Redevelopment of forensic-psychiatric institutions in former East Germany

International Journal of Law and Psychiatry 24 (2001) 509 – 526

Redevelopment of forensic-psychiatric institutions in former East Germany Norbert Konrad* Professor, Institute for Forensic Psychiatry, Berlin, Germany

1. Introduction In those areas of former East Germany before German reunification, legislation differed fundamentally from that in the Federal Republic of Germany (West Germany) with respect to commitment of psychically disturbed lawbreakers to penal institutions. The present study will first describe the process of application of the legal system of West Germany to the new German states of former East Germany: a process complicated by occasional contradictory adjudication of the various courts. The empirical part of this study will treat the question of whether and how the clientele of former East German forensic-psychiatric institutions developed after application of West German law to the whole of reunified Germany. The patient clientele of the Department of Forensic Psychiatry in the Saxon Hospital for Psychiatry and Neurology of Sa¨chsisches Krankenhaus (SKH) Arnsdorf, which can be considered representative for the patients of forensic-psychiatric institutions in the states of former East Germany, was accordingly examined on three reference dates to obtain sociodemographic, forensic, and diagnostic data from patient case histories. These data were compared with results from the few representative studies made in East Germany before and after reunification, and with the most definitive representative study carried out in the rest of Germany.

2. Legal basis The legal basis for commitment to penal institutions in the Federal Republic of Germany may be traced back to the ‘‘Law in Defense of Dangerous Habitual Criminals, and in

* Justizvollzugsanstalt Charlottenburg, Abteilung fu¨r Psychiatrie und Psychotherapie, Friedrich-OlbrichtDamm 17, D-13627 Berlin, Germany. Tel.: +49-30-90144-515; fax: +49-30-90144-512. 0160-2527/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 1 6 0 - 2 5 2 7 ( 0 1 ) 0 0 0 8 1 - 4

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Provision of Measures for the Prevention of Crime and for Reformation of Offenders,’’ passed by the National Socialist (Nazi) government in 1933. Although the Nazis introduced this panel code during the year in which they came to power, it was actually the result of previous decades of debate and deliberation on the development of special preventive measures to ensure the public safety against perceived dangers from the psychically ill. Contrary to the former East German government, the present Federal Republic of Germany (now reunited) has retained these measures of the Penal Code. Since the Second Penal Reform of West Germany, enacted in 1975, Articles 63 and 64 of the German Penal Code have regulated penal commitment under their title ‘‘Measures for the Reformation of Offenders and for the Prevention of Crime.’’ Article 63 contains the legal provisions for commitment to a psychiatric hospital. Article 64 contains the legal provisions for commitment in an institution for the treatment of addicts (Konrad, 1993). The following is a translation of Article 63 of the German Penal Code: Article 63 of the German Penal Code: commitment of offenders to a psychiatric hospital If a person has committed a legal offence in a condition of nonresponsibility for his or her actions (Article 20 of the German Penal Code: x20 StGB), or in a condition of reduced responsibility (Article 21: x21 StGB), a German court may decree commitment of the offender to a psychiatric hospital if its overall assessment of the perpetrator and his deed leads to the conclusion that, as a result of his condition, serious criminal deeds can be expected of him, and that he represents a danger to the general public.

A condition of at least considerable mitigation of responsibility is prerequisite in Germany for a decree of commitment (cf. Table 1). A further prerequisite for a decree of commitment is evidence of a long-lasting, pathological psychic disturbance, which impairs responsibility for criminal deeds. In the event of the existence of two or more psychic disturbances at the time of the crime, the perpetrator’s psychic disturbance, which crucially impairs responsibility for his criminal actions, must be of lengthy duration. In case of a combination, for example, of a personality disorder in the form of ‘‘another severe abnormality’’ together with alcoholic intoxication as temporary ‘‘pathological emotional or psychic disorder,’’ which impairs the ability of self control, commitment is possible only if the personality disorder is so serious that it would have considerably diminished responsibility for the deed, regardless of the state of alcohol intoxication, which existed at the time of the deed. A further prerequisite for commitment is what is called in Germany the symptomatological complex. This term signifies that a motivational relationship can be established between an unlawful offense and the verified psychic disorder. A symptomatological complex exists, for example, when a psychotically disturbed person follows perceived commands from auditory hallucinations and when he commits an offense in accordance therewith. In cases of the lack of a direct motive in the relationship between pathological disorder and criminal behavior, German law requires examination of whether the disorder occasions a specific disposition to commit an offense. It is especially necessary to recognize this failure to fulfill conditions in cases of occasional or infrequent offenders or for offenses committed in conflict situations. Assessment of the probability and the severity of possible future offenses by a particular offender is in Germany strictly the responsibility of the court. An expert witness must provide

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his evaluation, however, as to whether and with what degree of probability it may be expected that the offender may commit the same, similar, and/or other offenses in the future. Accordingly, the following matters fall exclusively under the jurisdiction of the courts in Germany: evaluation of the offense in question (i.e., with respect to premeditation, subjective and objective facts of the case, and judicial mistakes made with regard to judgment of the nature of the offense), examination of offenses in accordance with the principle of commensurability, assessment of the relevance of possible future offenses, and overall evaluation of the perpetrator with regard to the danger, which he represents to society in general. At the same time, expert witnesses from the fields of psychiatry and psychology are particularly responsible for problem complexes such as the following: the perpetrator’s responsibility for criminal offenses, the symptomatological complex of criminal acts — both those already committed as well as those which may be expected — in addition to duration of psychic disorder, and, in the sense of prognosis, the degree of probability and the nature of possible future offenses (see Table 1). The following is a translation of Article 64 of the German Penal Code: Article 64 of the German Penal Code: commitment to an institution for the treatment of addicts Paragraph (1): If a person has the tendency to consume alcoholic beverages or other psychotropic substances to excess, and if he is sentenced in a court of law as a result of a criminal offense, which he has committed in a state of intoxication, or if he is sentenced owing

