How does prison affect your mental health?

Punishment instead of therapyWhen sick people end up in prison

"Going back to the hospital: It was built between 1913 and 1914 as a remedial education home, so the two houses. The spatial structure of these is of course obsolete today. So that's still the dormitory structure. That's why we're building a new one. When you come to the side, you'll see behind it the new building, the shell, which will be ready for occupancy in about nine months. "

Rolf Jacob heads the "Leipzig prison with hospital", the official name of the prison on the outskirts of Leipzig. The former healing education home is now the said hospital. An imposing building with round arches at the rear of the extensive prison grounds.

Jacob: "We're going up to psychiatry, yes."

In addition to the 28 beds for physically ill prisoners, there are officially 48 beds for prisoners with mental disorders. That must currently be sufficient, not only for prisoners in Saxony, but also for the federal states of Thuringia and Saxony-Anhalt. There are no correctional hospitals there.

(imago stock & people / Jürgen Ritter) Increased risk of suicide among inmates
The risk of suicide is significantly higher for inmates than for people outside of prison. There are an average of 80 suicides each year in prisons. The most important prevention is personal contact by psychologists - however, there is a massive shortage of staff.

In the JVA one tries to restore the normality of a hospital, despite the barred windows and the heavy lattice doors, the crumbling plaster and the cells in which up to four seriously psychotically ill inmates are housed.

"This is an occupational therapy room. In the past, you see, the cells are all that big. But it is used as an occupational therapy room that the psychiatric patients here do creative painting, do handicrafts, and also things that they make for their relatives sometimes when they visit come, then you can hand over small presents. Here we have Ms. Moldenhauer, a specialist nurse of ours. "

Katrin Moldenhauer is a specialist nurse for psychiatry. She has been working here in the correctional hospital for 27 years. In her everyday work she is confronted with many serious clinical pictures.

"Psychoses, schizophrenia, addictions, personality disorders, everything is so random. Everything that arises in prison."

The prisoners in the hospital are in acute need of treatment. Either because they are experiencing an acute schizophrenic episode, because their life is at risk, for example due to alcohol withdrawal after imprisonment, or because of the risk of suicide. And because they cannot be adequately treated in the detention center, where they are normally housed.

Crisis intervention room in a forensic psychiatry clinic (imago / Friedrich Stark)

"In the detention center you have 80 men on the slopes, here in the hospital, we have an average of around 15 patients here in acute psychiatry. Downstairs in ward 7 there are a few more, there are 20. That’s already a time Setting, which is much quieter. "

Anyone who is brought over the threshold of the prison hospital is no longer addressed as a prisoner, but as a patient. Psychiatric nurse Moldenhauer and her colleagues wear hygienic clothing. But even here you won't get very far without a key. However, uniformed men do not work in the hospital.

Inpatient care "completely inadequate"

There is no clear indication of how many prisoners in Germany have a mental disorder. In 2015, an expert commission in Baden-Württemberg came to the conclusion that 40 to 70 percent of prisoners suffer from a mental disorder. Some estimates assume an even larger proportion. And: many prisoners have more than one disorder. Institution director Rolf Jacob:

"I would say there is a trend, an upward trend. However, you have to be careful to say that it is getting worse and worse every year, more and more. It is actually the case that nowadays, I believe, psychological sensitivities are also looked at more closely and in a more differentiated manner So that means there is more brightfield. "

Compared to the general population, the proportion of drug addicts, mentally ill and suicidal people in prison is generally higher. It cannot be proven whether the inmates bring with them increasingly severe disorders or even develop them in prison.

Only the most serious cases are treated in the prison hospital in Leipzig. Most of the prisoners are cared for a few hundred meters further on the premises in the detention center. Stephan Weber works there as an external psychiatrist. In addition to his work as a resident psychiatrist, every Tuesday afternoon he moves into a small consulting room on the ground floor of the detention center, where the prisoners have their cells. The psychiatrist stands by the window and listens to the voices of the prisoners talking from one window to the next.

"Extremely quiet. Usually it's much, much louder"

The noise of footsteps and the rolling of filing trolleys boom through the door of the consulting room. Inside there is a lounger and a desk with two monitors. His patients come here either at their own request or because the institution sends them to him. Weber estimates that the staff should not even notice some mentally ill prisoners. For example depressed prisoners who withdrew.

"I think the tolerance threshold is relatively high among the staff. What is still tolerated there would certainly not be tolerated in the outpatient sector or in the family. So in this respect, I think they are not overly sensitized to the subject of mental illnesses. "

The penal system in Germany is a matter for the federal states. And every federal state operates its own health system within the prisons. In many places, they are reaching their limits when it comes to caring for mentally ill inmates.

