits of the schema therapeutic approach in a forensic setting.     

Sind Körperpsychotherapeuten anders?

Following the “Generic Model of Psychotherapy” differences of treatment models are relevant with respect to optimal matching with patient's illness experience.Therefore it seems necessary to work out differences and similarities of treatment models.The results of 91 therapists, trained in Concentrative Movement Therapy (KBT), in the “Development of Psychotherapist Common Core Questionnaire (DPCCQ)” are compared to the therapists' results in other DPCCQ-studies, to find out,wether there are differences in therapeutic self concepts (theoretical orientation, therapeutic goals and attitudes). A few special features for KBT-therapists can be found which reflect characteristic aspects of the method.Despite some differences concerning socio-demographic characteristics (sex, age and basic professional education) similarities to other therapists predominate.     

Wie glaubhaft sind die Angaben von ehemaligen Maßregelvollzugspatienten zu ihrem poststationären Verlauf?

This article presents the results of the posttreatment course of ex-patients in forensic commitment. The various data sources are compared with respect to the main focal points. In the Regensburg study design the main attention is focused on the reports of ex-patients themselves because this has some advantages, especially with respect to a high number of those willing to participate. The results were compared with the data obtained from third party observers, mostly probation officials and with entries from the Federal central register (BZR). The results show generally a good agreement which, however, seems to be particularly associated with the quality of the therapeutic relationship. Ex-patients admitted under § 64 (addictive patients) whose treatment was discontinued showed the lowest agreement by far whereas the agreement was much higher for successfully treated patients admitted under § 63 (mentally ill) and § 64. In total it can be assumed that certain conditions a survey of the patients themselves delivers completely reliable results under and on the other hand that BZR entries do not per se have a higher element of truth.     

Glücksspielsucht in der Rechtsprechung des Bundesgerichtshofs

Among the non-substance-related addictions, pathological gambling is the only one that has gained noteworthy forensic relevance. There are numerous parallels to substance-related addictions and not only in the symptomatology. A high proportion of pathological gamblers commit criminal offences to enable them to continue gambling or to pay gambling debts. According to the jurisdiction of the Federal Court of Justice (BGH) pathological gambling in itself cannot be considered as a pathological mental disorder or other serious mental abnormality that substantially diminishes the responsibility of the offender (German Penal Code § 21 StGB); however, the BGH recognizes that in serious cases of pathological gambling mental changes and personality defects can evolve that show similar structure and severity to substance-related addictions and severe withdrawal symptoms might also develop. As with substance-related addictions a substantial diminution of the offender’s responsibility can be assumed, therefore, also with pathological gambling if it has led to most severe personality changes or if the offender suffered from severe withdrawal symptoms while committing an addiction-related crime. According to these criteria a substantial diminution of the offender’s responsibility can be stated only in very rare cases. A custodial addiction treatment order (§ 64 StGB), which is also possible for fully responsible delinquents, is not applicable to cases of mere pathological gambling because the order requires an addiction to alcohol or other drugs. A mental hospital commitment order (§ 63 StGB) can be issued by the court under the same strict conditions that are applied to cases of substance-related addictions. Based on these principles this can only be issued if the defendant is addicted to gambling due to a mental defect that can be distinguished from the addiction itself or if the dependence has already been manifested in very severe personality changes. Pathological gambling can cause a propensity to commit serious offences and therefore, under the further conditions of §§ 66, 66a StGB justify detention for the purpose of incapacitation or a deferred incapacitation order. Even during imprisonment, detainees must be offered a suitable therapy (§ 66c para 2 StGB); however, penitentiaries do not offer the best environment for the treatment of pathological gamblers. The treatment in an addiction therapeutic setting appears to be more promising. Criminal political demands to make custodial addiction treatment orders also applicable to pathological gamblers have, however, very little chance of success.     

Rule-following as coordination: a game-theoretic approach

Famously, Kripke has argued that the central portion of the Philosophical Investigations describes both a skeptical paradox and its skeptical solution. Solving the paradox involves the element of the community, which determines correctness conditions for rule-following behavior. What do such conditions precisely consist of? Is it accurate to say that there is no fact to the matter of rule following? How are the correctness conditions sustained in the community? My answers to these questions revolve around the idea (cf. P.I. §§198, 199) that a rule is followed insofar as a convention is in place. In particular, I consider the game-theoretic definition of convention offered by David Lewis and I show that it illuminates essential aspects of the communitarian understanding of rule-following. Make the following experiment: say “It’s cold here” and mean “It’s warm here”. Can you do it? Ludwig Wittgenstein, Philosophical Investigations, 1953, §510. I can’t say “it’s cold here” and mean “it’s warm here”—at least, not without a little help from my friends. David Lewis, Convention.      