Table 1 Prerequisites for committing a person to a psychiatric hospital in accordance with Article 63 of the German Penal Code (x63 StGB) Criterion

Prerequisite for committal

Commission of a crime

Commission of those elements of an offense as set forth in the German Penal Code At least significant diminishment of legal responsibility

Legal responsibility (Articles 20 and 21 of the German Penal Code) Duration of the psychic disorder Relationship of the offense being examined in court to the psychic disorder Probability of future offenses Relationship of the expected offenses to the psychic disorder Severity of future offenses Danger to the general public Commensurability (as per Article 62 of the German Penal Code) of penal commitment to a therapeutic institution

For a longer period of time The offense in question must be symptomatic for the psychic disorder involved To be expected with a definite degree of probability Symptomatological complex as for the offense being examined in court Considerable Exists Is satisfied

Questions posed by the expert witness –

Capacity to understand the wrongfulness of an act; ability to control one’s own actions Duration of the psychic disorder Relationship of the offense being examined in court to the psychic disorder Probability of future criminal offenses Relationship of future offenses to the psychic disorder Type of future offenses – –

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to an offense, which the result of said tendency — or in the event that he is not sentenced only because his lack of responsibility has been proven or cannot be excluded — then the court may decree his committal to an institution for the treatment of addicts if the danger exists that the person would commit serious offenses as a result of the said tendency. Paragraph (2): The court shall not make such decree in the event that evidence obviously indicates that such therapeutic treatment for addiction would from the very beginning be futile.

Unlike the committal prerequisites as set forth in Article 63 of the German Penal Code, the criterion of responsibility is irrelevant in the employment of Article 64. In addition, Article 64 of the German Penal Code contains no express mention of a danger for society (see Table 2). The term ‘‘tendency’’ as used in the above-stated contexts includes not only those persons who satisfy WHO criteria for addiction. From the German legal perspective, ‘‘tendency’’ likewise includes those persons who display an inveterate inclination — existing on the basis of psychic disposition or attained by persistent practice — of habitually consuming alcohol or other psychotropic substances to excess. It is all the more difficult to delimit forms of substance abuse, which apparently do not fall under the term ‘‘tendency’’: e.g., consumption of alcohol as a response to conflict, or in the attempt to gain relief from suffering. From the psychiatric standpoint, it could well prove effective — in association with successful treatment concepts on their own — to define the term ‘‘tendency’’ as an addiction or dependency syndrome (in accordance with ICD 10).

Table 2 Prerequisites for committing a person an institution for the treatment of addicts in accordance with Article 64 of the German Penal Code (x64 StGB) Criterion

Prerequisite for committal

Questions posed by the expert witness

Commission of a crime

–

Relationship of expected future offenses to the tendency Severity of future offenses Prospects of success for treatment

Dependency syndrome Relationship of the offense being examined in court to the tendency Probability of future criminal offenses Relationship of future offenses to the tendency Type of future offenses Prognosis for treatment

Commission of those elements of an offense as set forth in the German Penal Code ‘‘Tendency’’ to ‘‘excess’’ Has been determined Relationship of the offense being The offense in question must be examined in court to the tendency symptomatic for the tendency existing Probability of future offenses There is a danger of repeated offenses Symptomatological complex as for the offense being examined in court Considerable Sufficiently concrete prospects for treatment success Commensurability (as per Article 62 Is satisfied of the German Penal Code) of penal commitment to an institution for the treatment of addicts

–

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Analogous to the matters involved in Article 63 of the German Penal Code, committal to an institution requires that the already perpetrated and the yet to be expected criminal offenses exhibit a causal relationship to the ‘‘tendency’’: e.g., when the offense serves to procure intoxicating substances. Not symptomatic in this context, on the other hand, are criminal acts, which would have or could have been committed by a person in the same situation who does not habitually consume psychotropic substances in excess: e.g., in the context of a critical life conflict or under the circumstances of provocation by the victim. Prediction of the likelihood of repeated offenses must be based on more than the mere possibility of the commission of additional such offenses in the future. The question posed to the expert witness is the same as that involving Article 63 of the German Penal Code. Other than for Article 63, however, application of the measure of committal to an institute for addicts as set forth in Article 64 is allowed only if the primary purpose of the measure — i.e., to achieve protection from a dangerous perpetrator — can be fulfilled through a process of therapeutic-achieved rehabilitation and if a program of withdrawal treatment at such an institute must not from the very beginning be assessed as futile. The meaning of the term ‘‘futile’’ as often used in this context frequently becomes the subject of controversy, especially since possibilities of producing motivation to therapy can exist even in individual cases of advanced addiction. In Germany, cases are evaluated as ‘‘futile,’’ for example, if the person in questions has already undergone a number of unsuccessful course of treatment and if further therapy likewise offers no improved prospects of benefit. On the other hand, deliberation of the possibility of committal in accordance with Article 64 of the German Penal Code is particularly advisable if the person involved has repeatedly undergone detoxification therapy in a hospital but if no addiction treatment and rehabilitation have actually taken place. Contraindication of a decree for committal consequently appears plausible in cases in which the offender has already undergone several withdrawal programs, and such contraindication — especially in cases of advanced cerebral degeneration — will, as experience teaches, in all probability represent a realistic assessment of the case. Other criteria involving special diagnostic factors — e.g., secondary dependency, biographical data, or sociodemographic information — may well serve to support a differentiated assessment of the prospects of therapy and of the selection of treatment strategies, without the legal necessity (according to latest German adjudication) that they without doubt evidence the futility of therapeutic efforts. According to a decision reached by the highest German court, the Federal Constitutional Court (Bundesverfassungsgericht), in 1994, application of Article 64 of the German Penal Code is permissible only if there are sufficiently concrete prospects of healing the addict or at least of securing enough time to prevent relapse into a condition of acute addiction. In the area of former West Germany (i.e., the western states, which constituted the Federal Republic of Germany until German reunification in 1990), there are approximately 2500 patients presently being treated in a forensic context in psychiatric hospitals. The available statistics, which are, to be sure, not entirely accurate, indicate that this number has remained fairly constant in this part of Germany in recent years. Over the past 20 years, however, there has been an increase in the number of patients

