Centers for the treatment of psychiatric or addicted offenders in Saxony-Anhalt, Germany

Dr Gabriel Theren, Section chief, Ministry of Health and Social Affairs

1. History:

The history of placements and / or measures for psychiatric or addicted offenders in Germany is quite young and corresponds today to the modem criminal laws. During the 19th century only some hospitals or care homes for psychiatrically ill existed, often mixed with other fringe groups like beggars, mad, old and otherwise poor and ill people and there was no differentiation between the regular criminal and the psychiatrically ill offender.

However, a real change happened not until the mid seventies of the 20th century with the Psychatrie-Enquete in 1975, and the great reform of penal code in 1973.

2. Legal Structure in Germany:

Germany has different legal and regulation levels because of the federal structure. Most of the important regulations and laws considering the addicted and/or psychiatric offenders is based on the Federal Level.

Particularly this are the Basic Law (GG) which describes the rights of every person and which are reduced during the measure, the Criminal/ Penal Code (StGB), regulating the basis of German criminal law, and here especially Title six, Measures of Reform and Prevention" (section 61 following).

Following the regulations of the Penal Code, the psychiatric or addicted offenders are sentenced in the "MaBregelvollzug" (placements in special hospital).

The assumption for this therapy in placements is the lack of guilt of the criminal on the one hand, but a certain degree of risk to the public on the other. Therefore, these measures aim to both aspects: the security of the community and the rehabilitation of the patient.

Further important rules are also included in the Criminal Procedure Code (StPO) and the Prison Act, concerning the Execution of Prison Sentences and Measures of Rehabilitation and Prevention involving Deprivation of Liberty (StVollzG) The Code of Execution of Punishment gives some general rules of organisation of prisons and placements and special regulations for young offenders the Juvenile Court Law contains.

The 16 states themselves have the right to give themselves their own regulations as "Act of Executing of Measures". These state-laws determine the specific aspects of the placements like

On the working-plane the Ministry of Justice, responsible for Execution and the prosecuting authorities and the Ministry of Health and Social Affairs responsible as Executing authority and especially for the surveillance and/or regulatory authority for hospitals and for the costs, have to work together.

3. The Hospitals Bern burg and Uchtspringe

The Hospital Bernburg as the central institution for treatment of drug and alcohol addicted offenders in Saxony-Anhalt has the task to admit all offenders, which are sentenced under § 64 StGB. and have mostly diminished responsibility for their offence. In opposite to the placement under § 63 StGB, which is only possible in cases of a absolute lack or a diminished guilt, the placement under § 64 is also possible for full responsible offenders to guarantee the withdrawal.

In Bernburg there are now places and/or beds for about 150 persons. The hospital is divided in 2 sections, because the alcohol and drug offender are separted. The relation is about 60% alcohol (including the patients with both addictions because the treatment then goes to alcohol) and 40 % drug addicted persons.

The duration of the sentence and therapy is 2 years, given by law. The only exception is possible, if an extension is absolutely necessery to reach the aim of therapy.

The Hospital Uchtspringe is responsible for the placement for the psychiatric offenders, sentenced under § 63 StGB: Here the duration of the therapy in general is unlimited, only depending on the individual situation and therefore sometimes very long (longer than prison).

Both hospitals also admit persons under § 126a StPO for "Provisional Committal" or under § 81 StPO for "Committal for Observation" of the accused person.

The range of criminal acts in both hospitals is wide and has no restrictions. Even in Bernburg there are 7% sexual offenders, with the problem to deal very careful with loosening or easing therapy because of the public opinion to this offender group.

Hospital Bernburg:

The hospital was established in1991 and rebuilt 2000/2001 to achieve a modern frame for a high quality treatment.

The construction of the building matches to the inner structure of the hospital, considering the different treatment sections and wards.

The so-called "part one" of the reconstructed building includes five wards for about 80 patients. Until the opening of "part two" more addicted offenders were put up; the solution was possible by putting a third bed in a 2-bed room. In addition, there is another quite old building, the so-called house"Kraepelin" for 25 patients, especially for the drug addicted.

A basic additional element of this treatment phase is the ergotherapy. Goal of the ergotherapy is primarly to check and prove the skills for performing a job or activity But also to add new skills and expedient sportive activities (not only body-building etc.)

The medical and psychological staff of Bemburg is absolutely convinced, that it is essential for every patient to work with his individual offence as a preparation for a further crime free life after release.

Therefore, the hospital suggests some criminal-act specific group therapies, i.e. for sexual offenders, arsonists.

For this offence-work of the patient, there is the possibility to make anti-agressivity¬treatments and also to work in an individual therapy.

For some of the patients, especially a big group from the range of the drug-offenders, which are nearly under 25 years old the hospital tries to offer school education to get the secondary school qualification. Since several years, the hospital successfully manages in combination with the Adult Education Centre of Bemburg, that a part of these patient groups reaches this secondary qualification by going half a year to school

For patients from abroad there is also the possibility of learning the German language to facilitate the further life.

After this part of basic motivation the patient is able to take part in the „closed" group psychotherapy or main-therapy" to withdrawal of drugs and alcohol for 4-5 months under the leadership of 2 therapists.

