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ANALYSIS AND COMMENTARY |
Dr. Trestman is Professor, Departments of Medicine and Psychiatry, University of Connecticut Health Center, Farmington, CT. Dr. Eucker is Chief Psychologist, Haina Forensic Psychiatric Hospital (Giessen Branch), Giessen, Germany. Dr. Müller-Isberner is Medical Director, Haina Forensic Psychiatric Hospital, Haina, Germany. Address correspondence to: Robert L. Trestman, MD, PhD, Departments of Medicine and Psychiatry, University of Connecticut Health Center, 263 Farmington Avenue, Farmington CT 06030-1410. E-mail: trestman{at}uchc.edu
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Abstract |
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 Top Abstract The LawsPretrial Assessment of...Pretrial Risk Assessment and...Correctional FacilitiesCurrent TreatmentCurrent and Proposed ResearchTransition to the Community:...ConclusionsReferences |
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The Laws |
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TopAbstractThe LawsPretrial Assessment of...Pretrial Risk Assessment and...Correctional FacilitiesCurrent TreatmentCurrent and Proposed ResearchTransition to the Community:...ConclusionsReferences |
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In the correctional system, federal laws are also the basis for processes related to treatment and prisoners' rights and responsibilities. As a consequence of a current federalism reform, German states are expected to have more influence on the law of prison administration in the years ahead.
By contrast, the legal foundations of treatment during court-mandated forensic hospital treatment (hospital-order sentence) are already in the domain of state law. Generally, state laws define patients' rights and clinicians' authority and responsibilities. State law also regulates the conditions under which clinicians can gradually return the patient to the community. These laws vary considerably among the 16 German states. Recently, in response to public pressure, some states have shifted responsibility for decisions about release from a secure inpatient setting away from clinicians to prosecutors and to the courts.
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Pretrial Assessment of Responsibility |
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Pretrial Risk Assessment and Assignment |
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Offenders judged NGRI or guilty but having severely diminished responsibility for an offense punishable by incarceration may receive a hospital-order sentence in the forensic psychiatric system if their risk of re-offending is high. In all other cases, the offenders are allocated to the correctional system.
A hospital-order sentence is unlimited in time. Annual reassessments are required by the court. The federal court (Bundesgerichtshof; BGH) restricts the application of hospital-order treatment to those offenders whose criminal acts are symptomatic of the mental disorder.6 The expert witness typically declares the offense to be in a causal relationship to the mental disorder that was assessed as being present at the time of the offense. This assertion is often made and accepted by the court, whether or not causality is, in truth, a reasonable assertion. In this context, when the expert report is read, a co-occurring diagnosis of an antisocial personality disorder is not included in the diagnostic summary even though all criteria are present and described in the report. Hospital-order patients receive a conditional discharge when "it can be expected that no further offenses will be committed" (Ref. 3, 
67, paragraph d). The patient is then on probation. However, probation is revoked if the patient:
... commits a crime during the period of probation, contravenes persistently or considerably the probation order, escapes persistently from the probation officer or the probation service, or during the period of probation it becomes evident, that criminal acts are to be expected because of the individual's mental state [Ref. 3,Offenders judged to be guilty but with severely diminished responsibility typically receive a dual sentence of both a determinate prison term and indeterminate treatment in a forensic hospital. The time spent in the forensic psychiatric hospital is subtracted from the total sentence. Usually, when the court orders a conditional discharge from the forensic hospital, the remaining time of the prison sentence that has not yet been served is served on probation status.
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Correctional Facilities |
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65 StGB was canceled and replaced by a penal system protocol.8 Consenting prisoners could be assigned to an STI if their rehabilitation would benefit from the special methods of social-therapeutic treatment, but there was no claim to treatment in the general correctional system anymore. The law regarding mental treatment of prisoners changed again in 1998. After passionate public discussion of several spectacular sexual offenses, a bill to combat sexual offenses and other dangerous offenses was passed. In addition to the existing regulations, sex offenders with a prison term longer than two years have to be committed to a social therapeutic unit.8 Consequent to this amendment, the number of social therapeutic units has increased from 20 in 19979 to 45 in 2005, with a total of 1,829 individuals in such treatment locations.10
While most individuals in the prison-based STIs have committed sex crimes, one of the defining characteristics of these offenders is the presence of a personality disorder. It should be noted that the treatment programs to date generally are not developed for the treatment of personality disorders, per se. Rather, there is an acknowledgment that the presence of a personality disorder typically complicates treatment and makes functional improvement more difficult. In general, the goal of treatment is limited to risk reduction.