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Table 3 Persons committed to psychiatric hospitals and to institutions for the treatment of addicts in West Germany (including West Berlin) from 1970 to 1995 (for 1995, data include only former West German states, including West Berlin; cf. Dessecker, 1997) Year

Committed to psychiatric hospitals

Committed to institutions for the treatment of addicts

1970 1975 1980 1985 1990 1995

4222 3494 2593 2472 2489 2754

179 183 632 990 1160 1474

being treated in institutions for therapy of addicts (see Table 3). The number of patients treated in such centers accordingly rose from 179 in 1970 to 1474 in 1995 in the area of former West Germany. Treatment and care for patients in forensic-psychiatric institutions are governed in Germany by legislation, which differs among the various federal states (La¨nder). In addition, German-speaking countries in Europe feature widely divergent legislation applying to the commitment of psychically disturbed lawbreakers. Until now, there has been a lack of comparative studies of these various legal systems, which might have incorporated empirical data of the forensic-psychiatric clientele being treated and cared for.

3. Application of West German law to former East Germany upon German reunification Upon German reunification on 3 October 1990, the above-stated laws entailing measures for the prevention of crime and for reformation of offenders, which had applied in the western part of Germany, became binding law in the new eastern states as well (former East Germany). It consequently became necessary to organize a system in the new states of the reunited Federal Republic to care for those groups of persons defined under Articles 63 and 64 of the German Penal Code. Earlier in East Germany, in 1968, the East German Penal Code (StGB DDR) had been revised, and with it, laws concerning the commitment of persons to psychiatric penal institutions were abolished. Other legislation on commitment (including the law known as EinwG), which went into force in East Germany in 1968, provided equal legal status to patients committed on forensic and psychiatric grounds and to other patients committed by court decree for indefinite periods of time. The commitment law known as EinwG assigned jurisdiction to civil courts not only for the original court decisions, which committed persons to forensic-psychiatric institutions (in cases of persons judged not responsible for their actions), but also for all subsequent related adjudication. Physicians were given complete authority for determining penal measures,

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including the relaxation of such measures. Criminal courts retained only a peripheral role: they could order commitment to an in-patient facility in cases of accused who were not fully responsible for their actions or in cases in which the absence of such responsibility became apparent only during the trial process itself. In all other cases, civil courts enjoyed jurisdiction on commitment to forensic-psychiatric institutions: i.e., on the same legal basis, which also applied to persons judged a danger to themselves or to others without penal implications. This uniform legal basis applied to all subsequent adjudication, including the question of release from confinement. Despite this equality of legal status, special hospitals and specialized wards developed in former East Germany for the treatment of patients committed by courts: for example, the Waldheim Medical Department in Saxony, a high-security hospital for psychiatric patients considered to be especially dangerous or not easily manageable. On the whole, however, it was not possible to prepare those systems providing care for psychically disturbed lawbreakers in the psychiatric medical institutions of former East Germany to operate under the situation, which developed after German reunification and after reintroduction of laws providing for committal to forensic-psychiatric institutions in the new states of Germany. This impossibility of organizationally functioning according to new legislation also prevailed in those medical institutions in which specialization beyond general clinical psychiatry had already taken place before German reunification (Lammel, 1993b). An especially complicating factor was the lack of uniformity in legal practice, as well as application of the legal system of West Germany to the new German states, with respect to work with those patients who had been committed according to the pertinent laws of East Germany and who had not enjoyed special guarantees provided by a government of law. For a considerable length of time after German reunification in 1990, the procedures for work with patients who had been committed to psychiatric institutions in East Germany before reunification was a controversial topic in reunified German jurisprudence and in professional German literature. The two basic antagonistic positions were as follows: The Berlin Court of Appeal (Kammergericht: the Supreme Court of the Federal State of Berlin) held the view that the adaptation in the new German states should take place under consideration of the objective requirements of an orderly legal situation: i.e., in such a manner that the procedures heretofore followed in East Germany should be modified so as to smoothly merge with the system hitherto applied in West Germany for the committal of the psychically ill. In accordance with this approach, the legal bodies of jurisdiction for enforcement of law as regulated by Articles 63 ff. of the German Penal Code should have jurisdiction in the case of subsequent adjudication concerning patients committed by the former East German courts. By 1995, the German Supreme Court, the Federal Constitutional Court (Bundesverfassungsgericht), had espoused another view (Hanack, 1992; Volckart, 1992): i.e., patients committed to psychiatric hospitals by East German courts would not be affected by the introduction of West German law covering the prevention of crime and the reformation of offenders. In addition, the Supreme Court ruled that such cases of committal be treated by the procedures of civil law and not criminal law.