During this group therapy, there is intensive disputing, mainly with the problem of addiction, but not waiving the context with the criminal act(s).

The Rehabilitation and , Open Executing" Phase:

At the end of such a successful group or main therapy, the patient is able to step into the phase of Rehabilitation:

In agreement with the relevant prosecution authorities, the patient is allowed to take part in the Open Executing" and the so-called loosening and/or easing. This part of sequence of events normally has a duration of 3 to 4 months.

Goal of the open execution stage is to put into practise, what he/she has learned in therapy. Therefore actions like to go out in the city, leave of absence for day and /or night, always accompanied with therapy, are part of this therapy phase.

Sometimes the patients abuse the loosening of going to the garden, the city etc., but the number happily decreased very much since the new building was constructed in 1999/2000. The proportion to the total number of patients is around 4% in the last years. Normally the patients come back and/or are brought back in the next two days.

The last step of the rehabilitation phase is the "Probationary Living". As far as possible, the probationary living should be near to the potential place of release. Therefore, the patient is allowed to live in a private atmosphere to test his

The "part two" of the Hospital with two more wards newly opened in November 2004 for about 32 patients. Another "part three" is planned to cover the increased needs of treatment-places.

The structure of wards regarding the different needs of the symbiosis of punishment and medical treatment and considering the dangerousness of the offenders and the public interest of security is differenciated in:

Pictures for Hospital Bernburg:

Hospital Uchtspringe:

The Hospital Uchtspringe also was founded 1991, the construction of the new building was finished in 2000.

In opposite to Bernburg it is the central institution for treatment of psychiatric offenders in Saxony-Anhalt.

Uchtspringe has a capacity of Places / Beds for about 290 persons. Because the number of psychiatric offenders increased extremely since 2001, the hospital also has a high over-occupancy.

A new building nearly 80 km far from the main hospital is in construction with a capacity for 80 patients and will be finished in the middle of 2006.

Pictures for Hospital Uchtspringe:

4. Structure of the special therapy for addicted offenders in Bernburg

The conception of this special therapy is based on the experience of nearly 15 years and has three steps or phases:

  1. Admission and Orientation Phase
  2. Motivation and Treatment
  3. Rehabilitation and , Open" Executing

The Admission and Orientation phase

This is the first phase; the new admitted patient goes through, mainly as a phase of medical and psychologcal diagnosis, but also of social inventory At end of this phase, the treatment team makes a „treatment-plan"for every individual patient. This plan includes a timetable and the specific contents of the therapy. It also includes diagnostic results from the antecedent or anamnesis and the precise ideas of treatment conception for the individual patient to aim the individual therapy

The Motivation and Therapy phase:

After this treatment of the first phase, the patient in general is transferred to the intended therapy ward: Here now starts the motivation and preparation for a group therapy.

A basic additional element of this treatment phase is the ergotherapy. Goal of the ergotherapy is primarly to check and prove the skills for performing a job or activity But also to add new skills and expedient sportive activities (not only body-building etc.)

The medical and psychological staff of Bemburg is absolutely convinced, that it is essential for every patient to work with his individual offence as a preparation for a further crime free life after release.

Therefore, the hospital suggests some criminal-act specific group therapies, i.e. for sexual offenders, arsonists. For this offence-work of the patient, there is the possibility to make anti-agressivity-treatments and also to work in an individual therapy.

For some of the patients, especially a big group from the range of the drug-offenders, which are nearly under 25 years old the hospital tries to offer school education to get the secondary school qualification. Since several years, the hospital successfully manages in combination with the Adult Education Centre of Bemburg, that a part of these patient groups reaches this secondary qualification by going half a year to school

For patients from abroad there is also the possibility of learning the German language to facilitate the further life.

After this part of basic motivation the patient is able to take part in the , closed" group psychotherapy or , main-therapy" to withdrawal of drugs and alcohol for 4-5 months under the leadership of 2 therapists. During this group therapy, there is intensive disputing, mainly with the problem of addiction, but not waiving the context with the criminal act(s).

The Rehabilitation and "Open Executing" Phase:

At the end of such a successful group or main therapy, the patient is able to step into the phase of Rehabilitation:

In agreement with the relevant prosecution authorities, the patient is allowed to take part in the Open Executing" and the so-called loosening and/or easing.

This part of sequence of events normally has a duration of 3 to 4 months.

Goal of the open execution stage is to put into practise, what he/she has learned in therapy. Therefore actions like to go out in the city, leave of absence for day and /or night, always accompanied with therapy, are part of this therapy phase.

Sometimes the patients abuse the loosening of going to the garden, the city etc., but the number happily decreased very much since the new building was constructed in 1999/2000. The proportion to the total number of patients is around 4% in the last years. Normally the patients come back and/or are brought back in the next two days.

The last step of the rehabilitation phase is the "Probationary Living". As far as possible, the probationary living should be near to the potential place of release. Therefore, the patient is allowed to live in a private atmosphere to test his skills, his job related actions, vocational retraining or (re) education, to contact the possibility to cooperate in self-help-groups and also his ability to stay abstinent.

