Rising inpatient numbers in forensic security hospitals of German federal state of Baden-Württemberg: Background and explanatory approaches

In this article, we describe critical epidemiological trends in forensic psychiatric care in the German federal state of Baden-Württemberg. For some years, there has been a marked increase in the number of patients with psychoses and with a migration background in the high-security hospitals of Baden-Württemberg. We present a number of studies exploring hypotheses as to why this is the case. Taking into account a set of person-related and non-person (forensic system)-related variables, we suggest that rising treatment figures may be understood in terms of system variables rather than individual patient characteristics. Findings regarding predictors of treatment length and legal outcome, as well as characteristics of migrant patients and patients assigned to forensic aftercare, are discussed.     

Mindeststandards forensischer Nachsorge

In 2007 forensic aftercare was integrated into the German Penal Code as part of legal supervision. Since then a large and growing number of patients have been supervised by forensic psychiatric aftercare units throughout Germany. Forensic psychiatric aftercare appears to be very successful as measured by the relapse rates in delinquency. Nevertheless, only very little has been considered about which standards have contributed to and are indispensable for this success. This article presents the quality criteria which are the basis for a successful aftercare and outlines the minimum standards for the equipment and therapeutic approach and in combination with this forms the framework for an appropriate reporting system.     

Qualitätskriterien forensischer Ambulanzen des Strafvollzugs

In 2007 the legal reform concerning the supervision of conduct established forensic aftercare as mandatory for patients released from forensic commitment hospitals and offenders released from penitentiaries. Therefore, in the past 10 years forensic outpatient departments have evolved all over Germany in a state-specific manner according to the legal mandate of treating and managing released offenders. Some of these outpatient departments were newly founded and some were long established units for treating and managing offenders that expanded their services for offenders under supervision of conduct. During the past years these heterogeneous outpatient departments have formed a federal network targeting professional exchange, commonalities, discrepancies and distinct characteristics in realizing the legal mandate. Following the debate on minimum requirements in forensic psychiatric aftercare departments of forensic commitment hospitals in 2014, this federal network developed quality criteria. Despite diverse state and trusteeship-specific conditions, these quality criteria emphasize common content and formal factors for a successful forensic outpatient treatment. This article presents the result of a discussion process along with the agreed quality criteria in the categories of the quality of structure, process and results.     

Gemeinsame Entwicklung,unterschiedliche Inzidenz

Background

In order to understand the increasing numbers of detentions of forensic inpatients according to § 63 StGB (German Penal Code), the development of the sentences for forensic treatment is of great importance. The overall development over a longer time period, such as a breakdown by individual federal states may reflect changes in diagnostic and legal actions.

Method

According to the information supplied by the research data center of Germany (Forschungsdatenzentrum der Länder), the total number of detentions for forensic treatment from 1995 to 2009 for an average population number of 68.6 million inhabitants and the development of different characteristics (e.g. sociodemographic, crime-related) were identified during the investigation period. A total of12,063 records each with 9 attributes were evaluated.

Results

The number of detentions for forensic treatment increased by approximately half (47?%) during the study period. The patients who were not criminally responsible and the proportion of moderately severe offences (e.g. assault, arson and other violent crimes) increased over the investigation period. In contrast, the proportion of completed homicides and sexual crimes decreased as well as the number of previous and concurrent convictions. These developments showed similar tendencies in the individual federal states.     

Schizophrene Patienten der forensischen Psychiatrie im Vergleich zu schizophrenen Patienten der Allgemeinpsychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Some researchers assume that these forensic patients form a group of patients with very complex mental disorders, a number of risk factors and insufficient pretreatment in general psychiatry. This study aimed to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples included 72 male patients from forensic wards and 72 male patients from general psychiatric institutions diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as outpatient psychiatrists and patients’ legal custodians and by analyzing patient medical records.