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This dissent on the topic of introduction of West German law into East Germany, which lasted for a considerable number of years, had consequences in the legal practice, which directly involved the committed patients. Until the above-stated adjudication by the German Supreme Court, for example, there were changes in the legal status of those committed patients being treated in the hospital SKH Arnsdorf (a psychiatric institution in former East Germany), in accordance with the former West German legal system covering the prevention of crime and the reformation of offenders (all cases with conditional suspension in accordance with the German Penal Code). This was in addition to cases involving remanding to the Guardianship Court in accordance with civil law stipulations. In comparison to the process in the German Federal State of Berlin (Lammel, 1993a) of introduction of West German Law into East Germany, committal of patients into the legal system covering the prevention of crime and the reformation of offenders initially played a considerably greater role in Berlin. In actual practice in Arnsdorf after German reunification, the actual result was inequality in the treatment of patients. These circumstances not only created a potential for anxiety on the part of patients concerning their legal situation: by virtue of sudden redefinition of patients’ legal status, these conditions also had the result of necessitating the shift of patients within the hospital, from the psychiatric penal wards into the departments for general psychiatry. One consequence, in turn, was the impairment of treatment continuity (Konrad, 1995a). Statistics have been gathered on the location of patients who were being treated in Arnsdorf Hospital (SKH) on the reference date of 3 October 1990 (the day of German reunification) on the basis of the law governing committal to psychiatric institutions, which had prevailed in East Germany. These statistics have revealed, in accordance with the results on the situation in Berlin (Lammel, 1993a), a high percentage of patients who remained in the psychiatric hospital. This percentage exceeded analogous figures for conditional release from forensic-psychiatric institutions in the former states of West Germany (Bischof, 1987). Not infrequently, patients remained at the same treatment station (i.e., their beds) after redefinition of their legal status. This shortcoming was to a great extent the result of deficiencies in the patient-care system and of a lack of concepts for transferring patients away from hospitals (Rautenbach & Bach, 1994). This development to which the patients were subjected in addition to their illnesses had the effect of promoting social incompetence. Finally, the problems involving long-term treatment of forensic-psychiatric patients were shifted to the general psychiatric departments, especially the nursing-home section of the hospital, for them to cope with as best they could (Konrad, 1995b). In East Germany, it was extensive practice to integrate patients stigmatized by a criminal record into hospital wards offering general psychiatric treatment, in addition to those traditionally being treated there for psychic disorders. In the meantime, specific changes in the structural breakdown of patients have lead to critical questioning of this practice. Study of cross-section surveys made in the stated hospital SKH Arnsdorf and dated 3 October 1990, 1 January 1995, and 1 March 19981 provide evidence of this development.

1

I would like to express my sincere thanks for the support provided in making these surveys by the staff of the SKH Arnsdorf Department of Forensic Psychiatry directed by Dr. (Ms.) Buchholz.

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4. Empirical studies on care provided for forensic-psychiatric patients Before presentation of the reference-date results obtained for the present study, the following will summarize earlier studies (whose results will be included in Table 4 ff. for purposes of comparison). There is very little empirical evidence in the form of studies made on the actual treatment of patients who had been committed by courts to psychiatric hospitals in East Germany. Lange (1963) studied patients who had been committed to psychiatric hospitals in East Germany in accordance with Article 42b of the German Penal Code (the old version, which was valid in both East and West Germany: precursor to Article 63, which is now valid). It was only after the process of German reunification began that Sachs (1990) published his study on the situation with regard to Article 11 of the East German law for committal of psychiatric offenders in the Arnsdorf District Hospital (now SKH Arnsdorf). This study was followed by a catamnestic study (Blu¨mlein, 1991) on the treatment and rehabilitation of psychically ill criminals whom courts had committed in the Teupitz Psychiatric Hospital (in the new German state of Brandenburg). Lammel (1993a) collected data, which had been valid until German reunification on 3 October 1990 from patients committed to the Berlin-Buch Psychiatric Hospital (outside Berlin, in former East Germany). A follow-up study of these patients ensued 2 years later (Lammel, 1993b). The sociodemographic, diagnostic, and forensic data published in these studies differ significantly not only among each other but also with reference to the results of a reference-date study made by Leygraf (1988) on commitment of patients to forensic-psychiatric institutions in former West Germany. The author of the present study conducted his own investigations on approaches to the problem complexes involving the institution (or, more accurately, the reintroduction) of a system for commitment of patients to forensic-psychiatric institutions in former East Germany. Date were collected as based on three reference dates: 3 October 1990 (the date of German reunification), 1 January 1995, and 1 March 1998. These data were based on secondary analyses of medical records existing in the hospital SKH Arnsdorf, as well as on diagnostic data of all forensic-psychiatric patients admitted after German reunification (3 Table 4 Distribution of gender of patients committed by courts to the psychiatric hospital SKH Arnsdorf, as of each of the following reference dates: 3 October 1990 (n = 89), 1 January 1995 (n = 32), and 1 March 1998 (n = 45), as compared with studies made by Lammel (1993a; n = 51), Lange (1963; n = 904), Leygraf (1988; n = 1973), and Sachs (1990; n = 101) Author

