What is your opinion on forensics
The relevance of a coherent forensic assessment and treatment process
According to the legal basis, the aim of a therapeutic measure for offenders is to reduce the risk of renewed “significant illegal acts” (Sections 63 and 64 StGB, Germany) or with the “state of the perpetrator of related acts” (Art. 59 and 63 or . Art. 60 for dependencies on the Criminal Code, Switzerland). To achieve this goal, a coherent process is necessary that includes case conception (including diagnosis and hypothesis on the mechanism of the offense), treatment planning and treatment evaluation. As part of the first step, it must be worked out whether the offender is in need of treatment at all. This arises from the risk of repeated serious offenses as well as from the treatment options for the associated forensically relevant abnormalities of the offender. A broad range of scientific findings shows that such a need for treatment is by no means restricted to the mentally ill in the general psychiatric sense, and certainly not exclusively to criminals who are incapable of guilt. Rather, more can Criminal-relevant personal risk factorswhich are generally accessible to effective treatment, are causally related to delinquency and recidivism.
This finding is not reflected in the current case law in Germany and Switzerland. On the contrary: The prerequisite for ordering a therapeutic measure is the presence of a "severe mental disorder" according to the ICD / DSM and, in Germany, also a reduced culpability or incapacity.
This delimitation hides the need for treatment of a significant part of the criminal population and thus undermines what forensics would be able to achieve: differentiated, crime-oriented therapy. Processes such as the Forensic Operationalized Therapy Risk Evaluation System (FOTRES 3) can make an incremental contribution to the forensic diagnostics required for this compared to general psychiatric criteria catalogs. First empirical findings are presented in the article.
According to the jurisdictions of Germany and Switzerland, the aim of a court-ordered therapeutic intervention for offenders is to reduce the risk of repeated “substantial unlawful acts” (Sections 63 and 64 Penal Code, StGB Germany) or “acts related to the state of the offender ”(Art. 59, 63 and also 60 for dependencies, StGB Switzerland). This requires a coherent process that includes a forensic case formulation, which comprises diagnostics and a hypothesis about the offense mechanism, treatment planning as well as treatment evaluation. This process requires assessment of the offender’s need for treatment, resulting from the individual risk of serious reoffending and treatment potential of identified offense-related, forensically relevant issues. Broad scientific evidence suggests that such a need for treatment is not exclusively restricted to mentally ill offenders or offenders who are (partially) exempt from criminal responsibility. Rather, further so-called personality and offense-related risk factors may also be included in the cause for delinquency and recidivism and should constitute treatment targets; However, these findings are not reflected in the current jurisdictions of Germany or Switzerland. On the contrary, the prerequisite for ordering a therapeutic intervention is the presence of a severe mental health disorder, according to the ICD and DSM manuals and additionally in Germany another criterion is diminished or lack of criminal responsibility of the offender; However, this limitation ignores the need for treatment of a significant part of the offender population and undermines the ability of forensic psychotherapy to successfully treat offenders in a differentiated and offense-oriented manner. To overcome the limitations of the ICD / DSM, forensic tools, such as the forensic operationalized therapy / risk evaluation system (FOTRES 3) can incrementally contribute to risk-related diagnostics and case formulation processes. Initial empirical results on the validity of this approach are presented in this article.
A therapeutic measure for offendersFootnote 1 should be ordered if the punishment alone is not sufficient to reduce the risk of relapse. While in Germany, as in many other countries, this is only possible with simultaneous postponement or as an alternative to imprisonment via the court order for inpatient therapy in accordance with §§ 63 and 64 StGB, this can be done in Switzerland via Art 60 of the Swiss Criminal Code (StGB) for inpatient treatment can also be regulated within the framework of Art. 63 StGB with the simultaneous imposition of a prison sentence.
Regardless of the type of treatment (outpatient during detention or inpatient), a prerequisite for ordering therapy in Switzerland must be a “serious mental disorder” in the offender that is related to the offense. In Germany, an additional aggravating requirement is the reduction or elimination of the criminal's culpability. An independent expert - a forensic expert - is commissioned to assess the two issues mentioned.
As before, in parallel to existing legal practice, both countries are struggling to find an appropriate definition of what is meant by a “severe mental disorder”. In Switzerland, the existence of a “severe mental disorder” with a certain form of mental disorder according to the International Statistical Classification of Diseases and Related Health Problems (ICD; World Health Organization 2004) or the Diagnostic and Statistical is determined within the framework of a consensus that is not well-founded Manual of Mental Disorders (DSM; American Psychiatric Association 2013) equated. In Germany, the detour via the almost instantaneous presence of a mental disorder according to ICD / DSM, which can be assigned to the characteristics of a “pathological mental disorder”, a “profound disturbance of consciousness”, “nonsense” or a “serious other mental abnormality”, is used for assessment Gone from real-time insight and control ability.