Results

In contrast to the general psychiatric patients, prior to admission forensic patients were less integrated into psychiatric care and showed a lower rate of treatment compliance. They also showed a higher rate of previous compulsory treatment because of aggressive behavior towards other persons as well as higher rates of treatment difficulties and violent behavior during previous inpatient treatment. Furthermore, forensic patients had a higher number of previous criminal convictions and had been convicted more often for violent offences. With regard to other relevant risk factors (e.g. comorbid substance abuse disorder, age, education, conduct disorder, antisocial personality disorder, previous exposure to violent and abusive behavior) the two patient groups were, however, comparable.

Conclusions

Regarding schizophrenic patients with comorbid substance abuse disorders, previous violent delinquency and violent behavior during previous inpatient treatment, an intensive outpatient aftercare should be arranged before they are discharged from general psychiatric institutions.     

Zur Gefährlichkeit ehemaliger Patienten des Maßregelvollzugs (§ 63 StGB)

Background

The prediction of dangerousness in mentally ill offenders – and here mainly the issue of safety – is still of primary interest for forensic experts and also the public. The effectiveness of treatment and therefore of the whole German forensic system is generally measured by recidivism rates of this clientele.

Methods

The Essen prospective Multi-Centre Prognosis Study began in 1997, and 23 forensic hospitals in Germany took part. Data of 321 subjects were collected with a follow-up of up to 10 years (mean 7.5 years). This article presents topical recidivism rates.

Results

Currently the general recidivism rate is 31.5% and for severe reoffences 10.3% which is relatively low in comparison to other recent studies.

Conclusions

The rate of general recidivism of forensic patients in Germany has been reduced in the last years while the rate of severe reoffence was constant. In order to reduce the number of reoffences further studies should analyze the forensic aftercare.     

Forensisch-psychiatrische Versorgungsstrukturen in Deutschland: Ein Vergleich zwischen Alten und Neuen Bundesländern

Differences and similarities of the forensic mental health hospitals in the New Federal States (NFS) (former East Germany) and the Old Federal States (OFS) (former West Germany) were assessed. The focus of the study was set on institutional features of these hospitals as well as on characteristics of the detained patients. Data were based on a survey conducted in 2006. Specifically designed questionnaires were sent to the mental health departments of the State Ministries, and to all forensic mental health hospitals (response rates 100% and 62%). The general finding is that structures of forensic mental health services in NFS and OFS, e.g. the number of beds per million inhabitants and institutional features, have become similar since the German reunification. The health staff-patient relation is equal for some professions, whereas for other professions this relation is even better in NFS. Differences exist regarding the forensic mental health law of the Federal States. Moreover, the proportions of some delicts and diagnoses in the detained clientele differ. In NFS, the need for forensic aftercare facilities is even more urgent than in OFS. In both parts of the country there is a need for the development of some aspects of quality assurance for both forensic mental health hospitals as well as governmental institutions. Generally, the evaluation of quality of structures, processes and results is yet impossible for many fields of forensic mental health care, because there is no sufficient data base.     

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.     

Haft- und Therapieerfahrungen der Berliner Sicherungsverwahrten

The current reformation of preventive detention follows legal requirements and is not primarily derived from the treatment needs of inmates. Therefore, a fresh look at those persons who will be subjected to this new treatment is important before any legal provisions are put into practice. What are the individual life and delinquency experiences of inmates, how often, in which way and with which goal was treatment attempted? This article will expand on the current situation in the realization of the new legal standards and will describe first results on core delinquency data of a population study of 76 inmates with preventive detention in Berlin and 44 inmates in other federal states of Germany.     

Forensic follow-up care for outpatients in Germany

Legislation has revived forensic psychotherapy for outpatients in Germany. Since 2007, in almost all 16 federal states of Germany forensic outpatient clinics have been and are being established for criminal and sex offenders who have been released from prison or secure detention under conditions imposed by the court. This paper reviews the consequences of this legislation for forensic outpatients, and will focus on some of the central organisational, institutional and social aspects that stem from the experience of the author. Although the conclusions may not be new, they require repeated reflection and well-considered political commitment.     

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.     