In parallel with these changes, the conditions for early discharge from prison changed as well.3,11 For an offender to be eligible for conditional discharge from prison, a determination must be made that there is no further risk of dangerousness or re-offense. An expert risk assessment became necessary for all cases of a conditional discharge.
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Current Treatment |
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Given these many differences, no general picture can be provided. Instead, we will describe the treatment of personality-disordered offenders in the one forensic hospital and the correctional facilities in the German state of Hessen with a population of approximately 6 million.
Hospital-Order Treatment
The Haina Forensic Psychiatric Hospital treats all mentally disordered offenders who receive hospital orders in the state of Hessen. It has 440 beds distributed in 25 wards and a staff of approximately 600 people, including psychiatrists, psychologists, social workers, work therapists, teachers, and nurses.
Fully one-third of the patients in the hospital have a primary diagnosis of a personality disorder. An additional 25 percent of the patients present with co-occurring anti-social personality disorder. As is typical in many countries, most of the patients with a primary or secondary personality disorder diagnosis have a history of substance abuse or dependence. They tend to have poor social skills, weak socialization, a history of psychiatric problems, and a long history of criminal justice problems. Most of them have a lifestyle conducive to deviant behavior, have a poor prognosis, and are at high risk of recidivism.
Treatment is intended to reduce the risk of re-offending. That context leads to a multimodal approach that addresses the full range of impairments that are potentially changeable and related to criminal behavior. Until the middle of the 1980s, treatment was based entirely on a medical model. By the end of the 1980s, however, this treatment model was replaced by a pragmatic, multimodal approach to reduce dangerousness by neutralizing, compensating, reducing, or eliminating factors that increase the risk of violence and crime. Antisocial acting out is viewed as a learned behavior. The individual's personality and factors outside the individual (but associated with the criminal act) have gained weight in the treatment approach. Special consideration is given to problematic use of addictive substances, antisocial personality traits, a criminal identity and a history of living in antisocial environments.
In the 1990s, an evidence-based treatment paradigm gained strength. To improve our treatment attempts with personality-disordered offenders we began to introduce offender treatment components from multimodal cognitive-behavioral programs, based on the principles of risk, need and responsivity, and reduction of recidivism. In 1998, 22 clinicians of the hospital were trained in the Reasoning and Rehabilitation Program developed by the Correctional Service of Canada.
Social learning theory continues to provide one of the most generally applicable and theoretically well-grounded bases for offender treatment.12 From that perspective, we began in 1996 to implement cognitive behavioral approaches. This approach now orients our interventions with patients who present with primary and secondary disorders.12
The psychiatric and criminogenic needs identified during assessment are operationalized as treatment targets. For each, an explicit plan specifies how change is to be accomplished. Each goal is in turn broken into a series of manageable steps, enabling the patient to envision how each goal may be achieved.
The risk of re-offending determines the intensity of service. The risk is assessed primarily on an actuarial basis, using reliable and valid instruments (Psychopathy Checklist–Revised [PCL: SV]3; HCR-20 Assessment of Risk of Violence4). Risk assessment is performed annually by using file records, direct patient interviews, review of any changes in dynamic factors, and team discussions.
Main treatment targets include reducing symptoms and modifying antisocial, procriminal values and attitudes, and fostering the development of prosocial peer groups. As approximately 90 percent of Haina patients have a history of violence, our treatment programs focus on management of aggressive behavior. The treatment approach acknowledges the complexity of the task. As individuals respond differently to interventions, the treatment programs take into account the individual patient's impairments. These are, for example, cognitive deficits, co-occurring Axis I and II disorders, and specific criminal behavioral tendencies.