Region studied

Time covered by study

Male (in %)

Female (in %)

Lange (1963) Leygraf (1988)

East Germany West Germany

80 97.0

20 3.0

Sachs (1990) Lammel (1993a) Konrad (1995a) Konrad (1995a) Konrad (1995a)

Hospital SKH Arnsdorf Berlin-Buch Psychiatric Hospital Hospital SKH Arnsdorf Hospital SKH Arnsdorf Hospital SKH Arnsdorf

1962 from 1 Jun 1984 to 31 May 1986 30 Nov 1988 3 Oct 1990 3 Oct 1990 1 Jan 1995 1 Mar 1998

79.2 90.2 82.0 96.9 97.8

20.8 9.8 18.0 3.1 2.2

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October 1990). Since German reunification, the psychiatric hospital SKH Arnsdorf, located in Saxony near Dresden, has been responsible for admitting patients, primarily from the administration district of Dresden, who have been committed in accordance with Article 63 of the German Penal Code. A documentation form was developed to aid in collecting this data. It contained coding sections for content analysis of court opinions in cases of committal, as well as for the relevant psychiatric and sociodemographic data of the patients. The diagnostic data obtained were based on the classifications listed below. The diagnoses given here were taken both from the case histories in the reference-date results collected for the present study, as well as from the earlier studies cited (see Table 6 ff.).     

‘‘Organic brain disorder’’ to cover ICD 9 diagnoses 290–294 and 310, as well as ICD 10 diagnosis F0; ‘‘Endogenous psychosis’’ to cover ICD 9 diagnoses 295–297, as well as ICD 10 diagnoses F2–F3; ‘‘Personality disorder’’ to cover ICD 9 diagnoses 300–302, as well as ICD 10 diagnosis F6; ‘‘Intellectual subnormality’’ to cover ICD 9 diagnoses 317–319, as well as ICD 10 diagnosis F7; ‘‘Primary addiction’’ to cover ICD diagnoses 303–304, as well as ICD 10 diagnosis F1.

4.1. Sociodemographic aspects Upon consideration of the overview of sociodemographic data gained from various studies and presented in the following (Table 4), it should be borne in mind that these various studies and their data are comparable to only a limited extent. For example, the study made by Lange (1963) covered patients who had been committed to a psychiatric hospital on the legal basis of Article 42b of the German Penal Code (the old version, which was still valid at that that time in both East and West Germany: i.e., this was before each of these countries carried out their respective reforms in criminal law). Leygraf (1988), on the other hand, collected data from offenders in West Germany committed to psychiatric hospitals there in accordance with Article 63 of the German Penal Code. The studies made by Lammel (1993a) and Sachs (1990), as well as the investigation made of patients at the hospital SKH Arnsdorf based on the cross-section study with the reference date of 3 October 1990, did not all strictly differentiate between convicted criminals and other patients involuntarily committed to a psychiatric hospital for an indefinite length of time. As a result, these studies may also include a small number of patients who had not committed criminal acts, which directly led to their being committed. The cross-section surveys (dated 1 January 1995 and 1 March 1998) conducted by the author of the present study are exclusively based on patients with a criminal record. The small share of women included in the various studies stated here (see Table 4) reflects the fact that the frequency of female criminality among the general population in Germany is appreciably lower than the male. As can be seen in Table 4, the percentage of female patients treated by the author of the present study has considerably declined since the first study based

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on the reference date of 3 October 1990. By now, this share represented by women now corresponds fairly well to the male–female ratios determined by Leygraf (1988) in studies made in former West Germany. The mean age (see Table 5) for patients at the hospital SKH Arnsdorf was 46.7 at the time when data were gained on the reference day of 3 October 1990. This was slightly higher than the mean age determined by Sachs (1990) for 1988. The mean ages of the patients of the hospital SKH Arnsdorf revealed as per reference dates by the last two surveys were 35.8 and 35.9: still less than the mean age of 39.3 determined by Leygraf (1988) for patients studied in former West Germany. This discrepancy was primarily the result of differences in length of time spent in the respective psychiatric hospitals prior to the patient surveys. Under sociodemographic aspects, the ongoing changes in the distributions for gender and age during the time period covered here (i.e., between 1990 and 1998) have produced a movement away from similarity to distributions prevailing in general clinical psychiatry and toward those demonstrated by the inmate populations of German prisons who are not psychically ill (Leygraf, 1988). The mean age at the beginning of confinement at the hospital SKH Arnsdorf was 35.1 as of the reference date of 3 October 1990, 31.9 for the survey dated 1 January 1995, and 33.0 for the survey dated 1 March 1998. These ages are within the general range of data calculated by Leygraf (1988) for former West Germany. The following must additionally be taken into consideration: the higher age found in former East Germany at the beginning of committal may also result from the practice carried out for patients committed while East Germany still existed. This practice stipulated as general rule that, for those patients who had been sentenced to a prison term in addition to psychiatric confinement, such persons were first required to serve out their complete prison terms before being committed to a psychiatric institution. This East German practice, to be sure, accorded with procedures likewise followed in former West Germany up until its Table 5 Mean age, in years, at the point in time (reference date) when the data were collected, mean age at the beginning of committal, and average previous duration of committal of forensic-psychiatric patients in the hospital SKH Arnsdorf, as compared with the study made by Sachs (1990) and with the cross-section study made by Leygraf (1988) Author

