Switzerland is a federal state of 26 cantons, organised into three inter-cantonal concordats for the purposes of sentencing and therapeutic measures (the Latin cantons, East Switzerland, and Central and North West Switzerland). Individual cantons are relatively autonomous with regards the implementation of sentences and care orders. Twenty-five cantons have at least one prison each, while a dozen have one or more specific psychiatric facilities for people declared not to be responsible for their crimes by reason of mental ill-health.

People declared not criminally responsible are subject to therapeutic measures. A judge may order:

• “In-patient treatment” is carried out in a specific psychiatric institution, or in a prison facility where appropriate care is available. These measures are intended to reduce the risk of reoffending. Treatment is particularly focused on the crime committed and should eventually lead to rehabilitation.
• “Indefinite incarceration“ where the person has committed a crime with the intent “to cause serious detriment to the physical, psychological or sexual integrity of another person”. Such measures must be executed within a psychiatric facility. Some people who have been sentenced to indefinite incarceration are placed in prison. These orders are issued where the seriousness of the crime and an evaluation of the person’s dangerousness suggest they will not be able to be rehabilitated into society. Such orders are therefore not intended to treat the person’s mental illness. No time limit is fixed.
• “Out-patient treatment”. People suffering from serious psychological problems and substance dependence may be subject to out-patient treatment. In the case a prison sentence has been imposed at the same time, the judge may suspend its execution if they deem it incompatible with the treatment.

In 2018, there were nearly 960 people subject to therapeutic measures, of whom 543 were sentenced to in-patient treatment, and 148 were sentenced to indefinite incarceration.

Nearly 60% of people subject to in-patient treatment are placed in prison. Some are in high security settings, where conditions are similar to solitary confinement. In 2018, The European Court of Human Rights found Switzerland to be in violation of its human rights obligations in the case of a man suffering mental ill-health who was placed in a prison that did not have a psychiatry service.

Prisoners. Prisoners with mental health problems are usually placed in ordinary prison regimes. Limmattal prison has an “urgent care service” for prisoners experiencing a mental health crisis. The service has four shared cells and one individual cell.

Prisoners on therapeutic measures. Prisoners subject to in-patient treatment can be detained in a prison, if the facility has the necessary equipment and specially trained staff. These prisoners may be placed in dedicated areas of the prison, but due to the lack of mental health cells or wings, and the increase in numbers of prisoners on such measures, they are most often placed on ordinary prison regimes.
Prisoners who are sentenced to indefinite incarceration, and those on in-patient treatment who are deemed to be high-risk, are usually detained in high-security units. The European Committee for the Prevention of Torture (CPT) found that conditions in such units, where very little treatment is provided, were akin to solitary confinement. The CPT considers such placements, which can last several months and even years, to be “particularly dangerous”.

There are two psychiatric wings at Orbe Plain prison in Vaud canton. These wings are for prisoners with severe mental illness and those subject to in-patient treatment. Prisoners on therapeutic measures who require intensive care take up a considerable proportion of the nursing team’s capacity, meaning nurses are less available for other prisoners. Orbe Plain prison does not have enough capacity in these services, with, in 2015, only eight spaces available for the 55 people who were on treatment orders.

Access to mental healthcare¶

A prisoner should be seen by a healthcare professional within the first 24 hours of their incarceration. The initial appointment should include a questionnaire that covers addictions, suicidal tendencies and mental health. If the medical team at Champ Dollon prison in Geneva identify a mental health problem, they refer the prisoner to a general practitioner or psychiatrist.
The CPT found that, in Schwyz prison, the questionnaire is completed by prison officers and does not include an examination by a doctor. It noted that in Stampa and Farera prisons (Ticino canton) the medical examination only takes place some four or five days after arrival.
Prisoners wait on average three months to see a psychologist. In July 2018, in Champ-Dollon prison, more than 40 prisoners were on the waiting list for an appointment with the psychologist. Prisoners on therapeutic measures wait on average one month.