What at first sounds logical due to the connection of the mental disorder according to ICD / DSM with the requirement for therapy, turns out to be a closer look at the explicitly formulated mandate of therapy - namely a reduction in the risk of relapse (Germany: §§ 63 and 64 para. 2 in Connection with § 67d StGB; Switzerland: Art. 59, 1b StGB, Art. 63, 1b StGB) - as undifferentiated and incomplete. If the aim of the therapy is to reduce the risk, it must be recognized that characteristics of the perpetrator other than a diagnosed mental disorder according to the ICD / DSM can also harbor a risk, whereby the presence of such a disorder, contrary to the current handling, is still a possible one , but cannot be a necessary condition for the court order for therapy to be given to offenders.
The concept of mental disorder according to ICD / DSM, i.e. H. in the sense of a general psychiatric diagnosis, has a far-reaching meaning in the current legal context. It is decisive for how a criminal is dealt with in practice, regardless of whether the actual risk factors relevant to the crime can be mapped or not. In practice, this can lead to two problematic consequences: (1) In the absence of a general psychiatric diagnosis, criminals are not treated in spite of an accessible risk of danger. (2) General psychiatric diagnoses are named as the basis for therapy, which either do not apply or are not (alone) risk-relevant.
It must therefore be critically questioned whether general psychiatric disorders according to ICD / DSM in themselves form an appropriate basis for the forensic context and the diagnostic and therapeutic challenges that arise in this context. If not, a differentiation and reinterpretation of the term "severe mental disorder" in the sense of the declared therapy goal would be the alternative, so that the disorder is no longer understood here exclusively as an ICD or DSM diagnosis, but as an overall picture of the crime-related personal risk factors of a person, the may or may not contain elements of general psychiatric importance.
For several years this conflict has led to a corresponding technical controversy among psychiatric and psychological experts and practitioners about the interpretation of the term mental disorder in the assessment and treatment of offenders. Some complain, like the present article, that general psychiatric diagnoses alone cannot reflect the need for treatment of offenders (e.g. Urbaniok et al. 2016), which in turn prompts others to warn against a weakening or “psychiatricization” of the right to intervene (Kunz et al. 2004; Heer and Habermeyer 2013) and to demand strict requirements for the judicial order of therapeutic measures (Heer and Habermeyer 2013).
Two counter-arguments should be focussed on concerns about “psychiatric exposure”: (1) An extensive empirical basis clearly shows that often not (only) a mental disorder according to ICD / DSM, but other crime-related personality-related factors are risk and relapse-relevant. Taking into account such clinically forensic risk-relevant perpetrator characteristics for the need for treatment would therefore result in a reduction, not an expansion, of the importance of general psychiatric concepts in forensics and would therefore have to be in line with the aforementioned critics. (2) Since it is precisely this empirical evidence that is not taken into account in the current law on measures, it is more likely that the “psychiatricization” of the criminal population is already in full swing and is not feared as a result of a more differentiated discussion of the term “severe mental disorder” must become. Ultimately, the current case law in practice leads to the fact that in some cases people are desperately looking for an ICD or DSM diagnosis in order to be able to treat a criminal in a crime-oriented manner. Most famous for this is probably the almost tautological antisocial personality disorder (ICD F60.2) in the forensic field, which in “unclear” cases is often diagnosed in combination with a personality disorder of the emotional instability type (ICD F60.3). This usually does not explain the cases, and what an appropriate crime-oriented therapy for risk reduction would look like remains unclear.
Even the frequently formulated statement that an official forensic conceptualization of a need for action beyond the limits of a general psychiatric disorder would be tantamount to a relaxation of the law on action, only has a purely definitional justification within the framework of current case law and, as mentioned above, is empirically outdated. The criticism of the current approach is not based on the idea of an unspecific expansion of the need for measures, but the need for a targeted differentiation of forensic concepts and criteria in order to do justice to the specificity of the forensic population. The aim is the appropriate and effective crime-preventive treatment of criminals in order to react to robust scientific evidence that has been available for years, to be able to assign criminals - if indicated - to appropriate measures and not run the risk of overlooking the treatability of a risk or "bypassing it" .
With regard to the required “strictness” in the allocation of measures, it should be noted that this term can have two different meanings. If "strict" here means transparent, comprehensible, as reliable and valid as possible, then the statements in this article also speak out in favor of strictness in the recommendations for the ordering of measures and thus hit the core of the criticism of a frivolous transfer of general psychiatry to forensic practice Discipline. If "strict" but in the sense of a continued restriction to mental disorders according to ICD / DSM is to be understood, then from our point of view this is technically questionable and leads against the background of the criterion to be assessed - namely the risk of relapse for delinquent behavior - to an incomplete, often incorrect assessment.
In summary, it is unsuitable to assess only the dichotomous manifestation of a mental disorder according to conventional diagnostic classification systems on the one hand and, supposedly correspondingly, the danger on the other. Rather, the basic question seems to be: Which disorder in a person - defined beyond the boundaries of general psychiatry - causes danger in connection with certain offenses and can this disorder be significantly reduced or its risk-relevant effects alleviated by therapeutic interventions? In order to approach the answerability of this question, three related problems will be discussed below.
General psychiatric diagnoses according to ICD / DSM show a questionable reliability and validity.
General psychiatric diagnoses and delinquent behavior or relapse show a questionable relationship.
