Germany is a federal republic divided into 16 constituent states, or Länder. The Ministry of Justice oversees prison health care. Federal law does not provide for any mental health care in prison. The Länder, which have considerable autonomy over the organisation of their prison and health care systems, implement treatment measures. Significant variations have been observed from one territory and facility to another.

The ‘double-track’ system (Zweispurigkeit) applies to individuals suffering from mental illness or addiction at the time they commit an offence. If they are declared not criminally responsible, they are subjected to treatment orders, so-called preventive measures. If their judgment was only impaired at the time of the event, they receive a sentence. Both sentences can occur concurrently. The individual is first subject to treatment measures before entering a correctional facility.

There are many people suffering from mental disorders in prison. Some of them have not undergone a psychiatric evaluation, while others end up there when the connection between their offence and their disorder has not been established. In some Länder, forensic hospitals, which oversee physical care, include psychiatric care services known as psychiatry and psychotherapy units (Abteilung für Psychiatrie und Psychotherapie, APP). These departments admit prisoners who are in crisis or present a suicide risk. General psychiatric hospitals also admit prisoners in emergency situations.

Prisoners under preventive measures are placed in forensic psychiatric hospitals (Maßregelvollzug) pursuant to federal law. There are two types of forensic psychiatric hospitals: those for the mentally ill, and those for people suffering from addiction. Some hospitals admit both groups.

Nearly 6,300 people were in forensic psychiatric hospitals in 2017. The National Agency for the Prevention of Torture (Nationale Stelle zur Verhütung von Folter), the National Preventive Mechanism (NPM), has reported overpopulation in some facilities. Rooms measuring less than 18 m2 accommodate around three patients, and beds are placed in the hallways when the rooms are full. The Committee for the Prevention of Torture (CPT) reported on incidents of verbal and physical abuse by health care staff in the forensic psychiatric hospitals of Brandenburg and Wasserburg. The CPT observed prolonged use of mechanical restraint, which could total up to 700 hours in one year.

No national census has been taken regarding the percentage of prisoners with mental disorders. The ministries of justice for the various Länder confirm that the numbers are high and continue to increase.
An expert commission determined that the number of prisoners with mental disorders in the Land of Bade-Wurttemberg potentially represents between 40 and 70% of the prison population. These data are based on several studies conducted between 2005 and 2010 that combined behavioural disorders with those linked to psychoactive drug use.

Mentally ill prisoners are largely kept in general units. Their behavioural disorders are generally punished, and placement in disciplinary cells is common. Some prisons have implemented daytime treatment units.

Most Länder have ‘socio-therapeutic units’ (SothA). They admit individuals sentenced to two or more years for a sex-related offence or serious injury to others. Other prisoners who do not meet these criteria may be admitted with permission from the unit heads. In the Land of Berlin, the SothA accommodates prisoners previously placed in APPs.
In the Sotha, prisoners are separated from the rest of the prison population and housed in ‘communal living units’ (Wohngruppen), consisting of cells, therapy rooms, and common facilities, including a kitchen.

Access to mental healthcare¶

A general practitioner or nurse performs an examination within 24 hours of incarceration. The CPT reported on the varying quality of the visits. It also indicated that several prisoners complained of the lack of interpreters during consultations.
The physician evaluates for suicide risk and presence of addiction and transmits this information to the prison psychologist or psychiatrist if deemed necessary. In Grünstadt, each incoming prisoner has a consultation with the psychologists from the ‘orientation unit’.

Provision of mental health treatment¶

The prison administration is required to implement a personalised follow-up for each incoming prisoner. All prisoners have access to ambulatory psychiatric care in prison at the discretion of the Länder. External general practitioners generally provide this care. Consultations may take place outside the prison in the Länder of Saarland and Rhineland-Palatinate. Prisoners with personality disorders can pursue psychotherapy in certain facilities. Non-German-speaking prisoners generally do not have access. The SothA ensures psychological and psychotherapeutic treatment of prisoners deemed capable of undertaking this work. Art and work therapies are offered to help with rehabilitation and prevent reoffending.

Out of 179 correctional facilities, six include a psychiatric day unit. These units aim to establish a psychiatric diagnosis and to stabilise prisoners in crisis before their return to ordinary prison regime. Prison infirmaries sometimes include psychiatric beds. The Berlin prison has a psychotherapeutic unit, which offers voluntary prisoners various therapies: individual, behavioural or long-term.

