[Indicators of course of inpatient therapy in offenders with substance dependency]

[Predictors of Early Treatment Termination in Patients Detained under §64 StGB - A Literature Review]

BACKGROUND

The treatment of addicted offenders detained under § 64 of the German Criminal Code can be terminated prematurely. There is an extensive literature on predictors of such premature termination concerned with factors established before treatment.

OBJECTIVE

The aim of this paper is to present predictors of premature termination that become apparent during the course of therapy.

METHODS

We conducted a systematic literature search and included 16 publications.

RESULTS

Patients and therapists rated impulsivity/aggressiveness, substance use relapses and a lack of patient-therapist relationship as negative predictors. Both groups assessed as beneficial the presence of motivation and a positive social network.

CONCLUSION

To prevent early treatment termination a positive patient-therapist relationship, motivation and working through incidents during therapy is essential.

Mandatory substance use treatment for justice-involved persons in Germany: a systematic review of reoffending, treatment and the recurrence of substance use outcomes

Many jurisdictions implement mandatory substance use treatment for justice-involved persons. Germany is one such country; however, debates about the appropriateness and effectiveness of this disposal abound. Very little attention has been paid in the international literature to patients receiving mandatory treatment in Germany. This systematic review synthesises research on patients receiving substance use treatment in forensic hospitals under §64 of the German Penal Code with regard to three primary outcomes: treatment completion, reoffending, and the recurrence of substance use. Forty-five publications reporting on 36 studies were reviewed; publication dates ranged from 1988 to 2023. On average, 47% of patients did not successfully complete treatment, compared to 45% who did. Average follow-up reconviction rates were higher than in mentally ill and general offender populations as reported elsewhere. Approximately half of all patients reused substances during treatment. Suggestions for future research, including a focus on strength- and recovery-based indicators, and harmonising routine outcomes measurements, are given.

Gutachten gemäß § 64 StGB

Zusammenfassung. Hintergrund: Die Zahl der gerichtlich in der Entziehungsanstalt nach § 64 StGB Untergebrachten steigt seit Jahren. Gerichte werden dabei regelmäßig durch forensisch-psychiatrische Sachverständige beraten, für die die Auseinandersetzung mit den Voraussetzungen entsprechender Unterbringungsanordnungen mittlerweile ebenfalls zum Tagesgeschäft gehört. Zugleich stellt die Vielzahl und Komplexität dieser Eingangsvoraussetzungen eine besondere Herausforderung dar, während zur Erstellung entsprechender Eingangsgutachten bislang kein Leitfaden vorliegt. Zielsetzung: Der Beitrag kombiniert die juristische mit der praktischen Perspektive und leitet daraus konkrete Hinweise für gutachterliche Sachverständige ab, wie bei der Erstellung eines Gutachtens vorgegangen werden könnte, damit das Gericht alle nötigen Anknüpfungspunkte erhält, um über die Unterbringung in einer Entziehungsanstalt zu entscheiden. Methodik: Narrative Übersicht über empirische Literatur, Gesetzgebung und Rechtsprechung. Ergebnisse: Neben der Besonderheit einer qualifiziert negativen Risikoprognose, die auf die Begehung von Straftaten im Kontext eines Hanges zum Suchtmittelkonsum im Übermaß zu beziehen ist, stellt insbesondere die Einschätzung zum Vorliegen einer „hinreichend konkreten“ Erfolgsaussicht der Behandlung Sachverständige vor eine Herausforderung. Auch darüber können jedoch unter Einbezug der Faktoren Dissozialität und/oder kriminelle Vorbelastung, motivationaler Aspekte und der Analyse personaler und sozialer Ressourcen Aussagen getroffen werden. Schlussfolgerungen: Forensisch-psychiatrische Sachverständige haben bezüglich des § 64 StGB einen sehr großen Einfluss auf die gerichtliche Entscheidung. Die Beachtung der hier formulierten Hinweise dürfte die Gutachtenerstellung erleichtern und Missverständnissen zwischen Gericht und Sachverständigen vorbeugen.

[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

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.

Prädiktoren der Behandelbarkeit nach § 64 StGB aus Therapeutensicht

Einleitung: Der Maßregelvollzug nach § 64 StGB kämpft mit steigender Belegung und hohen Erledigungsquoten. Zahlreiche Studien untersuchten daher behandlungsprognostisch relevante Patienteneigenschaften. Deren Gesamtschau ergibt ein uneinheitliches Bild von meist schwachen Prädiktoren. Zielsetzung: Beantwortet werden soll im Wesentlichen 1) inwieweit die empirischen Befunde der praktischen Behandlungserfahrung entsprechen; 2) welche weiteren Prädiktoren sich daraus ergeben.

Methodik: Anhand von Fragebögen schätzten 35 MRV-Therapeuten den prognostischen Wert von 30 Prädiktorvariablen ein. Die Eigennennung weiterer wurde erbeten.

Ergebnisse: Trotz deutlicher Heterogenität der Einschätzungen spiegeln sich gesicherte empirische Befunde wider, z. B. intrinsische Motivation als positiver und psychopathische Persönlichkeitszüge als negativer Prognosefaktor für den Behandlungserfolg. Weitere Variablen umfassen Aspekte delinquenter Sozialisation als negative Prädiktoren – Intelligenz, weibliches Geschlecht, Beziehungs- und sprachliche Ausdrucksfähigkeit als positive. Schlussfolgerung: Die Prognosefaktoren für den Behandlungserfolg nach § 64 StGB werden in der Praxis uneinheitlich bewertet. Als Mediator kommt die individuell verschiedene Behandlungserfahrung in Frage.

The prognostic value of the PCL-R in relation to the SUD treatment ending

Scientific research about patients with substance use disorders (SUD) treated within the context of forensic compulsory addiction treatment is seldom available. Scientifically supported surveys regarding the treatability of SUD patients are rare. Some authors claim that the Psychopathy-Checklist-Revised (PCL-R) has value for predicting therapeutic success. PCL-R scores rely on extensive interview data and a detailed review of criminal records and social history. The scores reflect 1) the affective and interpersonal psychological traits; and 2) socially deviant conduct. This study was conducted by the forensic professional clinic at the hospital for Psychiatry and Neurology Hildburghausen. We assessed 102 male patients using the PCL-R. This investigation evaluated the Total score of the PCL-R and the score of Factor 1 and Factor 2 in relation to the end of treatment by court order. The results showed significant differences between patients who completed treatment and those who did not. Patients that dropped out of treatment had a higher score in PCL-R. With the use of the PCL-R it is possible to make a quantitative statement about which patients will complete treatment.