Outpatient treatment of mentally disordered offenders in Austria.

The mental health system is faced with a growing number of MDOs with treatment orders. For more than 90% of our sample of 157 discharged irresponsible MDOs a mandatory outpatient treatment was ordered. Considering the fact that half of these patients are transferred after discharge to institutions like psychiatric hospitals or nursing homes (Leygraf, 1988), institutional as well as outpatient treatment options are needed (Silver & Tellefsen, 1991). Within the Austrian mental health system here is an enormous lack of post-discharge treatment facilities for forensic patients (Meise, Rossler, & Hinterhuber, 1994). Furthermore, the existing structures obviously do not meet the special needs of forensic patients. Although this point of view is shared by the psychiatric hospitals and their contentment with the settings for forensic outpatient treatment was low, only one hospital intended conceptional change and modifications. Facing the reality that the same psychiatric hospital authorities complained that they could not release MDOs from an inpatient status because of inappropriate outpatient facilities, the responsibility for forensic patients seems to be projected from the medical to the legal system. This can be seen as a symptom of the tendency to a step wise and long-standing exile of forensic patients from the mental health system. Actually, forensic patients were for various reasons refused by mental health professionals and could not get psychotherapy, medication or adequate psychosocial care. A possible answer to these problems is to establish institutionalized outpatient facilities in the "hybrid" gap between the legal and mental health system (Lamb, Weinberger, & Gross, 1988). The new outpatient clinic in Vienna deals with rejected treatment-order patients, most of them with additional treatment problems such as impulsivity, substance abuse, and mental impairment (Cote & Hodgins, 1990). The special structure of the institution (i.e., a multiprofessional team that offers a wide and easily accessible spectrum of interventions, the realization of individual treatment programs with psychotherapeutic and psychosocial as well as biological aspects, and the long-term personal continuity of care by staff members with forensic psychiatric skills) promoted the experience that after some time half of the patients came on a voluntary basis (Fenell, 1992; Winick, 1994). Some pressure by the court was an efficient way to guarantee regular treatment for patients with personality disorders and perversions. The model of a special, structured, multiprofessional outpatient clinic is successful, but the role of such complementary pilot institutions is ambiguous. Simultaneously, the deficit of adequate outpatient care for MDOs has to be opposed by stopping the unacceptable withdrawal of general psychiatry from the forensic sector.

[Discharge of incompetent mentally abnormal criminals: experience from the Austrian central treatment institution]. / Die Entlassung von zurechnungsunfähigen geistig abnormen Rechtsbrechern: Erfahrungen aus Osterreichs zentraler Behandlungsinstitution.

Based on the data of 66 male patients not guilty for reason of insanity, who were treated in Justizanstalt Göllersdorf, Austria's central institution for mentally ill offenders, we examined the influence of age, duration of detention, diagnosis, and offence on discharge. Law provides a yearly, compulsory examination of the necessity of further inpatient-treatment. We also tried to describe a concept of further dangerousness (considered to be the essential basis for the decision of possible discharge) in a four-factor-model including the criteria psychopathology, insight, conflict behaviour, and social competence. Concerning the various levels of decision finding (institution, expert, court) different interpretations of these criteria could be demonstrated. Independent of diagnostic and prognostic considerations the court stressed mainly kind of offence as the most important factor for the possibility of discharge.