Region studied

Leygraf (1988) Sachs (1990) Konrad (1995a) Konrad (1995a) Konrad (1995a)

West Germany Hospital SKH Arnsdorf Hospital SKH Arnsdorf Hospital SKH Arnsdorf Hospital SKH Arnsdorf

Time covered by study

Mean age at the reference date

Mean age at the beginning of committal

Previous duration of committal

from 1 Jun 1984 to 31 May 1986 30 Nov 1988

39.3

33.0

6.3

43.8

–

9.7

3 Oct 1990

46.7

35.1

11.6

1 Jan 1995

35.8

31.9

3.9

1 Mar 1998

35.9

33.0

2.8

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Second Act in Amendment of Penal Law, although such procedures no longer agree with legal stipulations now valid throughout all of unified Germany. The above-stated discrepancies in average ages are primarily the result of the length of time spent by patients in former East Germany in the psychiatric hospitals. The following development in the mean length of confinement was recorded throughout the course of the three studies stated above: 11.6 years as of 3 October 1990, 3.9 years as of 1 January 1995, and 2.8 years on 1 March 1998. The mean length of confinement thus approached the terms recently recorded in those states of Germany formerly in the West. The average length of committal decreased between 1984 and 1994 from 6.1 to 4.8 years in North RhineWestphalia, the most heavily populated state formerly part of West Germany (Seifert & Leygraf, 1997). The decline in the length of the mean term of confinement in the Arnsdorf hospital is, at the same time, not the consequence of an actual reduction in the length of therapy. Rather, it is primarily due to adjudication of the West German Supreme Court, the Federal Constitutional Court (Bundesverfassungsgericht), before German reunification that psychically ill criminals committed to psychiatric hospitals be released from forensicpsychiatric institutions, regardless of further treatment indication and regardless of their danger to society. The reduction in the length of committal is accordingly the result neither of reorganization of the care provided nor of extensive reintegration into society of psychiatric patients (including the chronically ill). Rather, these shorter terms are the consequence of the redefinition of the legal status of committed patients, especially those who had already been confined for lengthy periods of time. This redefinition had taken place within the context of legal assessment of the ongoing necessity of confinement for the psychically ill, which took place after German reunification. Even though there is no such thing as a ‘‘typical’’ patient committed to a forensicpsychiatric institution in Germany (Seifert & Leygraf, 1997), there are certain unfavorable general conditions, which prevail among numerous such patients. Four-fifths are single, for example, and three-fifths lived without family or spouse relationships immediately before committal to a psychiatric institution in which they were living when data were gathered. Over 80% come from the two lowest social levels. Until the time at which they committed the crime, which lead to their confinement, furthermore, the patients had usually suffered an additional social decline: with the result that over 96% of the patients actually come from one of these two lowest social classes (Seifert & Leygraf, 1997). 4.2. Diagnostic aspects The spectrum of diagnoses of these patients confined on 3 October 1990 demonstrates certain special characteristics (see Table 6). In agreement with the studies made by Lammel (1993a) and Sachs (1990), there was a large percentage of patients with the diagnosis of intellectual subnormality: a phenomenon evidently the result primarily of a lack of alternative medical home and care institutions in former East Germany (Rautenbach & Bach, 1994). Upon study of the chronological development of diagnostic breakdowns of patients treated by the author of the present study, it is clear — in agreement with findings by Lammel (1993b) — that there has been a marked increase in personality disorders. Grouping the share of

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Table 6 Frequency of individual diagnosis groups among forensic-psychiatric patients at hospital SKH Arnsdorf, as of each of the following reference dates: 3 October 1990 (n = 89), 1 January 1995 (n = 32), and 1 March 1998 (n = 45), as compared with studies made by Lammel (1993a; n = 46), Lammel (1993b; n = 60), Leygraf (1988; n = 1973), and Sachs (1990; n = 101) Diagnosis group !

Organic brain Endogenous Personality Intellectual Primary Region studied and period covered by study # disorder psychosis disorder subnormality addiction Hospital SKH Arnsdorf, 30 Nov 1988, (Sachs 1990) Berlin-Buch Psychiatric Hospital, 3 Oct 1990, (Lammel 1993a) Hospital SKH Arnsdorf, 3 Oct 1990, (Konrad, 1994) West Germany, 1984 – 1986, (Leygraf 1988) Berlin-Buch Psychiatric Hospital, 3 Oct 1992, (Lammel 1993b) Hospital SKH Arnsdorf, 1 Jan 1995, (Konrad, 1995a) Hospital SKH Arnsdorf, 1 Mar 1998, (Konrad, 1995a)

7.9

32.7

12.9

27.7

18.8

17.4

13.0

28.3

39.1

2.2

12.3

46.1

4.5

28.1

9.0

6.6

36.5

36.6

16.0

4.3

1.7

11.7

51.7

15.0

16.7

15.6

21.9

25.0

28.1

9.4

24.4

8.9

42.2

20.0

4.4

Figures are in percent.