The focus with which the discussion about the need for treatment of the offender population from a psychiatric point of view is often conducted needs to be questioned critically.
Problem 1: General psychiatric diagnoses according to ICD / DSM show a questionable reliability and validity
The development of classification systems is a useful method to reduce the complexity of an issue, to increase objectivity and transparency and to find a common language about meaning and benefit. This of course also applies to the area of mental disorders. The therapy of mental disorders cannot do without classification. In order to make the most accurate assessment possible, an explicit classification is better than an implicit, non-operational and therefore non-objective and verifiable procedure (Margraf 2018). In forensic psychology and psychiatry, too, the first step is to identify the offender's disorder relevant to the offense as precisely and comprehensibly as possible. Therefore, in forensics, as in related fields, the following applies: Operationalized criteria and the abandonment of “survived” theories (such as equating illness and danger) can improve the reliability of diagnoses relevant for forensics.
In order to be able to draw coherent conclusions for a therapy indication and therapy planning, not only the reliability, but also the validity of such a system is important. In other words, it doesn't help if everyone is talking about the same thing but missing the topic. One example are the early forensic theories of Cesare Lombroso (1894), which initially produced a classification of offenders on the basis of external body features and thus led to a clear offender typology. Although this could be used reliably, it turned out to be of little use in identifying “criminals” in the general population.
The advances in categorical diagnostics with regard to transparency, objectivity and reliability are therefore not able to automatically remedy deficiencies with regard to the validity and specificity of these systems. A high reliability also increases the chance of high validity, but it is no guarantee for it. Heer and Habermeyer (2013, p. 39) rightly state for the forensic area that the diagnosis, which the court uses when ordering an outpatient or inpatient measure, is comprehensible in all parts and is based on a reliable and valid classification system must relate. The officially recognized systems available for this purpose, which are currently used to translate the legal and psychiatric understanding of a serious offense-related mental disorder - namely the ICD and the DSM - have major shortcomings in general and specifically for this assignment .
In the following, the conceptual and methodological points of criticism that have existed for decades and which question the reliability and validity of the systems in general, are exemplified using the ICD chapter on personality disorders (ICD-10: F6), which is often relevant for forensics, and which is used in forensic Psychiatry play a central role (Fazel and Danesh 2002; Stieglitz and Freyberger 2018), listed:
The categories and criteria of personality disorders according to ICD-10 were not determined empirically and often do not agree with findings from cluster and factor analyzes (Westen and Shedler 1999).
The entry criteria are not operationalized. T. a large scope for interpretation. This applies e.g. B. to the term "profound" (Stieglitz and Freyberger 2018).
In the case of no personality disorder according to ICD-10, there is agreement with the corresponding diagnosis in DSM-5. Individual personality disorders such as antisocial and borderline personality disorder, which have a high prevalence in the forensic setting (Fazel and Danesh 2002), are based on very different conceptions (Stieglitz and Freyberger 2018). Furthermore, there is no evidence that, as the ICD-10 still assumes, there is a definitive number of personality disorders (Hopwood et al. 2018).
The dichotomous division of the criteria into “available” or “Not available” is artificial, and there is no weighting of the criteria with regard to their relevance (Stieglitz and Freyberger 2018).
Such criticism does not only apply to the ICD. It is also known for the DSM that reliability and validity are still unsatisfactory (Cooper 2014). With the introduction of the DSM-5 in field tests, the “interrater” reliability even decreased again (only 3 of the DSM-5 diagnoses have κ values> 0.6), which, worthy of note, has led to considerations regarding methodological standards to shake and the criterion for a satisfactory reliability to be lowered significantly to 0.4 (Margraf 2018). That this cannot be a solution, because a low reliability of course still affects or will affect the validity, e.g. B. a current study on the validity of the diagnosis of a pedophile disorder according to DSM-IV-TR (Mokros et al. 2018): Against the background of the critical interrater reliability and low prevalence of the disorder, it can be assumed that a third of the diagnoses made are not is correct and this result can most likely be transferred to other disorders due to the very similar reliability and prevalence parameters.
According to the World Health Organization (World Health Organization 2018), the replacement of the ICD-10 by the ICD-11 is imminent. Loud criticism of the previous taxonomy of personality disorders was received and led to the goal of resolving them.
In principle, the development towards a dimensional understanding of personality disorders is very valuable. This on the one hand against the background of the critical validity of the previous conceptualizations and on the other hand with regard to the associated focus on a phenomenological, symptom-oriented and thus intervention-related level of assessment (in contrast to the recording of superordinate dichotomous disorders), which is long overdue for therapeutic work. However, an improvement in the system of the existing general psychiatric disorders does not automatically solve the overall problem of the comprehensible indication for forensic, therapeutic measures if the system as such does not provide for the assessment of the content-related issue in focus in forensics. In other words: no matter how much a classification system is able to systematize aspects of general psychiatric disorders, it will not always be helpful for assessing forensic-clinical questions.