Die Dauer der Unterbringung in der Entziehungsanstalt

In Germany offenders can be sentenced to forensic addiction treatment which is realized in secure mental hospitals (according to section 64 of the German Penal Code). As a rule the persons concerned are transferred to the treatment institution after having served part of their prison sentence. There is an ongoing debate regarding the appropriate length of time of inpatient treatment. The average time in treatment differs considerably between the States of the Federal Republic of Germany and varies from somewhat over 1 year (Bavaria) to more than 2 years (North-Rhine Westphalia). In the trials mandating the treatment order, psychiatric experts are expected to exactly quantify the appropriate time of treatment for a specific person. For a number of reasons this surpasses expert capabilities as there is little empirical evidence regarding the effects of the duration of long-term treatment on outcome criteria, such as relapse or reoffending. This article discusses relevant aspects and suggests a pragmatic way to handle courts’ expectations in these lawsuits.     

Young Offenders with Disabilities: Legal Requirements and Reform Considerations

Delinquency rates have been a persistent concern in the United States with juveniles involved in almost a third of arrests for major crimes in 1993. Further, a disproportionate number of youths incarcerated have a disability. Because youths with disabilities in correctional facilities present legal and educational challenges, we explored the parameters of providing appropriate services based on individual needs. Despite applicable federal legislation, the juvenile correctional system often fails to meet the educational needs of those with disabilities (i.e., some youths are denied special education services, services are often inferior to those provided by public schools, and teachers are often inadequately trained). According to federal legislation, juvenile facilities must observe procedural safeguards afforded to those individuals and provide needed services even for pre trial detainees (services, however, may be balanced against legitimate security concerns). Ultimately, state educational agencies have the responsibility for ensuring that youths with disabilities receive a free appropriate education. Promising practices applicable to all youths may include Positive Peer Culture, aggression replacement training, aftercare programs, and research validated instructional interventions.     

Die Behandlung paraphiler Störungen mit GnRH-Agonisten unter besonderer Berücksichtigung ethischer und rechtlicher Aspekte

Current guidelines recommend the use of antiandrogenic medication in addition to psychotherapeutic procedures in the treatment of patients and sexual offenders with severe paraphilic disorders and a high to very high risk of committing severe sexual offences. This article provides an overview about the current state of research concerning the effectiveness and possible side effects of antiandrogens and discusses the legal and ethical basis of using antiandrogens in the therapy of paraphilic disorders with a focus on gonadotropin-releasing hormone (GnRH) agonists. Meanwhile, a great deal of empirical evidence exists with respect to the effectiveness of GnRH agonists for lowering paraphilic sexual fantasies and behaviors; however, GnRH agonist treatment also still has a risk of mild to severe undesired side effects, e.?g. hypertension, hyperlipidemia, liver damage, bone demineralization and depression. Nevertheless, in German forensic psychiatric institutions a not insignificant proportion of patients are treated with antiandrogens and furthermore, in the last few years treatment with GnRH agonists has become more important. In Germany, GnRH agonists can only be used on a voluntary basis; however, in some European countries and North American states legal statutes for compulsory treatment also exist. This is clearly contrary to the recommendations of current international guidelines. In light of the fact that GnRH agonist treatment could violate basic human rights, the need for an ethically sound approach is even more important in the decision for therapy with GnRH agonists. This article provides some proposals for a treatment approach that is in line with current ethical and legal requirements.     

Essener Evaluation der Unterbringung in der Entziehungsanstalt

Over the past 20 years various studies have yielded findings regarding the treatment of offenders in forensic addiction treatment centers in Germany (section 64 of the Penal Code). For a number of reasons these studies hardly allow quantification of the assessment of the rehabilitative success of treatment. In 2009 the Institute of Forensic Psychiatry at the University of Essen, Germany was commissioned to engage in a long-term evaluation study that will be completed in 2017. The project is supported by the Ministry of Health of the State of North-Rhine Westphalia. The present paper summarizes the methodology of the study and draws up an interim balance of the data collection. The study involves the follow-up of 300 patients from 16 forensic mental hospitals from entry into the institution to discharge and further on to living in the community including a“time at risk of at least 2 years. A number of these patients will drop out of treatment by being sent back to prison. The rate of criminal recidivism in the complete group of subjects will be compared to a matched control group of 300 offenders serving a prison sentence only. Potential error sources related to the data collection are discussed in the paper.     