Medical staff¶

A team comprised of psychologists, educators and social workers is responsible for the follow-up of prisoners in the SothA. The CPT observed that in Celle and Tonna prisons, a psychiatrist visits prisoners once a week. It noted that in all the facilities visited, including those with a care unit, nursing staff are only present during the day. The CPT recommended, for example, the permanent presence of at least one mental health care professional in Kaisheim Prison.

Medical confidentiality¶

Requests for consultation are made in writing or orally, depending on the facility. Confidentiality is not always maintained, namely in cases of addiction or self-mutilation. The CPT observed that nurses prepare the medication, including psychotropic drugs, which the guards then distribute in the Celle and Kaisheim prisons. It recommended that health care staff handle the distribution.

Emergency measures¶

Prisoners experiencing a mental health crisis are transferred to a forensic hospital with a psychiatric unit (Justizvollzugskrankenhaus, JVKH, APP). The transfer is made upon joint decision of the prison physician and the forensic hospital psychiatrist. In Grünstadt, the person is first received in the prison hospital emergency department if no psychiatrist has given their recommendation. Women do not have access to the psychiatric department of the forensic hospital in Grünstadt.¹ The healthcare staff considers the single-sex department ill-equipped for them.

Prisons may sign local contracts with forensic psychiatric hospitals for them to provide care for prisoners in crisis, for example, at Rostock Hospital. If there is no available space in specific prisoner facilities, the person may be redirected to the psychiatry department of a general hospital. Transfers of prisoners in crisis are often difficult due to the lack of space.

Treatment can be administered without the individual’s consent if they pose a serious threat to their life or that of another person. It must be reasonable and not endanger the life or health of the prisoner. The physician prescribes and supervises the treatment, as far as possible.

Prison officer training¶

Prison guards take psychology and criminology classes during their training, completed by internships. During the performance of their job duties, they can pursue additional psychology training provided through associations. In Grünstadt, the guards known as ‘group leaders’ are trained in the management of prisoners with mental disorders or presenting a suicide risk. In 2012, half of the prison staff of 3,000 received training in mental health care.

Continuity of treatment¶

Prisoners may be subject to social and legal supervision upon release from prison. This may be paired with a psychiatric, psychotherapeutic, or socio-therapeutic follow-up. The judge may order a follow-up at a doctor or therapist’s office or an ambulatory forensic care centre. The judge may impose a treatment order known as ‘preventive detention’ in a specialised facility. This measure is reserved for prisoners considered dangerous.

Forensic care centres handle treatment of these individuals and ensure compliance with their obligations. They communicate information considered confidential to the judicial authorities in case of reoffence.

In Berlin, a forensic ambulatory therapy clinic (FTA) admits individuals released from one of the city prisons. The FTA houses individuals released due to a health status incompatible with incarceration but still considered dangerous, as well as sex offenders. It has 50 spots. It does not provide medication but does offer therapy.

Involuntary admission¶

General psychiatric hospitals admit individuals that have committed offences but have been declared not criminally responsible and deemed not dangerous. These are generally psychotic patients.
Substance-dependent and mentally ill individuals must be placed in a general psychiatric hospital. In practice, some psychiatrists or judges send them to a drug treatment centre to avoid admission for an indefinite period.

Transfers from prison¶

A prisoner must be transferred to a general psychiatric hospital if a more suitable treatment can be provided in this facility. In practice, they are transferred only in case of emergency or when they present a danger to themselves or others. General psychiatric hospitals regularly refuse prisoners arguing safety concerns for the staff and other patients. Most general psychiatric hospitals in North Rhine-Westphalia and Rhineland-Palatinate refuse to admit prisoners.

Rules for involuntary hospitalisation of a prisoner are the same as for a regular patient. The competent public authority of each Land requests hospitalisation from the ordinary court. The judge must hear the person in question, and the measure can only be ordered following a psychiatric evaluation. In the case of an emergency, the court may issue a provisional placement order, without hearing from the patient. During hospitalisation, the sentence is suspended.

Transfers from prison to a general psychiatric hospital are often difficult due to a lack of space. The CPT reported that in Tonna prison, a prisoner was placed in a ‘security cell’ for several days in a state of acute psychosis. His transfer to a psychiatric facility had been refused due to the lack of beds.

General psychiatric hospitals in North Rhine-Westphalia admit patients transferred from the forensic psychiatric hospitals who are not considered dangerous and are at the final stage of their treatment. A psychiatric assessment is required to approve the transfer.

Legal framework¶

In principle, involuntary placements cannot exceed one year. It frequently goes beyond this duration. A new psychiatric evaluation and patient hearing are necessary to renew the measure. If the measure lasts more than four years, a change of psychiatric expert is requested. For provisional proceedings, the hospitalisation period cannot exceed six weeks. The person subject to the involuntary placement order may lodge an appeal against this decision within a one-month period. This period is shortened to two weeks in cases of provisional proceedings.

