[Professionals' Views On Forensic-Psychiatric Patients With Intellectual Disability: Impact Of Structural, Systemic And Diagnosis-Related Aspects On Treatment And Release]. / Forensisch-psychiatrische Patient*innen mit Intelligenzminderung aus Sicht der Behandler*innen ­ Wie strukturelle, systemische und diagnosebezogene Besonderheiten Behandlung und Entlassung erschweren.

In forensic psychiatric clinics, patients who have committed a criminal offense on the basis of intellectual disability are also treated in according to Sect. 63 of the German Criminal Code. This group of patients has above-average lengths of stay and specific difficulties in treatment and in transition to aftercare systems are reported from practice. The present study is based on a content-analytical evaluation of ten structured interviews with practitioners of different professions who are familiar with the treatment of this patient group in forensic psychiatry. The aim was to identify treatment experiences and challenges of inpatient forensic care for this group as well as needs for change and suggestions for improvement. Respondents confirmed the specific treatment needs and person- and diagnosis-related challenges known from other studies, which were considered to be causally related to prolonged hospital stay and problems at discharge. Numerous structural and systemic barriers were also identified that impede the shortest possible forensic inpatient care and seamless transition to the non-forensic aftercare system. At the structural level, these included the need for human resources (both quantitative and qualitative) and adapted treatment concepts. Professional aftercare was considered very important for this group of patients. In this regard, the non-availability of suitable institutions, long waiting lists and reservations on the part of these institutions towards former forensic patients were identified as problems. The fact that patients with intellectual disability were less able to make their needs known than other patients and thus often received less attention from the treatment providers can be described as a systemic obstacle. This also applies to the rather high demands that the forensic system, with its goal of "improvement" through treatment, also places on people with intellectual disability. The findings of this study can contribute to improvement of the forensic inpatient care of people with intellectual disability at systemic and structural levels.

[What is effective in forensic addiction treatment? A non-systematic look into the evidence base for treatment approaches and interventions in the context of Sect. 64 of the German Criminal Code]. / Was ist wirksam in forensischer Suchtbehandlung? ­ Ein nicht-systematischer Einblick in die Evidenzbasierung von Behandlungsansätzen und Interventionen im Kontext des § 64 StGB.

Forensic addiction treatment according to Section 64 of the German Criminal Code is playing an increasingly important role in the German system of correctional institutions. In recent years, the question of the effectiveness of treatment as a whole has been the focus of numerous studies. Less frequently, however, research has addressed the evidence base of therapeutic interventions and efficacy factors. Since this article takes a non-systematic look into the current state of knowledge on specific interventions and factors that play a role in the effective treatment of addicted offenders, the question of what exactly works can only be answered in a rudimentary way. The concept of Therapeutic Community appears to be largely empirically supported. Based on such evidence as is currently available, motivational interviewing and dialectical-behavioral therapy can be considered the most promising forms of therapy. The effectiveness of forensic addiction treatment lies possibly less in the application of individual approaches than in questions of the setting and the attitude of those providing treatment.

[Treatment Outcome of Migrants and Non-Migrants in Forensic Psychiatry. A Retrospective Case Control Study Using Bavarian Data From 2010 to 2019]. / Behandlungsoutcome von Maßregelpatient:innen mit Migrationshintergrund. Analyse bayerischer Daten zur Qualitätserfassung von 2010 bis 2019.

Objective Analysis of the relationship between patients' migration status and the outcomes of forensic psychiatry in terms of time from entry to discharge and discharge mode.Methods Based on outcome data of the Bavarian forensic psychiatry, a retrospective case-control analysis between migrants and non-migrants was conducted. Participants were matched on age, sex, main diagnosis and main offence.Results Regarding treatment according to Section 63 of the German Criminal Code (Placement in psychiatric hospital), migrant and non-migrants didn't differ significanlty in the observed variables. Regarding treatment according to Section 64 of the German Criminal Code (Placement in addiction treatment facility), migrants' treatment was terminated prematurely more often and after less time than non-migrant's treatment.Conclusion Treatment according to Section 64 of the German Criminal Code is less successful for migrants.

[Self-determination and forensic addiction treatment : Reflections on the tension between patient autonomy and the preventive function of Sect. 64 of the German Criminal Code (StGB) from a psychiatric, ethical and normative perspective]. / Selbstbestimmung und forensische Suchtbehandlung : Reflexionen zum Spannungsfeld zwischen Patientenautonomie und dem Präventionsauftrag des § 64 StGB aus psychiatrischer, ethischer und normativer Sicht.