The discrimination of structure in vectorgraphs: Local and global effects

Many recent electrophysiological studies have demonstrated specificity for orientation and position tuning in single units of the visual system. Psychophysical investigations have produced complementary evidence for orientation and position coding in vision which is usually interpreted in terms of the underlying neuronal properties. To date, no studies have endeavored to relate such “local” receptive field response profiles to more “global” or field-specific aspects of the input signal. In a series of experiments, we have investigated orientation/position sensitivity as a function of general orientation and position rules governing line element, or “vectorgraph,” displays. We have discovered with such vectorgraph images that individual element acuities are determined by the field structures present. These results show that there are specific “top-down” components even to basic orientation/position coding in the visual system     

The psychodynamics of forensic mental health nursing

Abstract

The aim of this paper is to clarify some important interpersonal dynamics that underpin forensic patients’ presentations within the clinical environment, in a way that is accessible to nurses. The world of forensic mental health nursing is often difficult to describe to those who have not experienced first hand prolonged clinical contact with patients at the therapeutic interface of secure services. Even then, the characteristic, intense emotional phenomena that tend to arise out of interpersonal relationships with patients and colleagues is not easy to articulate. Yet, for those of us who consider our professional identity to be one of “forensic mental health nurse,” it seems important to find a way to put words to what appears to occupy a large component of our working lives. More importantly, if we can develop a way to make sense of the way our work makes us feel and the way we can find ourselves relating to others within our professional roles, we will be in a better position to harness our energy and enthusiasm in the service of supporting forensic patients towards effective care and treatment pathways. Of course, forensic patients are supported through services with or without a framework for articulating emotional and interpersonal experiences. However, this frequently occurs in the context of significant struggle. For patients, this struggle is often characterized by difficulty communicating what their needs are, and for nurses this struggle is often characterized by feeling emotionally overwhelmed by their task of providing containing, therapeutic relationships for patients whose interpersonal needs are not clear to them. This article will use case examples to describe some of the complex interpersonal and emotional challenges faced by forensic nurses, and explain how a psychodynamic framework could support nursing practice in each of the case examples.     

Umgang mit gefährlichen Straftätern in England und Wales

Forensic psychiatric institutions exist in all western European countries. Their organisation depends on a number of factors including the legal framework and societal attitudes towards mentally disordered offenders. This article describes and critically comments on the forensic psychiatric system in England and Wales, its legal framework and approaches to dealing with dangerous offenders. England and Wales have a long forensic psychiatric tradition with the first high security hospital, Broadmoor hospital, having been established in 1863. Evidence-based treatment approaches in forensic hospitals as well as in prisons, training of forensic psychiatrists and research in the field of forensic psychiatry have gained international recognition. However, there are some worrying aspects in the system of forensic psychiatric care and the criminal justice system more generally, in particular the high and still increasing number of prisoners in comparison with other European countries, the low age of criminal responsibility, long sentences, increasing length of stay in forensic care and the increasingly risk averse culture. A number of differences to the German system can be found; one such difference relates to the role of criminal responsibility which is irrelevant for decisions regarding commitment in England and Wales. Only the mental state and need for treatment at the time of trial (or later assessment in prison) determine whether an offender is admitted to psychiatric care or receives a prison sentence. A number of new initiatives have been launched in recent years resulting in an increasing number of individuals being detained in forensic psychiatric and criminal justice institutions, in particular the initiative for the detention and treatment of individuals with so-called dangerous and severe personality disorders, the sexual offenders register and the new sentence of indeterminate imprisonment for public protection. These initiatives have been the subject of a number of complaints to the European Court of Human Rights. Nevertheless, the trend towards a more and more risk averse culture continues.     

Eltern und Patienten als Subjekt der Behandlung

Background

There are hardly any alternatives to inpatient treatment for children and adolescents in need of intensive psychiatric treatment. In the randomized study BeZuHG (“behandelt zu Hause gesund werden”, treated at home become healthy), equality of treatments could be shown in the outcome parameters when comparing TAU (inpatient treatment) and the new treatment module BeZuHG (early discharge followed by intensive home treatment enhanced by clinical elements). Patient satisfaction with each treatment module was evaluated at follow-up.

Material and methods

In this study 144 parents and patients of the intervention group (n?=?79) and the control-group (n?=?65) were interviewed after an average of 8 months. Information on expectations, experience with BeZuHG, changes in communication and interaction within the family as well as problem solving strategies (and sustainability of the changes), overall satisfaction and treatment suggestions for modification of the BeZuHG treatment were collected in semistructured telephone interviews.

Results

The following aspects in the BeZuHG treatment were rated as important by parents and patients: support and help with transfer problems, single sessions, a trusting therapeutic relationship as well as treatment setting at home. Enhanced problem solving skills as well as improved family communication were noticed. In the intervention group 70?% would prefer the BeZuHG setting to inpatient care and 46?% in the control group.

Conclusion

The BeZuHG concept is a good and functional alternative to inpatient treatment. Continuity in treatment and therapeutic relationships are essential for successful treatment at home. Positive treatment results within the family as well as the patient remain stable at follow-up after 8 months.     

