[Sexuality in Forensic Psychiatry. Results of a Qualitative Study on Professionals' Perspectives and Recommendations for Clinical Practice]. / Sexualität im Maßregelvollzug. Ergebnisse einer qualitativen Befragung von Mitarbeitenden und Handlungsempfehlungen für die klinische Praxis.

OBJECTIVE: Investigation of employees' perspectives on sexuality and sexual health of inpatients in two gender-separated forensic psychiatries in Bavaria. METHODS: 19 semi-structured interviews were analyzed with qualitative content analysis. The results were discussed with employees and a recommendation for action was developed. RESULTS: Employees describe insufficient and non-systematic consideration of sexuality in forensic institutions. Regulations on permitted and non-permitted behavior either do not exist, are unknown or remain on an implicit level for many employees and patients. CONCLUSION: The consideration of sexuality and the sexual needs of patients should be comprehensible and transparent. An attached recommendation for dealing with sexuality can help institutions to give more consideration to sexuality in forensic institutions.

Gender-Specific Differences in Depressive Behavior Among Forensic Psychiatric Patients.

BACKGROUND: Women are almost twice as likely to develop depression than men, but men commit suicide more often. One explanation for this paradox is that current depression inventories do not fully capture typical male symptoms of depression. Several studies showed that most depression symptoms in men are masked by externalizing behaviors, such as aggressiveness, addiction, and risky behavior. Here, we explored the differences in depression symptoms between men and women in a forensic psychiatric sample. METHODS: We screened 182 forensic psychiatric patients and selected a matched sample (21 women and 21 men). External symptoms of depression were assessed with the Gender-Sensitive Depression Screening (GSDS) and internal symptoms with the Beck Depression Inventory Revision. RESULTS: Although externalizing behaviors were similar in both groups, we found a significant relationship between external and internal depression symptoms only in men. In addition, male forensic patients with a history of suicide had higher scores in the GSDS, whereas female patients with a history of suicide had higher scores in the Beck Depression Inventory Revision. DISCUSSION: The finding that the GSDS detected depression symptoms in men indicates that this instrument might be useful for developing assessments to prevent suicide in forensic practice.

Migrants With Schizophrenia in Forensic Psychiatric Hospitals Benefit From High-Intensity Second Language Programs.

Background: As a result of migration, an increasing number of patients in forensic psychiatric hospitals show poor skills in the national language, which can affect their treatment. Improving the second language (L2) of inpatients with schizophrenia may help to enable effective psychotherapy and thus reduce the risk of criminal recidivism and facilitate reintegration into society, for example because of a language-related higher degree of social functioning. For this purpose, a Hessian forensic psychiatric hospital established a ward specialized in L2 acquisition. The ward accommodates up to 21 patients with schizophrenia, who attend an L2 program consisting of 800-900 lessons within 1 year. Aims: The study aimed to evaluate whether patients on the specialized ward (experimental group) achieve at least Common European Framework of Reference (CEFR) level A2 in the L2 program. Additionally, it examined whether language acquisition is better among participants in the experimental group than among those on regular wards (control group). Methods: Achievements in the L2 were assessed by an L2 test 3 times: at the beginning of the program, after 6 months, and after 1 year. The impact of intelligence on achievements in L2 was evaluated using Raven's Standard Progressive Matrices. Results: The experimental group showed significantly better improvement than the control group. Literacy was a significant predictor of improvement in the L2. The majority of the experimental group reached at least CEFR level A2 after 1 year. Conclusions: High-intensity L2 programs are an effective way to improve the L2 of inpatients with schizophrenia in forensic psychiatric hospitals.

Immigrant Patients Adapt to the Culture of Admission and Experience Less Safety in Forensic Psychiatric Care.

Patients with an immigrant background are overrepresented in forensic psychiatric hospitals. As a result, daily work is impeded by language barriers and cultural differences. Furthermore, general therapy processes have not yet been adapted to this special patient population, and little reliable knowledge is available. All immigrants go through an acculturation process, which is related to their mental well-being. Four acculturation strategies exist: integration, separation, assimilation, and marginalization. The strategy chosen depends on the extent of someone's orientation toward their country of origin and the country of admission. The current study aimed to expand knowledge of forensic patients with a migration background in Germany by evaluating their self-reported acculturation processes and associated individual and social factors, e.g., the ward climate. Therefore, we studied forensic patients with a migration background from 11 forensic hospitals in Bavaria, Germany. Besides completing the Frankfurter Acculturation Scale (FRACC) and Essen Climate Evaluation Schema (EssenCES), the participants provided information on their clinical and biographical history. We recruited 235 patients with a migration background and found that the participants oriented themselves more toward the culture of admission and less toward the country of origin than the reference sample did. Moreover, the patients experienced significantly less safety on the ward than the forensic reference sample did. A possible explanation for the patients' orientation is the lack of possibilities to adhere to their cultural traditions. Patients may feel less safe because of their limited knowledge of German and cultural misunderstandings.

Measuring the Quality of Life in Forensic Psychiatric Hospitals.