Provision of mental health treatment¶

Prisoners. A treatment plan should be appended to the individual sentence plan of a prisoner experiencing mental ill-health. No such treatment plans are made in Basel-City canton. However, prisoners do have access to appointments with mental health professionals. At these appointments the prisoner’s needs are assessed to ensure that detention is not unreasonably detrimental to their mental health.
Prisoners at Champ-Dollon prison may be put on a psychiatric treatment plan under the care of a psychiatrist. The psychiatrist provides regular consultations and psychologists run weekly group therapy sessions. The most common treatment option is medication.

Prisoners on therapeutic measures. Prisons housing people on in-patient treatment are supposed to put in place a ‘treatment implementation plan’ on arrival to prison. In reality however, there is often a delay of up to several months before such a plan is put in place. Prisoners on indefinite incarceration have no such treatment plan. They can, if they wish, request treatment from the psychiatrist but the decision to treat remains at the psychiatrist’s discretion. Any such treatment would focus on the prevention of reoffending.

Prisoners with addictions. Monitoring of prisoners with substance addictions varies widely between cantons. In some cantons, treatment is provided by an external service that specialises in substance abuse. Treatment may include substitution programmes. Prisoners who have begun a substitution programme prior to incarceration are able to continue the programme. In Vaud canton, psychotherapy and specific programmes for addiction or perpetrators of sexual offences are available.

Medical staff¶

The composition of prison mental healthcare teams varies by canton. Generally, medical teams are made up of general practitioners, psychiatrists and nursing staff. Some prisons also employ psychologists. The largest prison facilities have several doctors, psychiatrists and psychologists on a permanent rota basis. These psychologists then offer clinics several times a week in the smaller facilities. In Basel-Country canton, psychiatrists are available only if required. The women’s prison at Hindelbank (Berne) has a visiting psychiatrist twice a week, and a psychologist is available Monday-Friday.

Some cantons, including Zoug, St. Gall, Appenzell Outer-Rhodes and Soleure, have no mental healthcare teams based in the prisons. Rather, visiting psychiatrists regularly attend to provide care.

The psychiatric units of Orbe Plain prison in Vaud have only one clinical lead and there is a high turnover of staff in the mental healthcare teams. Therapists often change every two months, which means that treatment programmes must start again from the beginning. The Geneva Grand Council (Prison) Visiting Committee (Commission des visiteurs du Grand Conseil) reported several complaints received from prisoners on therapeutic measures about the lack of availability of psychiatrist appointments.

Medical confidentiality¶

Requests for medical appointments in prison are usually made in writing, via a post system, to prison nursing staff. However, in small facilities it is prison staff who deal with the requests.
Medical appointments are usually confidential. The CPT found however, that in Schwyz prison, officers are routinely present during consultations. Medical files are not kept securely, and can be accessed electronically in some facilities. Prison officers therefore have direct access to prisoners’ medication records.
Medication is usually prescribed, prepared and distributed by healthcare professionals. In the evenings and at weekends, prison officers distribute medication.
The CPT found that in Stampa and Farera prisons, prison officers are responsible for preparing medication. This is also the case in Schwyz prison when healthcare staff are not available.

Emergency measures¶

There is no federal legislation governing treatment of a prisoner in the event of a mental health crisis. Some cantons transfer prisoners in crisis to a psychiatric ward if the prison facility is unable to meet the prisoner’s needs. The prisoner may be placed in solitary confinement whilst awaiting transfer. Prisons in Vaud canton rarely use solitary confinement in such cases, and ensure medical observation throughout any such placement.

A “crisis intervention service” in Limmattal prison takes prisoners in mental health crisis from any of the five prisons in Zurich canton. Prisoners may remain in the facility for up to ten weeks. In 2019, the service had 40 prisoner-patients¹.

In an emergency, medication can be forcibly administered, in accordance with the same rules as for non-incarcerated patients, i.e. only where there exists a serious risk of harm to the prisoner or to others. Mechanical restraint can also be used for several hours.² In Hindelbank prison, such a measure can be prescribed by a nurse and overseen by the prison doctor.

