Forensic psychiatric hospitals¶
Eighty ‘forensic psychiatric hospitals’ (Maßregelvollzug) admit individuals who have committed offences and require compulsory treatment. The number of places varies between Länder. Forensic psychiatric hospitals may be part of a hospital complex, for example, in Dortmund and Rostock. The regional health ministries administer them. In the Land of Mecklenburg-Western Pomerania, the security of these facilities falls under the responsibility of the Ministry of Justice.
Forensic psychiatric hospitals can admit patients before their judgment. The court may order temporary detention if it deems the measure necessary for public safety. Following judgment, the court can impose a treatment order measure in the same facility.
Some facilities have a contract with a prison to admit prisoners in case of a mental crisis; this is the case for the forensic psychiatric hospitals in Rostock, Schleswig-Holstein, Saarland, and Bremen.
Some facilities only admit individuals subjected to treatment orders for mental disorder. Others also admit prisoners undergoing compulsory treatment for addiction. The forensic psychiatric hospital in Rostock, previously specialised in the treatment of substance abuse, now has 20 places for people suffering from mental illness.
Their legal objective is to provide adequate treatment for the individual’s mental disorder, thereby reducing the risk of reoffence. However, when treatment orders have been imposed in recent years, security seems to have taken precedence over a successful treatment.
Transfer. Individuals may be transferred to a forensic psychiatric hospital several months after the transfer decision due to a lack of beds. The Grünstadt facility rarely admits women due to a lack of space and considers mixed-sex services unsuitable.
Placement duration. The duration of stay in a forensic psychiatric hospital depends on the Länder. The CPT reported that the average is over nine years in Brandenburg, while it is three years in Wasserburg.
Measure review. The forensic psychiatric hospital team reviews the prisoner’s individual plan every six months. If treatment is successful, the court re-examines the placement measure.
Placement review is legally stipulated every three years before the sentence enforcement court. An expert evaluates the improvement of the person’s mental state. The measure comes to an end if the criteria justifying placement are no longer met.
Only a heightened risk of reoffending can provoke an extension of the measure beyond six years. It can also be extended past ten years if the court considers the patient to be at risk of committing a crime.
Prisoners can appeal the placement decision. The procedure is similar to the appeal process for a prison sentence.
The hospitalisation conditions must lay the ground work for the patient’s reintroduction into everyday society. The rooms are either single or double, and there are numerous common areas.
The care team may decide on access to work if it is considered beneficial; professional training is offered. Prisoners can work outside in internships. The Land of North Rhine-Westphalia specifies that living conditions in the forensic psychiatric hospital must be similar to those outside.
Patients’ freedom may be restricted if it is essential to preventing serious danger. These may apply to visits, phone calls, or access to activities.
Forensic psychiatric hospitals can hire security guards. This practice varies between Länder. In most facilities, the surveillance staff exclusively monitors the building exterior. At the Rostock forensic hospital, the windows are equipped with bars, and the facility does not have a watchtower.
The physician can decide on solitary confinement and mechanical or chemical restraint. In Bavaria, Brandenburg and Berlin, this measure aims to prevent the risk of assault. The CPT has noted that physical restraint generally occurs without monitoring by health care staff.
Court-approved mechanical restraint cannot last longer than 24 hours in Bavaria. In North Rhine-Westphalia, court action is only necessary after 72 hours of restraint.
The CPT reported several abuse cases at the Brandenburg forensic psychiatric hospital. One person was subjected to restraint measures more than 50 times in one year, or 700 hours. Handcuffs are used in the beginning or even for the duration of the measure. This practice violates CPT recommendations advising the use of padded fabric straps. The NPM reported that mechanical restraint may have exceeded 800 hours per year, and the periods of solitary confinement lasted up to one year.
The CPT has noted that in most Länder, disciplinary sanctions may be imposed on patients, which it notes is not the case in other European countries.
Disciplinary sanctions vary according to the Länder. In Bavaria patients may be deprived of walks, television, or radio for a week. They can be excluded from group activities or work for a month.
The CPT reported that in Saxony-Anhalt, forensic psychiatric patients can be confined in their room, for up to four weeks, as a disciplinary sanction.