Problem 2: General psychiatric diagnoses and delinquent behavior or relapse show a questionable relationship
To date, there have been a large number of empirical studies that indicate that the presence of a psychiatric illness is not always causally related to delinquency, but rather that other characteristics, which are often referred to in the literature as criminogenic factors, are relevant to the crime . For example, a sample of n = 220 from the USA, where half of the offenders had a psychiatric illness, that the psychiatric disorder was only associated with the criminal behavior in 7% of the cases. Regardless of the disorder, characteristics such as hostility, disinhibition or emotional readiness to react were relevant to the crime for most of the perpetrators (Peterson et al. 2010). In a representative sample from the Netherlands (n = 6646) showed that the connection between psychiatric illness and violence lost its significant significance (except in the case of substance abuse) as soon as other factors such as e.g. B. own experiences of violence were included in the analyzes (ten Have et al. 2014). Similar results on criminogenic factors were also found, for example, by Elbogen et al. (2016; n = 34653; USA) and Chang et al. (2015; n = 47326; Sweden) specifically for recidivism with a violent offense: In only 20 or 40% (in male and female offenders, respectively) a psychiatric disorder could be assumed to be the cause of recidivism, and the effect decreased significantly if other, criminogenic factors were parallel to the disorder were considered (Chang et al. 2015).
A current Austrian study also reveals interesting results on the importance of factors that do not have any general psychiatric disease value. Here the crime relevance of the concept of hypersexuality was examined, which was initially a candidate for inclusion in the DSM-5, but was later deleted again. Obviously there were good reasons not to see this concept as a psychiatric disorder. Nevertheless, there was a clear connection between the existence of this concept and recidivism in the area of sexual offenses in the sample examined (Gregório Hertz et al. 2018).
With regard to the effectiveness of therapies, a current meta-analysis (k = 18) impressively states that treatment approaches that focus on criminogenic factors in mentally ill offenders are superior to those that focus on the treatment of the largely non-criminogenic aspects of psychiatric illness (Skeem et al. 2015).
The scientific evidence makes it clear that although mental illnesses can be directly relevant to the crime, in the majority of cases no exclusive causal relationship can be established (Bonta et al. 1998) and that their predictive power with regard to recidivism is lost or at least reduced if other factors beyond clinical factors based on general psychiatric diagnoses are taken into account.
Against this empirical background, different assumptions can be contrasted with regard to the question of the causal relationship between psychiatric illnesses and delinquent behavior (Skeem et al. 2014). The assumption that a psychiatric illness is directly and causally related to delinquent behavior would mean that treatment of the psychiatric illness leads to a reduction in delinquent behavior (direct model). As described above, the empirical support for this model is poor (Skeem et al. 2014). According to more indirect models, psychiatric illnesses are either (a) not directly related to delinquent behavior or (b) are indirectly related to it by inducing or promoting the development of disorder-specific criminogenic factors. In these models, congruent with the data situation already described, the pure focus on the treatment of the psychiatric illness with regard to risk reduction and relapse prevention would be inadequate (Skeem et al. 2014).
In summary, there are strong findings that support more indirect causal models and suggest that psychiatric disorders do not have to be viewed in isolation, but rather in connection with criminogenic factors, or that they even completely lose their relevance for the risk of relapse. Consequently, well-known forensic scientists and practitioners are calling for a focus on explanatory and intervention approaches that do not (exclusively) address purely general psychiatric phenomena, but also specific criminogenic factors that are related to the offense and that are certainly not diagnostic (e.g. Bonta et al . 2014; Bonta et al. 1998). The authors of the DSM-5 also explicitly state that the ICD and DSM are too unspecific and inadequate as a basis for establishing a risk-relevant diagnosis for forensic psychology and psychiatry:
Although the DSM-5 diagnostic criteria and text are primarily designed to assist clinicians in conducting clinical assessment, case formulation, and treatment planning, DSM-5 is also used as a reference for the courts and attorneys in assessing the forensic consequences of mental disorders. As a result, it is important to note that the definition of mental disorder included in DSM-5 was developed to meet the needs of clinicians, public health professionals, and research investigators rather than all of the technical needs of the courts and legal professionals. (...) (American Psychiatric Association 2013, p. 33).
The fact that this empirical evidence has so far not been strictly implemented in forensic-therapeutic everyday life is partly due to hesitant reactions from the professional groups involved.
The focus on general psychiatric concepts as an entry criterion for relapse prevention measures has the taste of a long scientifically outdated historical debate in which illness was still equated with dangerousness (Kumbier et al. 2013). In order to assess whether risk-relevant personality traits are present and whether these are fundamentally changeable and specifically treatable, a solid diagnostic classification according to current classification systems is necessary, also to clarify the presence of general psychiatric disorders; However, this first diagnostic classification is by no means sufficient. For this, a more specific, risk-relevant classification system would be necessary, on the basis of which risk-relevant, personal, including disruption-independent, risk characteristics can be recorded. Fortunately, a large number of these risk properties have already been identified and can be found in various validated risk models and survey instruments (e.g. the "central eight", Level of Service Inventory [LSI-R] by Andrews and Bonta (1995), the Historical Clinical) Risk Management [HCR-20] by Douglas et al. (2013) or the Violence Risk Scale [VRS] by Wong and Gordon (1999)).