Prison officer training¶

Prison officers undergo basic mental health training lasting approximately five days. The training covers the range of psychiatric disorders and how to prevent suicides. Officers may also volunteer for further training on managing prisoners with mental disorders, which lasts approximately two weeks. This training is supplemented with a three-week placement in a psychiatric ward.

Continuity of treatment¶

If a prisoner who is in the process of being released experiences mental ill-health, a judge may impose an “in-patient treatment measure”.

Involuntary admission¶

Individuals sentenced to in-patient treatment may be committed to psychiatric hospital by a judge.

A study by Berne University found that in 2014, 19% of people on such orders were placed in psychiatric hospitals.

Transfers from prison¶

Prisoners experiencing a mental health crisis are transferred to a psychiatric hospital. The judge can order a care-related hospitalisation measure to commit the patient to an appropriate institution. A doctor can request such an admission in an emergency, or if the prisoner is refusing treatment.
Timescales for transfer to hospital can be very long, due to a lack of available bed-spaces. One individual on a treatment order remained in remand custody for more than 410 days awaiting transfer to a specialist facility.

Where a prisoner has their sentence suspended for medical reasons, a judge may substitute a prison sentence by a therapeutic measure.

Legal framework¶

In-patient treatment measures are limited to five years. They are reviewed annually and can be renewed indefinitely by a judge. Medical assessments of a prisoner’s mental state should take place at regular intervals to assess conditions of the measure and to plan for conditional release. In Fribourg canton, such assessments do not take place regularly, but rather every three to four years, on average.
Prisoners are often refused release on the basis of their risk of reoffending.

A care-related hospitalisation measure as decided by a judge is without maximum duration. Cantonal law usually limits the duration of such admissions to six weeks. Individuals in psychiatric crisis usually spend two to three days in hospital or on a mental health ward. The medical team decides when they can be returned to prison. Individuals on “care-related hospitalisation”, or their next of kin, can at any time request their discharge. In the year following a “care-related hospitalisation” the prisoner’s mental health should be assessed twice, and at least once a year in subsequent years.

Daily life¶

Offenders are rarely admitted to general psychiatric hospitals. Some psychiatric hospitals have dedicated sections or wards for prisoners or prisoners on therapeutic measures. Conditions for these prisoners vary from one canton to another, but are usually similar to conditions for other patients, with the exception of permission to leave the premises.
Prisoners are usually handcuffed during transfer to and from hospital or psychiatric facilities and are escorted by the police.

Continuity of treatment¶

A prisoner on an “in-patient treatment” is conditionally released on completion of their treatment. The person is then under probation (conditional release) for between one and three years, during which time they are under the care of a mental healthcare team. The probation period can be renewed for between one and five years. Once the probation period is complete, the person is released.

Individuals subject to in-patient treatment or indefinite incarceration must be placed in specialist psychiatric facilities for offenders. These facilities exist in a dozen cantons. Depending on the canton, they are either administered by the Ministry of Justice or the Department of Health. Individuals on orders may also be placed in one of Switzerland’s seven forensic psychiatric units.
The Psychiatric University Clinic (Universitare Psychiatrische Klinkiken, UPK) in Basel also has 35 bed-spaces for prisoners and prisoners on therapeutic measures. The Psychiatric Prison Hospital (Unité hospitalière psychiatrique pénitentiaire, UHPP) at Curabilis prison in Geneva is the only such specialist facility in French-speaking Switzerland. The UHPP currently takes individuals detained on “care-related hospitalisation” and prisoners on detoxification measures. Some psychiatric facilities and hospitals also have specialist services for offenders.

Transfers to hospital. There is often a long wait for prisoners to be transferred to hospital. The CPT found that waiting times can exceed 18 months. Prisoners awaiting transfer to hospital are usually detained in prisons.

In-patient treatment period. A prisoner subject to an in-patient treatment measure is usually placed in a specialist facility for five to six years.