An individual treatment plan is developed for each patient based on their illness and can include pharmacotherapy or psychotherapy. The CPT reported that in Wasserburg, the care team often draws up individual treatment plans without consulting the patients concerned. Group, sports, and education therapies are routinely offered. ‘De-escalation’ techniques and nonviolent communication workshops are also available. In Rostock individual therapy is scheduled once a week in addition to group therapy.
Substitution therapy is available for drug-dependent individuals. Specific programmes are scheduled for patients who have committed sex offences. In Rostock a programme for violent offenders is being implemented. The CPT has noted that patients at Brandenburg hospital who have committed violent sex offences are subject to anti-androgen treatment (chemical castration). It has reported on the absence of the required written proof of consent. Several patients have spoken out about physician pressure to accept these treatments. Surgical castration is legally possible for sex offenders, but it was not practised between 2013 and 2015.
Recourse to involuntary treatment varies according to the Länder, but generally, it requires the authorisation of a judge. In Bavaria, the patient must give written consent for the treatment, except in emergency cases. Involuntary anti-androgen treatment must be subject to court order.
In North Rhine-Westphalia, endangerment of the patient or another’s life justifies involuntary treatment.
In Mecklenburg-Western Pomerania, the court provides for a maximum duration of involuntary treatment. These measures are rare and often reserved for those suffering from a psychotic disorder who present a risk to others.
The CPT has expressed reservations regarding the informed consent process of patients who must undergo anti-androgen therapy at Brandenburg prison. Some people have testified to the use of threats in cases of treatment refusal.
Healthcare staff training Upon being hired, the healthcare staff takes a training course on how to deal with forensic patients. This includes classes on therapeutic treatment and behavioural disorders, as well as law classes.
Several Länder require the staff to take a training course once a year on restraint measures and mental health crisis management.
Security staff training The forensic psychiatric hospitals can hire security guards, depending on the Länder. In most facilities, the security staff exclusively monitors the building exterior.
Continuity of treatment¶
Prisoners are subject to social and legal monitoring upon their release. Various social workers meet with the medical team to prepare for release.
Patients from some forensic psychiatric hospitals may be placed in a residential centre for several years, where they receive ambulatory treatment.
The Berlin ‘forensic ambulatory therapy clinic’ (FTA) admits outgoing patients from forensic psychiatric hospitals identified as liable to commit violent or sex offences.
Psychiatric units of forensic hospitals¶
Five forensic hospitals have psychiatric units (APP). The Länder introduced these units to address the lack of mental health care in prison and the lack of space in psychiatric hospitals. They report to the regional Ministry of Justice.
The Grünstadt prison hospital medical team is employed by the prison administration. These employees, nurses by profession, take a six-month training course for prison guards.
The APPs admit prisoners if they can provide more appropriate treatment. In practice, they admit prisoners who require full hospitalisation due to a severe mental health disorder or heightened suicide risk. The APPs refuse to admit women.
Individual consent is necessary to enter an APP. In some cases, the teams strongly insist or place the person in a security cell until they accept the hospitalisation measure. The court does not intervene at any point in the process; the prison hospital physicians decide the patient’s fate. The Grünstadt APP medical team visits the prisons each week to identify prisoners who require hospitalisation.
There is no recourse to appeal against an APP placement.
In the Grünstadt APP, prisoners receive therapy. They benefit from common activities, such as watching television. Hospital vocabulary is highly present, with references to ‘rooms’, ‘patients’, and ‘therapeutic activities.’ Patients only have free time in the morning.
Placement in solitary confinement is subject to the same rules as in standard hospital departments.
The Grünstadt APP medical team has developed an individual treatment project. Heavy neuroleptic treatments are often administered. Several group therapy sessions are offered, such as ‘psychoeducation’ for schizophrenic patients.
Group therapy sessions are organised for drug-dependent individuals at the Berlin APP.
Involuntary treatment, including pharmacotherapy, is possible under judicial supervision if the patient seems highly aggressive.
Psychiatric departments of forensic hospitals exclusively employ healthcare staff. Nurses take a six-month training course with the prison administration. Healthcare professionals generally receive training in forensic care.
Continuity of treatment¶
The APP contacts external ambulatory care facilities willing to accept the prisoner upon release. A personalised treatment recommendation letter is sent.