patients demonstrating both personality disorders with those with intellectual subnormality reveals a joint order of magnitude, which reaches or exceeds that calculated by Leygraf (1988). Indeed, this combined share amounted to something more than half of all patients committed to forensic-psychiatric institutions as of 1 January 1995 and to almost two-thirds of all those confined as of 1 March 1998. This development in the diagnostic breakdown, with a rising share of patients demonstrating nonpsychotic disorders, above all of those with personality disorders, demands the adaptation and further development of specific therapeutic concepts. This requirement applies likewise to the share of patients with primary intellectual subnormality, which is still disproportionally great, and also in comparison to patients being presently committed in former West Germany. For these patients, the creation of enhanced possibilities of care (i.e., by institutions specializing in curative education) outside psychiatric penal institutions could well serve to prevent future crimes from being committed by such persons (Jo¨ckel & Mu¨ller-Isberner, 1994). The increase in the share of addicted patients described by Lammel (1993b) has not occurred in the hospital SKH Arnsdorf. This is because the German State of Saxony has, since German reunification, reserved specialized institutions for the therapy of such persons in accordance with Article 64 of the German Penal Code. 4.3. Forensic aspects As of 3 October 1990, 12.3% of all those patients eventually treated by the author of the present study had been guilty of commission of crimes against life and limb (i.e., homicide

Figures are in percent.

6.5 15.2 6.5 15.2 13.0 23.9 6.5 13.0

27.7 11.2 14.0

12.7

7.2

13.7

10.8 2.7 –

Berlin-Buch East Germany, West Germany, Psychiatric Hospital, 3 Oct 1990 1962 1984 – 1986 (Lange 1963) (Leygraf 1988) (Lammel 1993a)

Homicide <5 Bodily injury 6 Sexual offense with (41) violence Sexual offense without violence Offense against property – with violence Offense against property 20 without violence Arson 7 Miscellaneous offenses <5 20 Offenses with special relevancy to the laws of East Germany

Primary offense #

Region studied and period covered by study !

11.7 – –

10.0

10.0

5.0

8.3 26.7 28.3

Berlin-Buch Psychiatric Hospital, 3 Oct 1992 (Lammel 1993b)

3.4 43.8 20.2

11.2

1.1

6.7

6.7 5.6 1.1

Hospital SKH, Arnsdorf, 3 Oct 1990 (Konrad, 1995a)

15.6 – –

6.3

3.1

18.8

25.0 9.4 21.9

Hospital SKH, Arnsdorf, 1 Jan 1995 (Konrad, 1995a)

15.6 4.4 –

2.2

6.7

20.0

8.9 20.0 22.2

Hospital SKH, Arnsdorf, 1 Mar 1998 (Konrad, 1995a)

Table 7 Overview of the offenses leading to committal of forensic-psychiatric patients in the hospital SKH Arnsdorf as compared with studies made by Lammel (1993a, 1993b), Lange (1963), and Leygraf (1988).

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and personal injury). By the reference date of 1 January 1995, however, this figure had significantly risen up to 34.4%. By the study dated 1 March 1998, this figure, however, had dropped to 28.9% (see Table 7). This development reflects the decision of the German Supreme Court, which involved exemption, by redefinition, of certain perpetrators, especially homicides who are psychically ill, from committal to forensic-psychiatric institutions. The increase in the population at hospital SKH Arnsdorf of such perpetrators was accordingly the immediate result of the closure of the Waldheim Medical Department and transfer of its patients to Arnsdorf. Considered on the whole, this shift toward patients with a record of more serious crimes has in Arnsdorf by now achieved greater similarity with the pattern of crimes committed by patients in institutions studied by Leygraf (1988) in former West Germany. It must be pointed out, however, that, since the study by Leygraf, an increase has been observed in individual of states of former West Germany in the proportion of patients who had committed the most serious crimes, i.e., homicide, bodily injury, violent sexual crimes, and arson. This trend was namely observed in the State of Hesse (Jo¨ckel & Mu¨ller-Isberner, 1994) and in North Rhine-Westphalia (Seifert & Leygraf, 1997). Comparison with the studies made by Lange (1963) is possible only to a very limited extent, owing to grouping, which took place where Lange worked. For example, a report by Lange grouped sexual offenses together with vagrancy and prostitution. In accordance with the results obtained by Lange, one-fifth of all those committed by courts to psychiatric hospitals in former East Germany by 3 October 1990 had been placed there on the basis of offenses, which had special relevancy to the laws of East Germany, e.g., antisocial behavior,2 desertion from the Republic,3 etc. On the other hand, the share of those who had been convicted of murder, and who had been committed to a psychiatric hospital, was relatively low in the various institutions of East Germany. This phenomenon may be explained by the fact that special psychiatric hospital wards were created in East Germany (Waldheim was a prime example) for the concentration of patients who had committed serious crimes. The comparatively low share of sexual offenders reflects tendencies in former East Germany to confine primarily to penal institutions those groups of perpetrators for whom nonpsychotic disorders (e.g., personality disorders, neuroses, and sexual deviations) are frequently diagnosed (Leygraf 1988). This conclusion is supported by the appreciable increase in length of time spent in penal institutions (Table 9) by those patients now committed to forensic-psychiatric institutions, i.e., patients who had evidently, before the opening of East Germany, been frequently sentenced to penal institutions as a result of criminal behavior (approximately three-fourths have a criminal record).

2

For example, East Germany classified absenteeism from the workplace without sufficient excuse as the punishable offense of ‘‘antisocial behavior.’’ 3 ‘‘Desertion from the Republic’’ was the punishable crime of leaving East Germany without permission.