Subjektive Einschätzung der eigenen Gesundheit und gesundheitsrelevantes Verhalten bei niedergelassenen Psychologischen Psychotherapeuten

From June until August 2004 we asked 488 established psychological psychotherapists in selected German federal states for a subjective evaluation of their own health, their utilization of the health care system and their health-related behavior. It turned out that the psychotherapists mainly reported a good state of health although their reported state of health was more negative than in the general population with equal age and level of education. This finding is surely connected with specific mental, physical and existential burdens of their profession as well as with specifics of the “psychotherapist personality”. The psychotherapists’ evaluations highly depend on age, but not significantly on sociodemographical criteria like gender and place of establishment (East/West Germany). Also the affiliation to a therapy school (psychoanalysis, depth psychological funded psychotherapy, behavior therapy) is irrelevant for the subjective evaluation of one’s own health. Concerning the annual number of consultations and disability days the psychotherapists are clearly below average. They report a lot of attentiveness about their health and practice a health-benefical behavior. In this case they make higher demands on themselves than the general population.     

Kontroverse zu Beschwerdenvalidierungsverfahren bei der Begutachtung psychischer St?rungen

The value of symptom validity tests in a forensic context is currently the subject of a controversial debate in Germany. The discussion primarily focuses on neuropsychological symptom validity tests, however, tests specific for mental disorders are neglected. Unfortunately, no assessment tools for symptom validation of mental disorders of German origin are available and adaptations of available English state of the art instruments have not yet been tested. Further research of assessment development and qualitative analysis of the decision-making process in medicolegal evaluation is needed in German speaking countries.     

Comparison of outcome in men and women after treatment in psychiatric security hospitals in Germany

Previous research has shown that forensic psychiatric treatment reduces reoffending, rehospitalization and premature mortality. Treatment outcome varies with diagnosis, but little is known about the influence of sex, psychosocial adjustment and aftercare. To assess these variables, we interviewed male and female patients discharged from three psychiatric security hospitals in Germany in the years 2010–2017. Participants were interviewed at discharge (n = 609) and 1 year later (n = 366) about reoffending, readmissions, substance use and psychosocial adjustment. Among patients with substance use disorder (SUD), 14% reoffended, 20% were re-hospitalized and 60% maintained abstinence. Among patients with severe mental disorder, 5% reoffended and 13% were re-hospitalized. Significant sex differences were found in offenders with SUD. The results suggest that sociodemographic and disorder-related risk factors are associated with treatment success and that female patients with SUD might need a specific treatment approach. Sex-specific aspects, diagnosis and psychosocial adjustment should be considered in forensic psychiatric treatment and risk assessment.     

Neue Felder in der Operationalisierten Psychodynamischen Diagnostik

After the operationalized psychodynamic diagnostics (OPD) system became well established in clinical as well as research contexts, especially in German speaking countries, the OPD task force now focuses on issues, such as modules and new manuals which are related to various clinical contexts. In this article new modules and manuals are presented and discussed in summarized form: the modules for addiction disorders and for forensic patients, the new OPD-2 manual for children and adolescents, an OPD-based manual for formulating initial assessment reports for insurance companies as well as a conceptualization for an operationalized psychodynamic therapy (OPT).     

Wo steht der Jugendmaßregelvollzug in Deutschland aktuell?

With up to 67% of all young offenders suffering from mental illnesses, the question of how professional care should be arranged for them arises. The ability to detain a young offender for an indefinite period of time in a forensic psychiatric institution represents the final solution in juvenile law. This currently affects approximately 300 patients nationwide, of which there is precise data available only for patients who were detained before the age of 18. This is due to the differing nationwide organisational structures within specific forensic psychiatric institutions for adolescents. There is currently a lack of forensic psychiatric units in several federal states providing treatment for adolescents. When examining under what basis, and when the relocation of a person from a young forensic psychiatric institution into the corresponding adult one occurred, and how long specific pedagogic facilities were provided to these individuals, the differences between various adolescent forensic psychiatric institutions become apparent. This especially concerns young adolescent offenders suffering from delayed mental development.