The German Forensic System and the Contribution of the Nursing Staff

1
The German Forensic System and the Contribution
of the Nursing Staff
Dieter Böcherer, Ward 24, Forensic Department ZPE
Emmendingen, South-West Germany (Black Forest)

• Based on the nursing work of a treatment ward
  for clients with personality disorders in the
  Psychiatry Center of Emmendingen(ZPE),South-West
  Germany

2
Admittance only after committing a criminal
offence

• A. in connection with a mental disorder
  unlimited accomodation
• B. in connection with drug
  addiction accomodation up to two years

3
The national German Rules are standardized I

• 20
• Innocent because of mental disorder
• t without fault act, are who at inspection of the
  deed because of a diseasedly spiritual
  disturbance (psychosis), because of a
  far-reaching consciousness disturbance (emotion
  deed in narrower meaning) or because of mental
  deficiency feeble-mindedness (inferior talent) or
  incapable of another spiritual Abartigkeit
  (personality disturbance) to see the wrong of the
  deed or to trade after this look.
• 21
• Reduced debt ability
• If the ability of the perpetrator to see the
  wrong of the deed or to trade after this look is
  reduced considerably from one in 20 described
  reasons at inspection of the deed, then the
  punishment can be moderated according to 49,
  paragraph. 1.

4
The German legislation is standardized II

• 63
• Accommodation in a psychiatric hospital
• Somebody has an illegal deed in the condition of
  the debt inability ( 20) or the debt ability
  reduced, ( 21), done the court orders the
  accommodation in a psychiatric hospital then, if
  the complete appreciation of the perpetrator and
  his deed yields, on that of him, because of his
  condition considerable illegal deeds have to be
  expected and therefore he is dangerous for the
  general public.
• 64
• Accommodation in a withdrawal institution
• ( )take alcoholic drinks or other intoxicating
  remedies as himself in the excess has somebody
  the slope and he becomes because of an illegal
  deed which he has committed in the high or which
  his slope open passes over because his proved
  debt inability, sentenced or not sentenced only
  therefore, or doesn't have to be excluded, the
  court orders the accommodation in a withdrawal
  institution then, if the danger insists that he
  will commit considerable illegal deeds because of
  his slope.
• ( )the order ceases, if a cure for drug addiction
  seems hopeless from the start.

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However, there are no unified legal grounds for
a unique form of therapy during the forensic
accommodation!

Forensic Service in Germany is organized and
guaranteed differently by every single federal
land .

6
The situation of the forensic penal system in the
German federal lands/structure report (country
survey 2000)
Increase quota 2000 -- 2004 approx. 20 (clients,
not costs)
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The therapeutical orientation is dependent on the
local tradition of the treating institution.

• Modern therapy forms(like psycho-educative
  groups or therapy programmes for sexual
  offenders) are nevertheless becoming morer and
  more important everywhere, as a result of the
  intensified public discussions about safety and
  security.

8
Which characteristics does the forensic
treatment have in Germany?

• Forensic departments are often settled together
  with hospitals for general psychiatry.
• The treatment course consists of two systems
• a. chronological sequence of treatment modules on
  different wards
• B. specific diseases are treated on special
  wards
• The treatment trend(like psychoanalysis,
  behavioural therapy or social therapy) is often
  chosen according to the different groups of
  diseases/disturbances being treated or according
  to tradition.
• The work in multiprofessional teams
• a mainly liberal attitude concerning sanction
  and safety stipulations
• little cooperation with non- forensic
  institutions
• Regional characteristics have big influence on
  the type of therapy.

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Conclusion
The therapy orientation, the room premises, the
personnel and financial equipment are very
different. Due to intensified discussions about
safety and security, as well as to the decreasing
of public financing , the existing structures are
getting unsure structures are being favoured,
that seem financially cheaper but at the same
time not very safe. This development gives birth
to sometimes dubious results.
10
An example of a forensic department in Germany
the forensic department of the ZPE
11
Ward 24
Premises Staff Max. 16 Patients 2
Therapists 11 Nursing Staff in each PCNG 2 Staff
100
Therapeutic Community acc. to Main can active
participation in everyday processes result in
alternatives to the behaviour shown up to now
and lead to improvements in responsibility, and
communication
The ward 24 forms a therapeutic community, where
a group of patients is treated by a
multi-professional therapeutic team.

The Life in this micro-society, to which each
patient contributes with his strengths, problems
and weaknesses is governed by the rules for
residents.
In this Holding Environment, he/she
can try out new behaviour patterns The
psychotherapy lies in the responsibility of the
therapeutic team Nursing Staff,
Psychotherapists, Social worker, MD, Ergo
therapists, Sportstherapist and Teachers.