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Table 8 Share of forensic-psychiatric patients at hospital SKH Arnsdorf who had a previous criminal record, as compared with results of a study made by Leygraf (1988) West Germany, 1984 – 1986 (Leygraf 1988) Hospital SKH Arnsdorf as of 3 October 1990 (Konrad, 1995a) Hospital SKH Arnsdorf as of 1 January 1995 (Konrad, 1995a) Hospital SKH Arnsdorf as of 1 March 1998 (Konrad, 1995a)

64.2% 34.8% 71.9% 68.9%

The increasing tendency to commit patients convicted of serious offenses to a psychiatric hospital is associated at the hospital SKH Arnsdorf with an increase of patients with a criminal record (see Table 8). For example, on 3 October 1990, 65.2% of the patients at Arnsdorf had no previous criminal record. By 1 January 1995, the share without a criminal record had sunk to only 28.1%, and by 1 March 1998, this share was 31.1%. Leygraf’s (1988) study disclosed a total of 35.8% who had not been previously convicted of an criminal offense. In the former West German state of North RhineWestphalia, Seifert and Leygraf (1997) observed an increase in the percent of patients with previous criminal records from 63.5% (1984) to 77.5% (1994). As Table 9 reveals, 14.6% of the patients had a record of confinement in a penal institution by the reference date of 3 October 1990. This figure was 58.4% as of 1 January 1995 and 55.6% as of 1 March 1998. Leygraf determined the figure 38.7% (i.e., those without already having served a term of confinement). In addition to a rising record of criminal offenses and confinement to a penal institution, the share of patients at the hospital SKH Arnsdorf likewise demonstrated over the years an increase in the share of those who had been sentenced to penal confinement at the same time as they had been committed to the psychiatric institution (see Table 10). Whereas, on 3 October 1990, 80.9% of the patients had been committed only to the psychiatric hospital (and not to a penal institution), this figure had fallen to only 43.7% by 1 January 1995. The further decrease to 37.8% as of 1 March 1998 corresponds to the simultaneous increase in the diagnosis groups, which include nonpsychotic patients who are psychically disturbed. As a result, conversely, the share of patients who have been committed to a psychiatric hospital, and who have also been sentenced to a penal institution, is significantly greater than in the states of former West Germany, with their share of 34.8% (Leygraf, 1988). In recent years, an increase has also become evident in the states of former West Germany of the share of offenders who have been judged

Table 9 The share of patients at hospital SKH Arnsdorf with a previous record of confinement in a penal institution, as compared with results of a study made by Leygraf (1988) West Germany, 1984 – 1986 (Leygraf 1988) Hospital SKH Arnsdorf as of 3 October 1990 (Konrad, 1995a) Hospital SKH Arnsdorf as of 1 January 1995 (Konrad, 1995a) Hospital SKH Arnsdorf as of 1 March 1998 (Konrad, 1995a)

38.7% 14.6% 58.4% 55.6%

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Table 10 Share of patients at hospital SKH Arnsdorf who had been sentenced to penal confinement at the same time as they had been committed to the psychiatric institution, as compared with results of a study made by Leygraf (1988) West Germany, 1984 – 1986 (Leygraf 1988) Hospital SKH Arnsdorf as of 3 October 1990 (Konrad, 1995a) Hospital SKH Arnsdorf as of 1 January 1995 (Konrad, 1995a) Hospital SKH Arnsdorf as of 1 March 1998 (Konrad, 1995a)

34.8% 19.1% 56.3% 62.2%

criminally responsible to only a diminished extent, and who have received additional sentences to penal institutions, i.e., up to almost half of those who have been committed by courts to a psychiatric hospital (Seifert & Leygraf, 1997 for North Rhine-Westphalia).

5. Conclusion This longitudinal study, performed within the context of three reference-date surveys, was based on secondary analyses of case histories archived in SKH Arnsdorf in former East Germany. The results disclose for the forensic-psychiatric clientele a change in the diagnosis spectrum after German reunification, i.e., an increasing share of patients with nonpsychotic disturbances. This development — and the still high share, when compared to the states of former West Germany, of patients primarily with intellectual subnormality — necessitates the adaptation and further development of specific therapeutic concepts. Under forensic standpoints, the following trend has become apparent: an increase in patients with a previous criminal record and with a history of confinement in penal institutions. This development entails a more pronounced permeation of ward environment by subcultural influences — a phenomenon, which will of necessity have an influence on therapy concepts. The distribution of the individual offense classifications over the course of years covered by these studies, and especially the increase in the share of patients who have been committed to a psychiatric hospital on the basis of sexual offenses as well as offenses against life and limb, allows certain conclusions in conjunction with the other development tendencies. One salient conclusion may be formulated thusly: as of the date of the present study, it is apparent that the forensicpsychiatric patients to be cared for in the hospital SKH Arnsdorf has already come to a point of close correlation, with respect to their special characteristics covered here, to the clientele committed by court to forensic hospitals in the states of former West Germany (Leygraf, 1988). On the other hand, it must be taken into consideration not only for the hospital SKH Arnsdorf but also for many other institutions in the states of former East Germany that the conditions regarding materials, organization, and staff are not capable of satisfactorily meeting the specific needs of therapy and security (Dahle, 1995). The most urgent requirements here include the equipping of stand-alone treatment units with adequate capacity of treatment places.

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