This section of therapy is very important, because the medical and therapist team of Bernburg has the experience, that the patients have a lot of problems to solve, if they lived until the day of release in such a close but very protected environment. The probationary living gives the staff the possibility of controlling the patient and eventually intervening i.e. to break the probationary living if patient is overstrained.

Precise regulations for probationary living are not given, but rules for vacancies, which make this step of therapy possible with approval of the responsible prosecution authority. During the years, a good cooperation between the hospital and the prosecution authorities was built up and guarantees an efficient communication for these decisions.

But not every patient is able, to pass this program of therapy so speedy. Individual specifics like

must be considered and have the consequence, that the "step three" (Rehabilitation and ..Open Executing) is not possible and the patient has to go from "step two" (Motivation and Therapy phase) directly into prison.

In these cases of re-transferral into prison after the measure, unfortunately the therapy is generally not very sustainable, because the offender has nearly no possibility to keep up the positive changes in behaviour he learned in the therapy.

Therefore, it is a better solution, to break the measure for the sentence in prison and to follow up after the punishment in prison with the therapy. Then it is possible, to create the therapeutic circumstances, to release a successfully treated patient into freedom.

In general, after a successful rehabilitation the patient can be discharged per decision of the chamber of prosecution.

Here the regulation of section 67 Requirements for suspended execution, i.e. to contact in regular terms the therapist and probation assistant, is necessary and usual. The keeping contact allows intervening in case of crisis.

Exceptions of Release after completion of the Three Phases,i.e: Aim: Release after measure:§ 67 subsection 4 StGB in most cases is helpful, because the time of measure shall be credited to punishment to 2/3. However, under § 67 StGB ..Sequence of Execution", unfortunately the measure shall be executed before the punishment and exceptions are only possible under § 67subs. 2 &3 StGB.

In the actual discussion of reforming these federal regulations this is a point most experts want to change.

To carry out this very pretentious but necessary therapy program the Hospital Bernburg has the following staff:

5. Structure of the special therapy for Psychiatric offenders in Uchtspringe

Likewise in Uchtspringe the conception of therapy bases on the experience of 15 years and is quite similar to the concept of Bernburg with some deviations considering the different type of patients.

In general, the "Three Steps" or phases like

  1. Admission and Orientation
  2. Motivation and Treatment, and
  3. Rehabilitation and "Open Executing"
are the same, but the last part of the last step is relatively seldom and also to start the rehabilitation needs a longer time :

In relation to the patients and the often very dangerous offences they did, there is no time limit for the duration of placement.

The judicial Hearing is only once a year to make the decision, if there can be a kind of loosening or easing etc.

6. Special Aspects and Problems

The Structure of age shows in Bernburg a low average age with around 21 years for the drug addicted patients. For the alcohol patients the average is quite higher with 33 years. Also the age to start the abuse of drugs with nearly 11 or twelve years is much lower than for alcohol.

Therefore, there are very different physical but also emotional needs, fantasies and interests.

Because the succeeding organic disease-results are nearly not comprehensible for the young patient, the motivation is a problem. In addition, the deficits in maturating are very complex.

As a canon it can be said, that the development of personality stagnates by starting to consume drugs and has a regressing aspect of nearly two years while several year consumption. Therefore, the drug-addicted show the wild, self-willing, protesting and ambivalent behaviour of puberty and/or early adolescence.

As every parent knows, this is a problematic phase of development and is aggravated by the multiple dysfunctions and the often very complicated biography.

The main problem for placements not only in Saxony-Anhalt but also the other states in Germany is the increasing number of offenders/patients and the resulting problems with capacity and increasing costs.

In the last ten years, the number of admissions per years has more than doubled from 41 admissions in 1994 to 106 admissions in 2004. A specific phenomenon of the East-German states is the "start" of the admission of drug addicted nearly since 1998, because it was the needed time to establish a drug scene also in Saxony-Anhalt. On the other hand the part of drug-addicted seems to become stable with around 40 persons p.a.. In general, the part of women is very low under 4% (in both hospitals).

The problem of increasing patient numbers aggravates, because even the high number of released, based on the legal limit of two years is under the number of admissions. Interesting is, that the part of release of drug addicted and alcohol addicted in absolute numbers is nearly the same, which means that the drug patients release is relatively higher.

A part of these releases is a so-called completing or ending of measure, because the patient and/or the hospital decide, that a further therapy will not be useful or successful. In most cases -about three times more - the decision is made by the hospital.

In a close relation to this capacity problem stands the problem of aftercare-possibilities. After 2 years of treatment in protected setting, it is difficult to handle normal life. Supporting attendance is indispensable, but existing institutions or practical physicians are overstrained with the special requirements of these released patients

The decision of release, which has always the risk, that the patient re-offends, would be easier for the judge, if there is a well-working network of support and control. A higher number of releases however would have a positive effect on the increasing numbers and the costs.

Therefore such institutions and possibilities would be helpful not only for the patients but also for the probation officers and would be an active victim-protection

Therefore, the creation of such a well working after-measure-care will be one of the important future tasks.