BACKGROUND: Among the current proposals for the upcoming reform of forensic addiction treatment according to Sect. 64 of the German Criminal Code (StGB), that of the DGPPN stands out as the most far-reaching. Among other things, it calls for making the ordering of the measure dependent on the consent of the defendant and the regular and voluntary demonstration of the willingness to undergo treatment. Prior to treatment in a forensic addiction facility, those affected should reliably participate in addiction-specific treatment offers in the prison setting. AIMS: A critical reflection on the key assumptions and implications of this reform proposal with respect to treatment motivation and the right or ability to self-determination. MATERIAL AND METHODS: These assumptions are analyzed and discussed from psychiatric, medical-ethical and legal-normative perspectives. RESULTS AND DISCUSSION: Neither the setting nor the resources of a prison seem to make it a suitable place for the motivationally critical phases of (probationary) addiction treatment. The approach that only those who have previously demonstrated therapy motivation in word and deed should have the "advantage" of forensic withdrawal therapy, would not do justice to the complexity of substance use disorders and would lead to an overestimation of the already elusive concept of therapy motivation in the context of this disorder. Also, from an ethical perspective, self-determination in forensic addiction patients appears too understudied, both conceptually and empirically, to justify such a far-reaching approach. On a normative level, the new approach would remove an effective special prevention instrument from the hand and create an imbalance in the structure of sanctions.

[Predictors of Legal Probation after Forensic Addiction Treatment: Review of the Determinants of Success of a Treatment order According to sec. 64 of the German Criminal Code - Part II]. / Prädiktoren der Legalbewährung nach forensischer Suchtbehandlung ­ Zweiter Teil einer Übersichtsarbeit zu Erfolgsdeterminanten einer Unterbringung gemäß § 64 StGB.

BACKGROUND: Before a forensic addiction treatment can be ordered by the court according to sec. 64 of the German Criminal Code (StGB), a prognosis of success must be made and affirmed. In recent years, several studies have been devoted to the search for appropriate predictors of a "sufficiently concrete" prospect of success. Legal probation after release is the legally stipulated criterion for success in forensic addiction treatment. OBJECTIVE: As the second part of a two-part review on the determinants of success in forensic addiction treatment, this paper aims to provide an overview of the current evidence on predictors of legal probation after forensic addiction treatment and relates this to the evidence to the predictors of the discharge mode. METHODOLOGY: Based on systematic literature research, the results of eight empirical studies published between 2002-2019 were processed in depth and presented in an overview table. RESULTS: Despite heterogeneous findings in detail, the presence of motivational, practical life and social resources, on the one hand, and criminal history and characteristics of current delinquency, on the other hand, show relatively clear relationships to legal probation after successful forensic addiction treatment. At the same time, the exclusive consideration of legal probation as the only criterion for the prognosis of treatment success reveals conceptual imprecision, since this is then overlaid by the criminal prognosis. CONCLUSION: The limitations of the current state of research suggest a two-step approach for the preparation of a treatment prognosis: first, the predictors of the discharge mode could be used to examine the question of the likelihood of success of a regular course of treatment; then, the predictors of legal probation could be used to examine whether any conclusions can be drawn on the relapse-preventive effect of forensic addiction treatment. Both parts of the review can thus support forensic psychiatric experts in making a reliable prognosis of treatment prospects. In addition, consideration should be given to whether the information base for experts could be improved, for example, through a probationary phase.

Bayes Factors show evidence against systematic relationships between the anchoring effect and the Big Five personality traits.

Examining personality traits as predictors of human behaviour is of high interest. There are several but inconclusive reported relationships of personality and the susceptibility to the "anchoring effect", a tendency to adjust estimates towards a given anchor. To provide an answer to variably reported links between personality traits and the anchoring effect, we collected data from 1000 participants in the lab and validated typical anchoring effects and representative personality scores of the sample. Using Bayesian statistical data analyses, we found evidence for the absence of a relationship between anchoring effects and personality scores. We, therefore, conclude that there are no specific personality traits that relate to a higher susceptibility to the anchoring effect. The lack of a relationship between personality and the susceptibility to the anchoring effect might be due to the specific anchoring design, be limited to specific cognitive domains, or the susceptibility to anchors might reflect no reliable individual cognitive phenomena. In the next step, studies should examine the reliability of anchoring effects on the individual level, and testing relationships of individual traits and anchoring effects for other types of anchors, anchoring designs, or cognitive domains.