Problem 3: The focus with which the discussion about the need for treatment of the criminal population from a psychiatric point of view is often conducted needs to be questioned critically - on the need to maintain a status quo
Forensic considerations should secure or improve the quality of the indication (based on the disorder, risk assessment and treatment ability), interventions and progress assessments and not protect psychiatry as a specialist or even forensic clinics from uncomfortable developments or clients.
For example, it is said that current practice should not be changed, since if psychiatry were to forego the narrowing down of diagnoses according to ICD or DSM by accepting "other offenders", it would be confronted with those for whom it is conceptually unprepared, and "the therapeutic milieu" could change negatively in forensic clinics (e.g. exchange at the forensic ambulance symposium in Munich 2018). It remains unclear what exactly is indicated by this finding, since the real clientele of offenders and the empirical evidence of which offender characteristics are (more) risk-relevant cannot adapt to the competencies of psychiatric institutions. On the contrary, a better fit between clientele and practitioner can only be achieved by bringing the latter closer to the former.
In Germany, the status quo is, among other things, also obtained through the legal requirements with adherence to the concept of incapacity or reduced culpability as a formal reason for admission to the penal system. However, this concept contradicts a differentiated and targeted forensic assessment and care. It is questionable whether it should be assumed that only those criminals can be treated as a crime prevention in forensic-psychiatric clinics who were incapable of insight and control during the offense. It is much more likely that the question of culpability has nothing to do with the danger or the need for treatment of an offender (Urbaniok 2012). Interestingly, in terms of content, this weak point in the concept of culpability was already referred to several decades ago in Germany (Drenkhahn 2007). The consequence, however, was not the comprehensive reform of the law of measures, but the creation of a parallel treatment format for culpable criminals, initially anchored in the Prison Act, whereby the entry criteria were defined very imprecisely except for a provision for sex offenders, which in purely formal legal terms only relates to the sentence (§ § 6 and 9 StVollzG). In these so-called socio-therapeutic institutions or correctional departments, the offense-relevant risk profile is treated without any orientation towards guilty capacity and largely without an indication-defining orientation towards ICD or DSM diagnoses (ideally). Although this approach is roughly in the sense of our argument against the pure restriction to diagnosis-related need for treatment, the question arises as to the usefulness of such a patchwork treatment landscape, if a coherent forensic approach could offer a much clearer assessment of the indications and the course of the disease.
To the fear of an inflationary measure order
For some representatives of forensic psychiatry and the judiciary, concerns about a shift in the focus of treatment go hand in hand with the fear of an inflationary order of measures. A limitation on the arrangement requirement of a "severe mental disorder" according to ICD or DSM is therefore necessary (Heer and Habermeyer 2013). However, it is unlikely that a careful and coherent assessment of the forensic-clinical case concept, which is expressly not linked to a psychiatric diagnosis, will result in a drastic increase in the number of measures. There are two primary reasons for this. 1) Just as the proponents of an orthodox interpretation of the term “severe mental disorder” demand, an indication for treatment should only be given if there is actually a severe disorder. However, this does not necessarily have to be of a conventional general psychiatric nature, but rather of a forensically relevant nature, i. H. characterized by crime-related personal risk factors. The main focus is the content-related focus on the need for treatment of a criminal, which in our opinion would automatically lead to a mapping of the real need for order due to the greater coherence between the disorder and the risk of relapse. 2) With compliance with the previously required therapy thresholdFootnote 2 and the general principle of proportionality, the treatment indication would, as before, be based on the existing and sensible legal framework.
Suggested solution: Alternative to severe mental disorder according to ICD or DSM as a prerequisite for ordering therapeutic measures for offenders
In order to be able to implement the basic legal and forensic idea with regard to ordered treatment measures for criminals, d. In other words, to carry out risk-reducing interventions with (mentally disturbed) offenders, a clearer focus on needs-orientation in the offender population is necessary.
The current assessment and treatment framework - general psychiatry - does not provide any exhaustive forensic-diagnostic and intervention-oriented constructs for the forensic discipline. With this, as mentioned above, evidence-based knowledge and the associated demand, we are by no means alone. Well-known forensic experts from the German-speaking area have also already taken a position and publicly stated that the relevance of disease-specific information for forensic assessments is viewed as ambiguous (e.g. Rettenberger et al. 2018; Eher et al. 2016; Noll and Endrass 2018; Urbaniok et al. 2016; Urbaniok 2018). In addition, developments can be observed in practice that already indicate an alternative way of dealing with criminals in the specific treatment setting. For intervention planning, implementation and evaluation, structured forensic procedures are often used in order to be able to identify and address the crime-relevant risk factors that cannot be recorded via the DSM or the ICD.
Despite these trends, one is still a long way from formalizing these findings - v. a.where it would be most important and would subsequently lead to a coherent and thus effective assessment and treatment process: with the legally formulated prerequisites for measures. The interface between legal decisions and psychological-psychiatric measures needs to be translated, so to speak. At the moment, the need for treatment with the help of a severe mental disorder is being translated according to the ICD or DSM “dictionaries”. We doubt the appropriateness of this from the aspects discussed in detail above.