In-patient treatment measure review. In-patient treatment measures are limited to five years and can be indefinitely renewed. This is typically the case when a prisoner is ”unable to demonstrate” their ability to function in the community. Indefinite incarceration measures have no maximum duration.
Prisoners on therapeutic measures detained in specialist facilities have the same legal rights as patients in ordinary psychiatric wards.

Daily life ¶

Conditions for prisoner-patients vary from one facility to the next. Prisoner-patients usually have some degree of freedom of movement: time spent in cells is brief and they are able to participate in activities.
Prisoner-patients in the Bitzi facility (Saint-Gall) undertake the ordinary tasks of daily life. They do their own laundry, cooking and cleaning. A range of learning opportunities is available in the ‘open’ section of the prison to maximise entry to employment on release. Prisoner-patients in the ‘closed’ section of the facility can work in prison industries and undertake basic training.¹
In Curabilis prison there are five wings of approximately 15 bed-spaces each. Prisoner-patients eat together and interact with the healthcare team. A wide range of activities is offered including cooking and carpentry workshops. A broad programme of therapies is available. Work-related training is provided by voluntary sector organisations.
Prisoners in Basel University Psychiatric Clinic (UPK) are not allowed to leave the premises. They may exercise in a secure outdoor area for at least an hour a day. There are no security personnel at the facility, but rather, an enhanced medical team.

Prisoner-patients may incur disciplinary sanctions. The Rheinau facility (Zurich) uses “treatment sanctions” including periods of solitary confinement. There is no system of appeal against such punishments.
Solitary confinement is also used as a disciplinary sanction in Curabilis prison. The CPT found the material conditions of solitary confinement rooms to be adequate. Prisoner-patients can be confined to solitary confinement cells for up to 10 days. Transfers to solitary confinement may be undertaken by the “Cell Intervention Unit”: a team of prison officers who are authorised to use force and are equipped with balaclavas, shields and handcuffs.

Treatment plans¶

A treatment plan should be put in place with the patient on admission to a specialist facility. Every patient should be assigned a lead psychiatrist. In reality, many patients wait months, even years, without an agreed plan. In 2016, only a third of patients in Curabilis prison had an individual treatment plan. In Bitzi prison, treatment plans are put in place on average 12-15 weeks after admission.²

The type of treatment available varies depending on the facility. The forensic units at Rheinau and Curabilis utilise more individual therapy than group therapy. The administration of medication against a prisoner’s wishes is permitted where it is medically necessary. Such non-consensual measures are administered without formal decision. Medical teams rarely record the reason for or duration of such measures.

At Basel University Psychiatric Clinic (UPK), patients who are on antiandrogen treatment are not always told about the effects of the treatment or of their right to refuse it. Their consent is not requested. The CPT found that some patients erroneously believed their antiandrogen treatment to have been ordered by the court, and that they had no choice but to take it.

Training¶

There is no legal requirement for training of prison officers or healthcare staff in specialist centres. They may attend joint training on the management of psychiatric crises.

Healthcare staff training. At the psychiatric unit at Soleure prison there is no specific training requirement for healthcare staff. At Hindelbank prison, staff usually have a training background in psychiatry or socio-pedagogy.

Prison officer training. Specific training for prison officers in specialist facilities was introduced in 2016. As of 2019, nearly 87% of prison officers in these settings have completed the training and hold a nationally recognised qualification in mental health care.
In Soleure and Hindelbank prisons, some officers are also trained psychotherapists.

Continuity of treatment¶

Individuals on ‘in-patient treatment’ are conditionally discharged at the end of their order. A ‘probation’ period is imposed for between one and three years following discharge, during which the individual is under the care of a mental health care team. The probationary period can then be renewed for a further one to five years. Once completed, the individual is then released.

Individuals on indefinite incarceration measures must undergo a medical assessment before they can request conditional release. This assessment is only undertaken if healthcare professionals agree that there has been an improvement in the patient’s mental health. Indefinite incarceration is sometimes commuted to in-patient treatment. In practice, few prisoners are actually released. Healthcare professionals are averse to the risk of reoffending and often prevent release for this reason.

Between 2004 and 2017 only 2% of prisoners on in-patient treatment were granted conditional release.