A therapy process develops according to a
therapy plan. The long way through an
admission phase, a treatment period and a
rehabilitation phase should enable the patients
to find their way back into the Macrosociety
and enable them with their new emotional and
behavioural possibilities to stay away
from deliquency.
Nursing Team Confrontation with Personal Contact
Nurses 1 Female 1 Male for max. 4 - 5 patients
Patient Group Mainly patients with
63, Personality Disorders
Sexual deviations ,
Co-therapists. Social Worker Ergo therapists
(WT OT) Sports therapists Teachers and the
social workers are part of the therapeutic
team with regular reports in meetings and
doctors rounds
Holding Environment Acc. to Winnicott, a Safe
Area that can be used by the patient to catch
up with his personal development.
2 Psychotherapists 2 Psycho. a Psychoanalytic Beha
viour Therap. 2 sessions max 45 min.
each Relation Work Explanatory models for the
team
Articles 20, 21 63 64
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Work Therapy
Relatives
Nursing Staff
Administration
Rehabilitation
Occupational Therapy
Therapist
Networking all areas Information
management Overview Organisation Time scheduling
etc. ................................
Docu- mentation
according to of primery nursing or purchase care
system to H. Peplau
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Communication and Cooperation in the Nursing Team

• Level A
• with the patient
• (essential for getting into relation)
• Level B
• with the people that are involved in the
  treatment process

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The four pillars of nursing
Transparency
Understanding
Clearness
Continuity
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Understanding (I)

• Understanding is essential in our attitude
  towards the Patient.
• The Patient is seen in his totality, as a person
  with good and bad parts, he is not reduced to his
  disease or to his deed(s).

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The understanding II

• Knowledge about illness and its symptoms
  psychosis, personality disturbance, addiction,
  learning disability.

• Knowledge about the legal basis of the
  accommodation ( 20, 21, 63 64 81 126 ares
  StGB/ZPO etc.)

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The understanding III(questions to our
everyday work)
?

• WHAT are we doing?
• WHY?
• HOW?
• HOW does this effect the patient?
• HOW does this effect us?
• WHICH dynamics does this trigger?
• WHAT is the patient doing?
• WHY?
• HOW?
• HOW does this effect us?
• HOW does this effect the patient?
• WHICH dynamics does this trigger?
• Aim Developing an understanding attitude
  towards the patient.

?
?
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What contribution has the nursing staff in
preparing a legal prognosis?

• according to 67,d,e,Criminal Code of Germany
  once a year(63),twice a year(64)-for
  checking(together with patients and legal
  representatives), whether the accomodation is
  still justified.

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Procedure - construction Prognosis / Advisory
Opinion

• The nursing personell(persons to whom patients
  relate) prepare the individual report of the
  relation nursing care from a defined criteria
  catalogue.
• This will be read and discussed by all the
  members of the team. On the prognosis day ,the
  therapist and nursing team are changing opinions
  on the report.
  .
• Overview and Focus are formed.
• The patient also gets the possibility to tell his
  point of view.
• The therapist makes a summary of the different
  points of view and sends a statement to the legal
  representatives in charge.

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Nursing prognosis construction consists of
. Framework

• Length of accomodation
• short report on the course of treatment

• b) Personality development
• c)Social behaviour and taking part in therapy

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b. Personality Development

• Insight of the personal range of problems
• Reality perception
• Self-criticism
• Therapy motivation
• Therapy expectations
• Resistance to stress
• (aggressive) impulse control, self-control
• Ability to build up relations
• Empathy and sympathy
• Self-esteem
• Non-delinquent value system

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c. Social Behaviour and Participation to Therapy

• Behaviour in critical situations
• Type of contacts to patients and staff
• Type of participation in therapy
• Behaviour during work
• Reliability in keeping agreements
• Hygiene and personal hygiene
• Independence in structuring daily activities
• Dealing with money
• Special areas of interest /hobbies and leisure
• How did various restriction-loosening measures
  work upon the patient?
• special incidents
• Conclusions

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Experience of patients with professional nursing
care

• results of a survey made by patients for
  patients on the ward 24 in the Center for
  Psychiatry in Emmendingen

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Client answer 2002 -- I
acceptance
disapproving
25
Client answer 2002 - II
disapproving
acceptance
26
Client answer 2002 - III
acceptance
disapproving
27
Client answer 2002 - IV
acceptance
disapproving
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Client answer 2002 - V
acceptance
disapproving
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Client answer 2002 - VI
acceptance
disapproving
30
Client answer 2002 - VII
acceptance
disapproving
31
Client answer 2002 - VIII
acceptance
disapproving
32
Client answer 2002 - IX
acceptance
disapproving
33
Client answer 2002 - X
acceptance
disapproving
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Final note

• Our clients aren't happier than yours.
• Our system should let us understand the patients
  better and thus help us to stand them better.
• The nursing staff is the largest group of the
  multiprofessional team, we are the ones to spend
  most of the time with our clients therefore is
  the theme of delinquent relapsing not to be
  discussed without us.
• National and international exchange of
  information is helpful in improving our work and
  the situation of our patients.

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In part I placed this at the end - the model is
an ideal Germans are only humans!

• Human and personal insufficiencies are there
  everywhere.
• Dealing openly with them-this is the task of the
  nursing staff, as well as functioning as an
  example to the patients.

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The End