Rather, we need a specific forensic-psychological-psychiatric diagnostic system for the implementation of the judicial mandate, which does justice to the specifics of the criminal population and the question to be assessed. Many components (in particular risk and intervention-relevant factors in the person and in the environment of the criminal) that would flow into such a diagnostic system are already known to the forensic experts, but still require a stringent systematization that enables the forensic expert to identify a Carry out a coherent assessment process that includes the 3 elementary aspects of assessing and treating offenders - case design, treatment planning and evaluation.
With such a system, the forensic expert contributions required within the framework of this diagnostic system would be the assessment of perpetrator behavior and the identification of the associated crime-related, personal risk factors. If the functional level of the personality and the psychosocial functional level are at least significantly impaired by these factors, from a clinical perspective one can speak of a crime-relevant psychosocial disorder that is to be classified as requiring treatment if there is a simultaneous risk of relapse. As described above, this disorder may or may not correspond to a general psychiatric disorder according to the ICD or DSM.
The coherent forensic assessment process: risk and intervention oriented
To illustrate a coherent forensic assessment process, the individual steps - based on a differentiated forensic diagnosis and defined as being different from previous practice - are compared in Fig. 1 and their process character and their meaning are described.
A coherent, risk- and intervention-oriented forensic assessment process for treatment indication, treatment planning and course assessment is characterized by a high degree of consistency, comprehensibility and context. The assessment bases should therefore logically build on each other in each step of the assessment process, and the sub-steps should consistently be based on a uniform case concept.
The coherent forensic assessment process in practice: a desirable course of action
With the coherent risk and intervention oriented In the first step of the assessment process, functional diagnostics are implemented using a forensic-psychological-psychiatric diagnostic system. The individual offense-relevant psychosocial disorder is described with a focus on the present risk profile (case-related compilation of the offense-relevant personal risk factors). The formulation of an individual and target crime-specific hypothesis on the crime mechanism (case-related interaction of the crime-relevant personal risk factors) belongs to this disorder. Subsequently, based on this functional diagnosis, the (relapse) risk and separately the ability to treat are assessed. Functional diagnostics and assessments of the risk and the ability to treat together form the clinical-forensic case concept.
On the one hand, this provides the basis for assessing the treatment indication (need for treatment and treatment ability) and, on the other hand, the basis for individual treatment planning. This defines which interventions should be used to work on which risk factors and with which goals.
After a significant period of treatment or treatment attempts, a course evaluation is carried out with reference to the case concept and the treatment planning. In this 3rd step, as part of the review of the achievement of goals, it is assessed to what extent the (target-specific) recidivism risk could be reduced, whereby in two sub-steps the development of the crime-related disorder from the original case concept, but also developed or acquired coping strategies for one A crime-free handling of this disorder should be assessed.
The extent of a possibly existing mental disorder according to ICD or DSM can influence this risk-oriented process in 3 ways:
The mental disorder is a (partial) aspect of functional diagnostics that is relevant to the offense.
Although the mental disorder is not relevant to the crime, it is relevant to the ability to treat (e.g. harmful use of cannabis or a narcissistic personality disorder, both of which are not part of the risk profile in a specific case, can prevent or complicate crime preventive treatment).
The mental disorder is neither crime nor treatment-relevant and must be viewed as a parallel problem from the point of view of the clinical-forensic case concept (which must be treated for ethical and professional reasons, but does not reduce the risk of relapse in the event of successful treatment).
Against the background that the psychiatric disorder (according to ICD / DSM) is currently a prerequisite for an order of measures, a coherent assessment, treatment and evaluation process is also possible under certain circumstances. This is the case if a psychiatric case concept is created based on the result of the psychiatric diagnosis using the ICD or DSM classification systems and this forms the basis of treatment planning and course evaluation. The aim of the evaluation would then be to check the symptom reduction in the psychiatric disorder initially assessed as being relevant to the crime. If there is an exclusive causal connection between the disorder and the offense in the assessed case, this procedure is not only highly coherent, but also very likely effective with regard to the expected reduction in the risk of relapse. For the majority of all other cases, however, specific forensic concepts are not taken into account in this process, or they are unclearly located.
As indicated, in current clinical forensic practice this fact is often caused by an incoherent string of psychiatric diagnostics and the structured forensic assessment that is too often decoupled from it (mostly with the focus on risk assessment, occasionally with the aspects of treatment ability, planning and evaluation) tries to compensate. A coherent process sequence in which the various sub-steps relate to one another in a meaningful way and which guarantees the effectiveness of a treatment because it is tailored to the risk profile that is actually relevant to the crime, is still not given. The result of such a practice is the lack of correspondence between the initial case concept and later treatment practice. This complicates the traceability of the treatment planning, the start of treatment with clients, the objectives of the treatment evaluation and communication with the institution ordering the measure.
The proposal is therefore to develop a forensic diagnostic system that takes psychologically and psychiatrically relevant aspects into account and initially includes 3 levels for assessing a disorder:
Determination of crime-related personal risk factors,
Determination of the functional level of personality,
Determination of the psychosocial functional level.