[Predictors of the discharge mode from forensic addiction treatment: Review of the determinants of success of a treatment order according to sec. 64 of the German Criminal Code (Part I)]. / Prädiktoren des Entlassmodus aus forensischer Suchtbehandlung ­ Erster Teil einer Übersichtsarbeit zu Erfolgsdeterminanten einer Unterbringung gemäß § 64 StGB.

BACKGROUND: Before a forensic addiction treatment can be ordered by court according to sec. 64 of the German Criminal Code (StGB), a success prognosis must be made and affirmed. The search for appropriate predictors for a "sufficiently concrete prospect of success" was the focus of several studies in recent years. In addition to legal probation, the mode of release from the measure, i.e. whether regular release on probation or an end of the accommodation due to a lack of prospect of success, represents the central success criterion of forensic addiction treatment. OBJECTIVES: As the first part of a two-part overview of the determinants of success in forensic addiction treatment, the aim of this paper was to provide an overview of the current state of knowledge on predictors of the discharge mode, both univariate and multivariate. METHODOLOGY: Based on a systematic literature search, the results of 16 empirical studies from the period 1999 to 2019 are summarized and presented in detail. Univariate findings on individual predictors are presented in an overview table, while multivariate results are summarized in "typical" treatment discontinuations. RESULTS: On a univariate level, the findings were predominantly heterogeneous. The factors personality disorder and psychopathy as well as "static" anamnestic factors such as criminal background could be considered as reasonably reliable predictors. Multivariate, in particular the combination of an early onset of delinquency, a problematic social and/or occupational or educational background together with certain personality components, indicated a very high risk of premature discharge. CONCLUSION: The current state of research cannot provide an exhaustive answer to the question of decisive determinants of success or failure of a treatment acc. to sec. 64 StGB - measured by the discharge mode. However, the overview can assist forensic psychiatric experts in making a reliable prognosis of treatment prospects.

Women in German forensic addiction treatment: Epidemiology and gender-related decision making in jurisdiction.

PURPOSE: Within the German legal framework, if an unlawful act is committed by a substance-addicted offender, courts shall make a forensic addiction treatment order (referred to as FAT). In 2010-2015, German courts applied this rule to 14,576 individuals. The article aims to explore the development of FAT sex ratios, its relation to other criminological measures and its regional distribution - and to describe gender-related differences within the FAT population. METHODS: Yearly and state-specific sex ratios in FAT orders were calculated and related to general delinquency figures. Women were compared to men on various variables. We computed chi-square, t- and Kruskal-Wallis tests. RESULTS: Compared to registered and sanctioned delinquency, women are steadily underrepresented, but the sex ratio differs largely among German states. Compared to men, women are 1 year older, have a less severe criminal history and a different distribution of addiction-related delinquency. Their average concurrent prison sentence is shorter, indicating less severe offences. CONCLUSIONS: Findings largely conform to epidemiological knowledge. However, it is unlikely that these effects explain the extent of women's underrepresentation concerning FAT. Instead, FAT-application seems to be influenced by gender-related decision biases in jurisdiction. Regional differences cannot be explained epidemiologically, they seem to indicate different juridical "cultures".

Therapists' and Patients' Perspectives on Therapeutic Dynamics Leading to Therapy Failure in Forensic Addiction Treatment.

Background: Among drug- or alcohol-addicted offenders under forensic treatment, therapy failure is a potent predictor of substance-related re-delinquency. Given this evidence, high drop-out rates pose a major problem in forensic addiction treatment in Germany. Legal preconditions for a premature discharge due to therapy failure are defined, and behavioral correlates are well described, but the precedent dynamics between patients and therapists have rarely been analyzed. The present study intended to shed light upon the subjective perception of the treatment course prior to therapy failure. Methods: Applying parallel questionnaires and structured interviews, patients' and therapists' perspectives on perceived reasons for therapy failure were retrospectively investigated and compared to each other on a dyadic level. Following this predominantly qualitative and explorative approach, the examination of 32 dyads could be realized; 13 patients with regular (i.e., successful) therapy termination served as controls. All patients had been treated within two specialized forensic addiction hospitals in the German federal state of Baden-Württemberg and were assessed shortly before discharge took place. Results: As expected, patients' and therapists' perspectives differed largely on perceived reasons for failure. In most cases, they appeared to have very different views on what happened during treatment and why therapy eventually failed. Patients mentioned psychological tension and aggressiveness, frequent quarrels with fellow patients, and a bad therapeutic environment as most important reasons for therapy failure. Therapists highlighted patients' unwillingness to make an effort or to change behavior. The analysis of patients' narratives regarding how to explain the negative treatment course confirmed pre-assumptions on predominantly negative feelings and attitudes towards the clinic. The precedent dynamics of therapy failure were shown to be highly individual. However, despite varying notably, a cluster analysis revealed that they seemed to follow "typical patterns" that could partially be linked to patients' characteristics. Conclusions: A better understanding of treatment dynamics during forensic addiction therapy is a prerequisite for the avoidance of therapy failure with negative effects on re-delinquency. It seems that the incapacity to establish a common frame of reference for assessing the therapy process could be one of the major reasons why treatment dynamics take on a life of their own towards a disruption of the therapeutic relationship, leading to therapy failure. The knowledge of "typical" risk patterns towards therapy failure could facilitate early therapeutic measures.