Daily life¶

Prisoners are generally not separated from the other patients. Some hospitals have intensive care units reserved for prisoners. These units are small and not suitable for prolonged stays. Mechanical restraint measures must be limited to 24 hours in North Rhine-Westphalia. Their renewal must be approved by a judge.
Prisoners admitted to general psychiatric hospitals are escorted by prison guards or police officers.

Continuity of treatment¶

Some Länder provide for follow-up care with external psychosocial services. It can be imposed without consent.

Forensic psychiatric hospitals¶

Eighty ‘forensic psychiatric hospitals’ (Maßregelvollzug) admit individuals who have committed offences and require compulsory treatment. The number of places varies between Länder. Forensic psychiatric hospitals may be part of a hospital complex, for example, in Dortmund and Rostock. The regional health ministries administer them. In the Land of Mecklenburg-Western Pomerania, the security of these facilities falls under the responsibility of the Ministry of Justice.

Forensic psychiatric hospitals can admit patients before their judgment. The court may order temporary detention if it deems the measure necessary for public safety. Following judgment, the court can impose a treatment order measure in the same facility.
Some facilities have a contract with a prison to admit prisoners in case of a mental crisis; this is the case for the forensic psychiatric hospitals in Rostock, Schleswig-Holstein, Saarland, and Bremen.

Some facilities only admit individuals subjected to treatment orders for mental disorder. Others also admit prisoners undergoing compulsory treatment for addiction. The forensic psychiatric hospital in Rostock, previously specialised in the treatment of substance abuse, now has 20 places for people suffering from mental illness.
Their legal objective is to provide adequate treatment for the individual’s mental disorder, thereby reducing the risk of reoffence. However, when treatment orders have been imposed in recent years, security seems to have taken precedence over a successful treatment.

Transfer. Individuals may be transferred to a forensic psychiatric hospital several months after the transfer decision due to a lack of beds. The Grünstadt facility rarely admits women due to a lack of space and considers mixed-sex services unsuitable.

Placement duration. The duration of stay in a forensic psychiatric hospital depends on the Länder. The CPT reported that the average is over nine years in Brandenburg, while it is three years in Wasserburg.

Measure review. The forensic psychiatric hospital team reviews the prisoner’s individual plan every six months. If treatment is successful, the court re-examines the placement measure.
Placement review is legally stipulated every three years before the sentence enforcement court. An expert evaluates the improvement of the person’s mental state. The measure comes to an end if the criteria justifying placement are no longer met.
Only a heightened risk of reoffending can provoke an extension of the measure beyond six years. It can also be extended past ten years if the court considers the patient to be at risk of committing a crime. Prisoners can appeal the placement decision. The procedure is similar to the appeal process for a prison sentence.

Daily life¶

The hospitalisation conditions must lay the ground work for the patient’s reintroduction into everyday society. The rooms are either single or double, and there are numerous common areas.
The care team may decide on access to work if it is considered beneficial; professional training is offered. Prisoners can work outside in internships. The Land of North Rhine-Westphalia specifies that living conditions in the forensic psychiatric hospital must be similar to those outside.
Patients’ freedom may be restricted if it is essential to preventing serious danger. These may apply to visits, phone calls, or access to activities.

Forensic psychiatric hospitals can hire security guards. This practice varies between Länder. In most facilities, the surveillance staff exclusively monitors the building exterior. At the Rostock forensic hospital, the windows are equipped with bars, and the facility does not have a watchtower.

The physician can decide on solitary confinement and mechanical or chemical restraint. In Bavaria, Brandenburg and Berlin, this measure aims to prevent the risk of assault. The CPT has noted that physical restraint generally occurs without monitoring by health care staff.
Court-approved mechanical restraint cannot last longer than 24 hours in Bavaria. In North Rhine-Westphalia, court action is only necessary after 72 hours of restraint.
The CPT reported several abuse cases at the Brandenburg forensic psychiatric hospital. One person was subjected to restraint measures more than 50 times in one year, or 700 hours. Handcuffs are used in the beginning or even for the duration of the measure. This practice violates CPT recommendations advising the use of padded fabric straps. The NPM reported that mechanical restraint may have exceeded 800 hours per year, and the periods of solitary confinement lasted up to one year.¹

The CPT has noted that in most Länder, disciplinary sanctions may be imposed on patients, which it notes is not the case in other European countries.