Last year, a commission of experts in North Rhine-Westphalia came to the conclusion that outpatient care for mentally ill people in prison was "barely sufficient". The inpatient care by the penal hospital in Fröndenberg is "completely inadequate".

The obstacles to restraint or coercive medication are high

According to the report, a prisoner had to wait 16 months for a treatment place. Some mentally ill prisoners are more likely to be released than treated in the correctional hospital. Instead, they are kept in the specially secured detention room, or bgH for short. An empty room with nothing but a mattress, toilet and sink. During its investigation, the Commission took a look at such rooms. The prisoners paced restlessly, spoke hallucinating, or lay motionless on the mattress. They describe what the experts saw on the monitor of the surveillance camera as follows:

"Sometimes the rooms were kept 'clean' with binding agent. Seeing this was not easy to endure, although for the commission - unlike for the responsible officials - these were only snapshots. In many cases this existed for the prisoners as well as for the servants unacceptable situation, for months. "

A prisoner in the prison yard (symbolic image) (AFP / JEFF PACHOUD)

Psychiatrist Stephan Weber from Leipzig is also familiar with such situations. He sometimes visits his patients in the specially secured detention room if they are not allowed to be brought into his consulting room.

"Patients then stand in front of you in paper underpants. So there is no way to create a piece of privacy. In principle, there is no way to put things down or go to the toilet with a privacy screen. None of that exists. Of course, that is a very good one humiliating experience. And that can also be traumatizing. "

The barriers to restraint or forced medication in prison are high. The bgH is therefore often the last resort in practice when prisoners become aggressive towards fellow inmates or servants or when they injure themselves. After all, prisons should also ensure security within the institution. Just because someone becomes aggressive doesn't necessarily mean they have to be treated in hospital, says Weber:

"The staff must also be protected or the fellow patients must also be protected. Then I think it is a more appropriate arrangement. If there is a mental illness behind it, then it is completely inappropriate. Then they actually belong in the hospital."

Whether a prisoner is brought to the bgH or even out of the asylum to a civilian hospital is something that prison doctors decide completely independently, says prison director Rolf Jacob. However, he believes it is legitimate to point out to doctors about the alternatives of inpatient accommodation in a public hospital. Because the health system within the judiciary is only in emergency mode at the weekend. Treatment outside the prison walls ties up additional staff. After all, the prisoners have to be guarded.

Bad image makes recruiting more difficult

"So there are cases, especially at the weekend, when there is no doctor there, that first of all an accommodation in the bgH as an immediate measure and then of course on Monday is looked at. Either the institution can clarify this itself through its doctor or possibly by consulting a psychiatrist. "

In the penal system, the medical decision is never alone. As the head of the institution, Jacob always has to take security aspects into account.

"You can't, suppose I'll say it fictitiously, you have five arsonists on the waiting list, you can't get all five arsonists at once. In the end there is no hospital anymore - burned down."

In fact, a few weeks ago a patient in the correctional hospital started a fire in his cell. A servant suffered from smoke inhalation. Often a referral to the correctional hospital fails simply because of the capacities.

"We have ten institutions in Saxony. All institutions have waiting lists between one to ten or 15 prisoners, and we are currently in the process of drawing up a list of priorities so that each institution says which cases are particularly important to them. can come to us within hours, but I think there are cases that wait months. "

This is not least due to a lack of staff. In almost all federal states, the prisons are understaffed and there is a high level of sick leave. Acquiring employees for the Leipzig prison hospital and also retaining them is a challenge, according to the Saxon Ministry of Justice. The psychiatric-psychotherapeutic department can therefore only be operated to a limited extent for some time. The prison hospital - like hospitals outside - is currently trying to cover the shortage of medical specialists with the help of a temporary employment agency.

The penal system has another disadvantage when it comes to the search for personnel: its image. The fact that the working conditions in prison are special was repeatedly shown to him by colleagues from outside, says psychiatrist Stephan Weber.

"Just the environment, the cramped, then closed doors. Always such a latently aggressive climate. These are certainly working conditions that do not primarily lead to people saying: Yes, I really want to work here, yes."

Kirstin Drenkhahn is professor of criminal law and criminology at the Free University of Berlin and has researched, among other things, the mental health of prisoners. She says: Psychologists in prison are often busy with group offers or work as highly qualified employees in the prison management.