If there are at least clear manifestations or restrictions on all of these 3 levels, it must be assumed that there is a crime-related psychosocial disorder that can serve as an indication for therapeutic measures. In the next step, the (relapse) risk associated with this disorder should be assessed, target-specific if possible, and then the ability to treat should be examined. In this way, the need for and the ability to treat results in a forensically relevant case concept which - if indicated - forms the basis for interventions tailored to the specific case. Such a forensic diagnostic system could, based on previous research results and forensic procedures that have already been developed over the past 30 years, help to solve the above-mentioned problems.
To what extent the crime-related disorder contained therein is to be legally classified as a "serious disorder", what danger emanates from the perpetrator and whether the proportionality of measures is maintained, the next step is of course to take legal decisions, taking into account the forensic expert assessments and recommendations.
However, in order to be able to offer valid and comprehensible recommendations for these decisions on the part of the forensic experts, the development of an independent forensic diagnostic system as outlined above, which enables an assessment process that is coherent with the question, is imperative.
FOTRES as a contribution to the future of forensic diagnostics
A comprehensive standardized and validated system for the entire process of diagnostics, case conception and therapy planning is still pending, but would make a significant contribution to the necessary differentiation and specification for the implementation of the action order in the forensic area of application. One of the most differentiated proposals for a forensic diagnostic system in German-speaking countries is the Forensic Operationalized Therapy-Risk-Evaluation-System (FOTRES; 3rd version; Urbaniok 2016), an operationalized, forensic documentation and quality management system related to the individual case. In addition to the structured forensic procedures mentioned under point 3, this system aims to make a significant contribution to the conceptualization of risk properties.
It is used to assess and standardized documentation of the (relapse) risk of an offender, the ability to influence or change a risk disposition (e.g. through therapy) and the evaluation of the course of treatment of crime preventive treatments (or the general course if no therapy is carried out becomes). According to the author of the procedure, it is important to describe an individual risk profile on a case-by-case basis on the basis of identified "risk-relevant personality traits in an independent forensic diagnostic process in the categories of a special forensic diagnostic system" (from FOTRES 3, standard text for expert opinions and reports; Urbaniok 2016). FOTRES serves the requirements of such a special forensic diagnostic system, as it defines around 100 potential risk properties that, according to Urbaniok (2016), can occur in criminals independently of general psychiatric diagnoses. The selected risk characteristics (based on extensive case knowledge and understanding) form the risk profile of a person. In this context, the procedure tries to establish a connection between the clinical flexibility and competence of the forensic user with clear item operationalizations and accounting rules in order to be able to make forensic assessments of offenders in a differentiated manner, but at the same time in a highly structured manner through a strongly operationalized diagnostic concept.
FOTRES was developed as part of a clinically iterative process (Endrass and Rossegger 2012) with the help of literature reviews on forensic risk factors and the analysis of several hundred forensic cases. The focus was on content validity.
With the current version (FOTRES 3 from 2016), the system can now look back on an evaluation process lasting more than 10 years with continuous troubleshooting. Although data on the central quality criteria of FOTRES 3 are still missing, satisfactory results are already available for earlier versions. So Rossegger et al. (2011) after various clarifications and criticisms by Keller et al. (2011) report a satisfactory interrater reliability. Regarding the validity, Endrass and Rossegger (2012) point out that FOTRES achieved similarly good values for the assessment of the risk of relapse (predictive validity) as the VRAG or the Static-2002 and, due to the construction process, a good content validity of the FOTRES instrument is assumed can. A current therapy evaluation study in which, on the basis of a FOTRES case concept, treated violent and sexual offenders were compared with untreated violent and sexual offenders, indicates a positive, i.e. H. therapy-effective trend (Seewald et al. 2018).
A structured forensic assessment process such as FOTRES offers inter alia. then incremental validity for the initial and course diagnostic assessment of offenders, if the criteria operationalized therein can make a crime-relevant contribution to the structured assessment of offenders beyond the above-mentioned common general psychiatric classification systems.
The relationship between FOTRES and ICD or DSM
The core diagnostic idea of FOTRES, as mentioned above, is the need to describe an individual risk profile based on established "risk-relevant personality traits in an independent forensic diagnostic process". According to this attitude, the FOTRES concept in the area of criminal offender assessments only represents added value compared to classic psychiatric diagnostics if there are FOTRES risk characteristics that are conceptually far removed from general psychiatric diagnoses and these are also used to describe a crime-relevant risk profile . These requirements for FOTRES were checked in 2 partial investigations that were carried out as part of a currently ongoing, large-scale validation study on FOTRES.
The conceptual proximity of FOTRES risk characteristics to general psychiatric diagnoses
Seven independent forensic experts (the author of FOTRES was not involved in the rating) who have many years of experience in the application and e.g. Some of the training in FOTRES conception and application as well as well-founded diagnostic knowledge from clinical-psychiatric-psychotherapeutic practice were asked to rate the FOTRES risk properties. The hypothesis for this was that a majority of the approx. 100 risk properties of FOTRES 3 do not have a clear conceptual proximity, but some risk properties have a content-conceptual proximity to a diagnosis of the DSM or ICD. A rating sheet should be used on a 4-point scale (0 to 3) to assess which risk properties of the FOTRES 3 are more or less close to the diagnostic concepts of the ICD or the DSM.