Socioeconomic disadvantage and schizophrenia in migrants under mental health detention orders.

BACKGROUND: Migrants with mental hospital orders according to section 63 of the German criminal code are overrepresented in relation to their numbers in the general population. Subgroups originating from certain world regions are diagnosed with schizophrenia at a much higher rate than others. In the present literature, there is a strong evidence for a substantial correlation between migration, social disadvantage and the prevalence of schizophrenia. AIMS: This study investigates the relationship between countries of origin, the risk of becoming a forensic patient and the proportion of schizophrenia spectrum disorders. METHOD: Data from a comprehensive evaluation tool of forensic inpatients in the German federal state of Baden-Württemberg (FoDoBa) were compared with population statistics and correlated with the Human Development Index (HDI) and Multidimensional Poverty Index (MPI). RESULTS: For residents with migration background, the risk ratio to receive a mental hospital order is 1.3 in comparison to non-migrants. There was a highly significant correlation between the HDI of the country of origin and the risk ratio for detention in a forensic psychiatric hospital. The proportion of schizophrenia diagnoses also correlated significantly with the HDI. In contrast, the MPI country rankings were not associated with schizophrenia diagnoses. CONCLUSION: Two lines of explanations are discussed: first, higher prevalence of schizophrenia in migrants originating from low-income countries, and second, a specific bias in court rulings with regard to involuntary forensic treatment orders for these migrant groups.

[Multimorbid Patients in Forensic Psychiatry: Chances of Being Discharged]. / Entlasschancen multimorbider Patienten im psychiatrischen Maßregelvollzug.

OBJECTIVE: to determine the chances of discharge of forensic psychiatric patients (section 63 of the German Legal Code) diagnosed with comorbid psychiatric and somatic disorders. METHODS: N = 364 patients were evaluated. Diagnostic groups were compared with regard to types and frequencies of comorbid diagnoses, and treatment duration. RESULTS: Both personality disorders as main diagnoses and comorbid personality disorders were associated with prolonged inpatient treatment. Substance dependence in addition to a personality disorder was an aggravating factor. Comorbid somatic disorders affected treatment duration of patients diagnosed with a psychotic disorder. CONCLUSIONS: Somatic comorbidity may negatively interact with the treatment of psychiatric problems in schizophrenic patients and thus affect the prospects of discharge in this patient group.

Predicting discharge in forensic psychiatry: the legal and psychosocial factors associated with long and short stays in forensic psychiatric hospitals.

In Germany, both the number of patients treated in forensic psychiatric hospitals and the average inpatient treatment period have been increasing for over thirty years. Biographical and clinical factors, e.g., the number of prior offences, type of offence, and psychiatric diagnosis, count among the factors that influence the treatment duration and the likelihood of discharge. The aims of the current study were threefold: (1) to provide an estimate of the German forensic psychiatric patient population with a low likelihood of discharge, (2) to replicate a set of personal variables that predict a relatively high, as opposed to a low, likelihood of discharge from forensic psychiatric hospitals, and (3) to describe a group of other factors that are likely to add to the existing body of knowledge. Based on a sample of 899 patients, we applied a battery of primarily biographical and other personal variables to two subgroups of patients. The first subgroup of patients had been treated in a forensic psychiatric hospital according to section 63 of the German legal code for at least ten years (long-stay patients, n=137), whereas the second subgroup had been released after a maximum treatment period of four years (short-stay patients, n=67). The resulting logistic regression model had a high goodness of fit, with more than 85% of the patients correctly classified into the groups. In accordance with earlier studies, we found a series of personal variables, including age at first admission and type of offence, to be predictive of a short or long-stay. Other findings, such as the high number of immigrants among the short-stay patients and the significance of a patient's work time before admission to a forensic psychiatric hospital, are more clearly represented than has been observed in previous research.