"And that means that they have very little time to care for individual prisoners. And then there is the fact that there are very few psychologists per very many prisoners. And then of course you always have such a supply problem. "

"They then sit in the cell, are totally apathetic"

This supply problem not only directly affects the prisoners, but also affects the primary goal of the prison system: rehabilitation, i.e. a life free from punishment after release.

"In order to create the prerequisites for participating in rehabilitation measures at all, you just have to look, that is, whether a mental illness is somehow a hindrance to a prisoner. And if that is the case, then you definitely have to take care of it Quite apart from the fact that it is of course a health risk. Well, depression is one of the deadliest diseases. "

The standard for health care in German prisons is the so-called equivalence principle. This means that prisoners should receive the same treatment as people in freedom. In general, however, the opinion has prevailed that the treatment of mental illnesses is not an enforcement goal, says Professor Drenkhahn.

State Parliament of North Rhine-Westphalia: A commission of experts doubted whether treatment behind bars could even work (picture alliance / dpa / Federico Gambarini)

"One can safely say that it is much more difficult to get good treatment in prison, including crisis intervention that solves the crisis in the long term, so to speak."

In addition, the expert commission from North Rhine-Westphalia expresses doubts in its report as to whether psychiatric treatment behind bars can even work. In the highly regulated everyday prison life, the inmates had little leeway for self-determined and responsible behavior, write the experts. But that stands fundamentally in the way of psychiatric treatment. Marco Bras Dos Santos, spokesman for the self-proclaimed prisoners' union GGBO, says that some prisoners are not even liable due to their mental illness.

"They then sit in the cell, are totally apathetic, are super blatant conditions and they just can't get out of there. But they have no place in the building themselves, say the people who work in the institution."

The prisoners could not be helped either by psychologists and doctors in the detention center or in the correctional hospital. Because a relationship of trust between medical staff and prisoners, as is necessary in psychotherapeutic treatment, does not exist, says the GGBO spokesman.

"People who help out in jail, prison doctors, psychologists or something like that, are always perceived as part of the system. This is a very inhuman area where you stay in jail and the people who patronize you there or who because are there for you, they are not necessarily perceived as friends now. "

At this point, the principle of equivalence, i.e. the demand for equal treatment as in freedom, is restricted. Detainees cannot choose their psychiatrist or psychotherapist. You are dependent on the medical institution staff. They don't have a chance for a second opinion.

With a few exceptions - for example in the case of planned criminal offenses - the duty of confidentiality applies to the practitioners in prison as well as outside. However, the assessment of the therapeutic staff would not remain without comment, says Professor Kirstin Drenkhahn.

"They are usually involved in the execution planning. The execution plan is an individual plan that ultimately determines what should happen to a specific prisoner during the term of imprisonment. And it has to be revised regularly. That means, you also have to regularly talk about what has happened in the meantime. And of course what has come out in such treatment settings plays a very important role. "

Positions not yet filled

What experts agree on is that there must be more beds, more staff and more consultation hours in the penal system. The expert commission in North Rhine-Westphalia has presented numerous measures and also specific figures. The Ministry of Justice there announced that it had increased the number of beds in the penal hospital in Fröndenberg by re-occupying double cells with two instead of one prisoner. However, the implementation of the 160 beds required by the Commission is still a long way off.

In the North Rhine-Westphalian Ministry of Justice, a coordination round with representatives from all parliamentary groups has been advising how the other recommendations from the report should be implemented. The ministry announced that there are not yet any estimates of costs. After all, there has recently been a state working group on suicide prevention and an additional twelve posts for suicide prevention officers in the institutions. The positions are not yet occupied.

In 2015, the expert commission in Baden-Württemberg also presented a number of recommendations. With success, you could say.The Ministry of Justice there increased the salary of medical staff to make the professions more attractive and created around 150 new jobs in the penal system. Overall, the execution has become ten million euros more expensive.

The Saxon Ministry of Justice sees the waiting times for treatment in the Leipzig detention hospital according to its own information "an urgent need for action". After all, the Saxon state government agreed in its coalition agreement on improved psychiatric care behind bars. One wants to work together with doctors from the penal system. In addition, several positions are already advertised. How much the improved care will cost cannot be said at the moment. For Rolf Jacob, the head of the institution, the construction of the penal hospital is an important step.

Jacob: "Well, that a new building had to be done has been known for 15 years - we've been out here for 20 years now - that we need a new hospital."

Reporter: "Why did it take so long?"

Jacob: "You have to ask the Treasury Department."