In summary, the main approach in treating offenders with personality disorders focuses on interpersonal skill training and modifying criminal thinking by using cognitive-behavioral techniques. Pharmacological agents are applied in only a few cases. In some cases, selective serotonin reuptake inhibitors or carbamazepine are used in an effort to reduce extreme impulsivity or lack of self control.
Correctional Facilities
On March 31, 2005, Hessen had 4,281 inmates in its prisons. Of those, 2,165 were sentenced to a term longer than 2 years.13 The Hessian Social Therapeutic Unit has only 140 slots, providing only a fraction of the needed treatment capacity. This lack of adequate treatment resources is a consistent problem in other German states, as well.
Criteria for offender assignment to the Hessian Social Therapeutic Unit (STU) include high risk of re-offending (treatment necessity), normal or near-normal intelligence, and sufficient verbal and interpersonal competencies to participate in a language-based treatment.14 Treatment necessity is unfortunately ambiguous. If other existing less-intensive treatment services may be of benefit and can be offered, then the offender is not eligible for the STU. Further, offenders are only eligible if the remaining sentence is longer than 18 months and shorter than 60 months. Some offenders are excluded from treatment because of these time limits. The time required to satisfy the administrative procedures for assignment to the STU can be substantial.
As is typical in the structure of STUs, offenders live together in small groups,10–14 separate from the normal prison environment. Single-person cells, a shared kitchen, and rooms for groups and group meetings, and services for the group are intended to create an environment that serves as an important therapeutic agent.14 Other basic essentials of treatment are attendance at school (if appropriate), work and vocational training, leisure skills training, and extensive discharge planning.
Current Hessian STU treatment is in general consistent with the programming offered in other German states. Group treatment programs include social skills training, empathy training, self-management, and health education. Specialized treatments include a Sex Offender Treatment Program (SOTP) and a subprogram for child molesters. Individual therapy and counseling and addiction treatment are also offered. It is important to note that since the legal amendment of 1998, the programming has changed.15 Evidence-based and -informed offender treatment programs from other countries have been rapidly adopted, often without any training or accreditation procedures.
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Current and Proposed Research |
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Consistent with many other nations, evidence-based structured offender assessment and treatment methods began in Germany in the forensic psychiatric system and only thereafter began in the correctional system. One such example is the Haina Forensic Psychiatric Hospital. Faculty at this hospital have, among other initiatives, translated and implemented the assessment tools PCL-SV,4 HCR-20,5 and Sexual Violence Risk (SVR)-2020 in the early 1990s and translated and implemented the Reasoning and Rehabilitation Program in 1998. The knowledge and expertise gained from these and related experiences have been shared through multiple regional, national, and international workshops and congresses.
Currently, two collaborative international research projects on the treatment of personality-disordered offenders are under way: an adaptation of Dialectical Behavioral Therapy (DBT) to an offender population and an adaptation of the Canadian Reasoning and Rehabilitation Program.
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Transition to the Community: Treatment During Probation |
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With one exception (an outpatient clinic for sex offenders created in 199822), such specialized clinic treatment services for offenders do not exist in the German correctional system. In most cases, similar to the North American model, a personality-disordered offender who receives an order for treatment during probation is committed to an ordinary psychotherapist, and it is a matter of chance whether the psychotherapist is trained and experienced in treating offenders. Funding of the treatment, cooperation, and communication with the legal system and confidentiality are further problems of current practice in the German correctional system. Rarely, there are local networks or incorporated societies for aftercare or probationary treatment composed of psychotherapists working with offenders, probation officers, prison employees, and members of the forensic psychiatric aftercare services. These are concerns identical to those concerning the system of care in the United States, where many personality-disordered offenders are ineligible for intensive community-based services.
Against this background, a bill in the German legislature attempting to reform and improve the supervision of psychiatric care for probationers is in discussion. The parallels with unfunded mandates in the United States are striking.
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Conclusions |
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9 Strafvollzugsgesetz
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