The 4 levels of the scale were operationalized as follows:
no proximity: The risk characteristic is not close to an ICD or DSM diagnosis.
close proximity: The risk characteristic shows little proximity to a diagnosis according to the ICD or DSM if certain conceptual overlaps exist, but the differences clearly predominate.
rather clear proximity: The risk characteristic is more closely related to a diagnosis according to ICD or DSM if the risk characteristic and diagnosis according to DSM or ICD describe a similar phenomenon, but at the same time relevant differences in the conceptions can be determined.
clear proximity: The risk characteristic shows a clear proximity to a diagnosis according to ICD or DSM if there are extensive conceptual overlaps, i.e. That is, if the risk characteristic and the diagnosis according to DSM or ICD describe an almost identical phenomenon.
After an initial expert assessment of the conceptual proximity of each individual risk characteristic of FOTRES to a diagnosis of the DSM or the ICD, it was shown that all raters were in 86.6% of the items (n = 84) agreed. 31 (32.0%) of the 97 risk characteristics at the timeFootnote 3 were unanimously assessed by all 7 experts as clear or rather close to the diagnosis. 54.6% (n = 53) of the risk characteristics were rated with 100% agreement as rather remote from the diagnosis. The next step was a consolidating expert discussion based on the assessments obtained with a focus on the 13.4% (n = 13) of the risk characteristics that were not assigned consistently by the experts. For this purpose, every description and operationalization of the FOTRES risk properties were compared with the criteria of the diagnoses from ICD-10 and DSM 5 and taking into account the current literature on these criteria catalogs.
The criteria for these consolidating assessments were:
The risk characteristic and criteria of a diagnosis from ICD / DSM show a relevant overlap area in the main criteria (e.g.increased urge to sexuality, hyperactive risk behavior)
the main criteria of a risk characteristic stand on their own as a risk-relevant forensic syndrome and are at most a partial aspect of a diagnosis according to ICD / DSM.
Ultimately, the result was 100% agreement, with a total of 37 (38.1%) of the 97 risk characteristics being assessed as clear or more closely related to the diagnosis and 60 risk characteristics (61.9%) being described as (more or less) remote from the diagnosis (Table 1).
This expert assessment of the diagnostic proximity or diagnostic remote of the FOTRES risk characteristics indicate a forensic-diagnostic added value of the basic FOTRES conception.
Use of general psychiatric “non-diagnosis” risk characteristics based on the FOTRES
In order to analyze the use of the risk properties made available in FOTRES for forensic diagnostics, taking into account their proximity to classic general psychiatric diagnoses according to ICD or DSM, an extensive FOTRES data set was used in the next step, which is based on case assessments in FOTRES and experienced forensic experts in various settings (psychiatric-psychological service in the prison department of the canton of Zurich, n = 330; Probation and enforcement services in the prison department of the Canton of Zurich, n = 208; Vitos Clinic for Forensic Psychiatry Hadamar, n = 104). After reducing the data set to include test, training and duplicate cases, a sample of 642 "FOTRES cases" resulted. A total of 2038 risk properties were used for the 642 case assessments. On average, a case was thus represented in the risk profile as a combination of 3 risk characteristics. The analysis of which type of risk characteristic was used in relation to their general psychiatric closeness to the diagnosis showed that in a quarter of the 642 cases (n = 160, 24.9%) the risk-relevant disorder profile - and thus the personal determinants of the hypothesis on the mechanism of crime - was viewed exclusively as an expression of psychological disorder shares according to ICD or DSM (Tab. 2). In 9.0% of cases (n = 58), the offense mechanism was only formulated with reference to ICD or DSM-remote risk characteristics, and in two thirds of the cases (n = 424; 66.0%), the risk profile was mapped using the combination of risk characteristics related to and unrelated to the diagnosis.
The 3 most frequently used risk characteristics from the general psychiatric diagnosis-related spectrum were “dissociality”, “alcohol problem” and “drug problem”. From the pool of ICD and DSM-remote risk characteristics, these were “chronic willingness to use violence”, “angry aggressiveness” and “dominance problem”.
On the basis of conceptual considerations and empirical findings, it was shown that a differentiated and needs-oriented assessment of offenders with regard to risk, treatment planning and treatment course should be carried out in a coherent process. A forensic case concept understood in this way as the basis of the most valid measure arrangements and comprehensible assessments in all relevant sub-steps can too often not be adequately justified and evaluated in a process-oriented manner with a general psychiatric-oriented diagnosis according to ICD or DSM.
The interface between legal decisions and forensic psychological-psychiatric measures requires a more appropriate translation than the current classification systems. To this end, we advocate the (further) development of a specific forensic-psychological-psychiatric diagnostic system. In the German-speaking area, FOTRES is currently one of the most differentiated proposals for such a forensic diagnostic system. Conceived as an individual diagnostic documentation and quality management system, the method aims to make a relevant contribution to the diagnostic conceptualization of risk properties. A comprehensive validation of the process is still pending, however, and further optimizations can be assumed in this process.
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