Therapieverläufe von Sexualstraftätern

Throughout the past decades evaluation studies on sexual offender treatment have led to controversies. While numerous studies examined the effectiveness of different interventions, the possible underlying mediating mechanisms have largely been neglected. This study took a multimethod approach to investigate the measurability of change processes in sexual offenders serving a sentence in the social therapeutic institution (SothA) of the detention center in Tegel, Germany (n?=?105). A longitudinal design with three groups (i.e. waiting group, treatment group and day release group) from four perspectives on change processes (i.e. external criminal prognostic assessment, therapists’ view, staff observation and clients’ perspective) was employed. Most criminal prognostic risk and protective factors improved over the course of treatment and this effect was smallest in the waiting group. While therapists reported increased therapeutic constraints in the course of treatment, they were more favorable in the criminal prognosis and detected more differentiated patterns of needs and resources of clients as conceptualized by the primary and secondary assets of the good lives model (GLM). In contrast, during the course of treatment the sexual offenders showed an increased awareness of the criminogenically relevant problems in the sexual domain. Nonetheless, the overall number of problems they identified as criminogenically relevant decreased. The internal problem attribution in the sense of internal causes (“It is my fault”) and capability of change (“Only I can solve the problem”) was increased. The stronger the clients’ perception of own problems in the sexual context increased over the course of treatment, the more positive the change in the staff’s view of their behavior became and the more their dynamic risk factors improved. Overall, this study found strong evidence that change processes in SothA might already be detectable during ongoing social treatment. It is currently uncertain whether these changes influence future recidivism. A comparison with recidivism data is necessary and in planning.     

Respect in Mengzi as a Concern-based Construal: How It Is Different from Desire and Behavioral Disposition

Previous scholars seem to assume that Mengzi’s 孟子 four sprouts are more or less homogeneous in nature, and the four sprouts are often viewed as some sort of desires for or instinctive inclinations toward virtues or virtuous acts. For example, Angus Graham interprets sìduān 四端 as “incipient moral impulses” to do what is morally good or right, or “spontaneous inclinations” toward virtues or moral good. However, this view is incompatible with the recently proposed more sound views that regard Mengzi’s four sprouts as a particular type of emotions or feelings having some “cognitive” or “rational” aspects. In this essay I develop this new approach to Mengzi’s four sprouts, and specifically argue that respect in Mengzi should be considered neither as a moral desire nor as a behavioral tendency to do deferential acts but as some sort of ethical sensibility that is responsive to the relevant features of a worthy person.     

L’intelligence artificielle peut-elle aider à estimer le risque de récidive dans les comportements violents ?

In forensic psychiatry, magistrates raise the question of the existence of a risk of recidivism and dangerousness to psychiatric experts. Follow-up studies in forensic psychiatry showed that the psychiatric elements predictive of recidivism were mainly related to serious mental illnesses, toxic consumption, addictions, high levels of impulsivity, low insight, associated personality disorders, in particular antisocial personality disorders. There are also protective factors, in particular the observance of treatments. Given the complexity of psychiatric and criminological risk factors and protection, can artificial intelligence (AI) help psychiatrists and magistrates to improve the predictivity of recidivism?MethodsSystematic review of the literature on AI applications in the prediction of recidivism in forensic psychiatry, conducted according to PRISMA criteria, using the: “Artificial Intelligence”, “Recidivism”, “Personality Disorder”, “Impulsive” Behavior”, “Alcohol abuse”, “Drug Abuse”, “Schizophrenia”, “Bipolar disorder” on the PubMed, Science Direct, Clinical Trial and Google Scholar databases.ResultsThe vast majority of studies come from legal or computer reviews and very few from medical databases. The studies evaluating the AI in Forensic Psychiatry most often used Machine Learning based on sociodemographic, sociological and criminological data, notably the age of the first offense and the number of previous convictions. To date, there are very few studies evaluating psychiatric parameters, focusing on psychopathic personality disorders.Discussion/conclusionThe applications of the AI in Forensic Psychiatry are still very premature. However, some psychiatric criteria should be more prominent in this field, especially those from Webster's HCR-20 and Hare PCL-R scales. The challenge will also be to find relevant behavioral, psychological and psychiatric keywords to include in AI.     

Psychoanalysis: Practical and Research Aspects by Willi Hoffer

The outcome of clients who saw one of four “expert” professional group therapists selected by peer nomination or four “natural helper” nonprofessionals nominated by students is contrasted in a 15-session psychotherapy group. Process measures tapping specific group and “common factors” were drawn from sessions 3, 8, and 14; outcome was assessed at pre-, mid-, posttreatment, and a 6-month follow-up. Results were examined by leader condition (professional vs. nonprofessional therapists) and time (group development). Virtually no reliable differences were found on measures of outcome primarily because of a floor effect on several measures. Therapist differences on the process measures tapping the “common factors” of therapeutic alliance, client expectancy, and perception of therapists were either nonsignificant or disappeared by the end of treatment. A complex picture of differences on one therapeutic factor (insight), common factor measures, and subtle variation in the outcome data suggests a distinct pattern of change, however. Methodological limitations are also addressed including problems inherent in large-scale clinical-trial studies, ethical concerns raised by using nonprofessional leaders, and problems with generalizability, given the absence of significant psychopathology in group members.