Background: In Germany, a large proportion of mentally ill offenders spends many years in a forensic psychiatric hospital. To ensure that the highly restrictive living conditions in these closed institutions meet patient needs, research must assess and analyze patient quality of life. For this purpose, we adapted the Measuring the Quality of Prison Life questionnaire to measure the quality of life in forensic psychiatric hospitals from the patient perspective. This study aimed to assess the reliability (internal consistency) and construct validity of the adapted questionnaire. Methods: To evaluate the questionnaire, a one-time survey was carried out at 13 forensic psychiatric hospitals in Germany. Item characteristics and internal consistency of the scale and subscales were calculated and the factor structure was tested using confirmatory factor analysis. To test of responsiveness we compared the mean quality of life between the 13 hospitals and further investigated whether the patients' evaluation of quality of life is depending on age and duration of accommodation. Results: The analysis of the psychometric properties revealed very good item characteristics and very good to excellent internal reliability. Construct validity was demonstrated. Patient's quality of life was significantly associated with age and duration of accommodation. Discussion: The adapted Measuring the Quality of Prison Life questionnaire is a reliable and valid instrument for measuring quality of life in forensic psychiatric hospitals and can be used in the future to compare hospitals and identify the strengths and weaknesses of each.

Perceived Institutional Restraint Is Associated With Psychological Distress in Forensic Psychiatric Inpatients.

Background: Patients in forensic mental health care experience internal and external coercion; the latter comprises different levels of institutional restraint. These restrictions of individual freedom are mainly justified by the safety interests of third parties and are not necessarily in the patients' best interests. The effects of such a setting on mentally disordered offenders' psychological state and treatment course are not fully understood. Assessing both patients' perception of restraint and psychopathological symptoms would allow us to better understand how restraint and psychopathology interact and how they might influence treatment. Methods: In 184 forensic psychiatric inpatients, we assessed perception of institutional restraint with an adapted version of the Measuring the Quality of Prison Life (aMQPL) questionnaire and current psychological state with the Brief Symptom Checklist (BSCL) and Beck Hopelessness Scale (BHS). Results: Perceived institutional restraint (as expressed in the aMPQL subscales Transparency of procedures and decisions, Fairness, and Respect) was associated with a higher general level of psychological symptoms. Furthermore, patients who perceived a lack of institutional transparency and respect were more likely to have higher scores for hostility, depression, and suicidal ideation. We also found age and sex differences, with higher levels of psychological symptoms in younger and female patients. The diagnosis and duration of detention did not relate to perceived restraint. Discussion: Our results indicate that certain aspects of institutional restraint in long-term forensic inpatient settings correlate with certain psychological symptoms. The observed association might be explained by different kinds of factors: institutional (custodial focus), individual (self-efficacy, diagnosis, and personality), and situational (duration of detention). Although not all of these explanatory factors were addressed by the present study design, forensic mental health professionals should be aware of the relationship between perceived institutional restriction and psychopathology because it might influence treatment course and outcome.

[Self-Aggression as Mediator between Depression and Aggression]. / Selbstaggression als Mediator zwischen Depression und Aggressivität.

OBJECTIVE: The aim of the present study was to examine the relationship between depression, self-aggression and externalized aggression. METHODS: In order to check a possible mediator effect of self-aggression on the relationship between depression and externalized aggression, we investigated a clinical sample of patients diagnosed with major depression (n = 134) and conducted a mediator analysis. RESULTS: Self-aggression mediated the relationship of depression and externalized aggression in terms of a total mediator effect. CONCLUSIONS: Patients with major depression tend to exhibit both, self-aggression and externalized aggression equally.

High Quality of Life Reduces Depression, Hopelessness, and Suicide Ideations in Patients in Forensic Psychiatry.

BACKGROUND: Suicides are more common in forensic patients than in the general population. Two reasons for this discrepancy are discussed: (1) Suicides are the consequence of maladaptation to the restrictive living conditions in forensic psychiatry, and (2) suicides are explained by the demographic, social, and psychosocial characteristics of the inmates themselves, i.e., suicides happen because the inmates belong to a particularly vulnerable group. Therefore, the present study aimed to analyze the relationship between quality of life, as an indicator of the restrictive living conditions, and hopelessness, depression, and suicide ideations in a sample of forensic patients. METHODS: We assessed quality of life with a German version of the Measuring the Quality of Prison Life questionnaire that had been adapted to forensic hospitals (MQPL-forensic) and depressive symptoms with the Beck Depression Inventory, hopelessness with the Beck Hopelessness Scale, and suicide ideations with the Beck Scale for Suicide Ideation. The study included a total of 159 patients in 12 German forensic psychiatric hospitals who had been admitted in accordance with Section 64 of the German Criminal Code. We analyzed the relationships between quality of life and depression, hopelessness, and suicide ideations on the patient and hospital levels. Hospital characteristics were generated by aggregating the MQPL-forensic variables measured at the patient level. RESULTS: In generalized estimating equation models, the MQPL-forensic total score and almost all the subscale scores were significant negative predictors of depressive symptoms, hopelessness, and suicide ideations at the patient and hospital levels. At the patient level, patients who experienced a supportive welcome at the hospital, good relationships with their therapists, respectful interactions, transparent decisions, and supportive therapeutic approaches were significantly less depressed, less hopeless, and less likely to consider suicide. At the hospital level, good relationships with therapists and respectful interactions were significant negative predictors of these variables. DISCUSSION: The results indicate that the social framework within forensic psychiatric hospitals influences the frequency of suicide ideation and the severity of depressive symptoms and hopelessness among forensic patients. Forensic-psychiatric hospitals should be aware of these significant relationships and try to improve patients' quality of life.