Disciplinary sanctions vary according to the Länder. In Bavaria patients may be deprived of walks, television, or radio for a week. They can be excluded from group activities or work for a month.
The CPT reported that in Saxony-Anhalt, forensic psychiatric patients can be confined in their room, for up to four weeks, as a disciplinary sanction.

Treatment plans¶

An individual treatment plan is developed for each patient based on their illness and can include pharmacotherapy or psychotherapy. The CPT reported that in Wasserburg, the care team often draws up individual treatment plans without consulting the patients concerned. Group, sports, and education therapies are routinely offered. ‘De-escalation’ techniques and nonviolent communication workshops are also available. In Rostock individual therapy is scheduled once a week in addition to group therapy. Substitution therapy is available for drug-dependent individuals. Specific programmes are scheduled for patients who have committed sex offences. In Rostock a programme for violent offenders is being implemented. The CPT has noted that patients at Brandenburg hospital who have committed violent sex offences are subject to anti-androgen treatment (chemical castration). It has reported on the absence of the required written proof of consent. Several patients have spoken out about physician pressure to accept these treatments. Surgical castration is legally possible for sex offenders, but it was not practised between 2013 and 2015.

Recourse to involuntary treatment varies according to the Länder, but generally, it requires the authorisation of a judge. In Bavaria, the patient must give written consent for the treatment, except in emergency cases. Involuntary anti-androgen treatment must be subject to court order. In North Rhine-Westphalia, endangerment of the patient or another’s life justifies involuntary treatment. In Mecklenburg-Western Pomerania, the court provides for a maximum duration of involuntary treatment. These measures are rare and often reserved for those suffering from a psychotic disorder who present a risk to others.
The CPT has expressed reservations regarding the informed consent process of patients who must undergo anti-androgen therapy at Brandenburg prison. Some people have testified to the use of threats in cases of treatment refusal.

Training¶

Healthcare staff training Upon being hired, the healthcare staff takes a training course on how to deal with forensic patients. This includes classes on therapeutic treatment and behavioural disorders, as well as law classes. Several Länder require the staff to take a training course once a year on restraint measures and mental health crisis management.

Security staff training The forensic psychiatric hospitals can hire security guards, depending on the Länder. In most facilities, the security staff exclusively monitors the building exterior.

Continuity of treatment¶

Prisoners are subject to social and legal monitoring upon their release. Various social workers meet with the medical team to prepare for release. Patients from some forensic psychiatric hospitals may be placed in a residential centre for several years, where they receive ambulatory treatment. The Berlin ‘forensic ambulatory therapy clinic’ (FTA) admits outgoing patients from forensic psychiatric hospitals identified as liable to commit violent or sex offences.

Psychiatric units of forensic hospitals¶

Five forensic hospitals have psychiatric units (APP). The Länder introduced these units to address the lack of mental health care in prison and the lack of space in psychiatric hospitals. They report to the regional Ministry of Justice.
The Grünstadt prison hospital medical team is employed by the prison administration. These employees, nurses by profession, take a six-month training course for prison guards.

The APPs admit prisoners if they can provide more appropriate treatment. In practice, they admit prisoners who require full hospitalisation due to a severe mental health disorder or heightened suicide risk. The APPs refuse to admit women.

Individual consent is necessary to enter an APP. In some cases, the teams strongly insist or place the person in a security cell until they accept the hospitalisation measure. The court does not intervene at any point in the process; the prison hospital physicians decide the patient’s fate. The Grünstadt APP medical team visits the prisons each week to identify prisoners who require hospitalisation.
There is no recourse to appeal against an APP placement.

Daily life¶

In the Grünstadt APP, prisoners receive therapy. They benefit from common activities, such as watching television. Hospital vocabulary is highly present, with references to ‘rooms’, ‘patients’, and ‘therapeutic activities.’ Patients only have free time in the morning.
Placement in solitary confinement is subject to the same rules as in standard hospital departments.

Treatment plans¶

The Grünstadt APP medical team has developed an individual treatment project. Heavy neuroleptic treatments are often administered. Several group therapy sessions are offered, such as ‘psychoeducation’ for schizophrenic patients.
Group therapy sessions are organised for drug-dependent individuals at the Berlin APP.

Involuntary treatment, including pharmacotherapy, is possible under judicial supervision if the patient seems highly aggressive.

Training¶

Psychiatric departments of forensic hospitals exclusively employ healthcare staff. Nurses take a six-month training course with the prison administration. Healthcare professionals generally receive training in forensic care.

Continuity of treatment¶

The APP contacts external ambulatory care facilities willing to accept the prisoner upon release. A personalised treatment recommendation letter is sent.