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The rehabilitation of the mentally ill in Broadmoor and elsewhere
Wednesday 3 March 2004, 5.00pm

Dr Raj Persaud and Dr Kevin Murray are answering your questions This webchat has now finished. Thank you for all your questions - we apologise for those of you who we have not been able to answer. Our special thanks to Dr Kevin Murray, Associate Medical Director of Broadmoor.

Dr Raj Persaud
Hello everyone and welcome to this All in the Mind webchat.
Sitting with me is Dr Kevin Murray, Associate Medical Director of Broadmoor Hospital and whose voice was one you would have heard in our special All in the Mind visit. Broadmoor is part of a larger NHS organisation, West London Mental Health NHS Trust, and our apologies for the erroneous description of it as a prison prior to the news at 9 pm yesterday. Those who have specialised questions about Broadmoor in particular should address those to Kevin while more general questions around psychology and psychiatry and violence plus any other issues raised in the programme and this series should address those to me. For those of you who've written in with reference to specific patients, I'm afraid we're unable to answer those in this public forum.

Do the Government stop you releasing high profile patients, even if they are well?

Dr Kevin Murray
It is important to understand the different legal circumstances of different patients to answer this accurately. If a mentally disordered defendant is sent to hospital for treatment, it is likely to be on a "restricted" hospital order. This means that he/she may not be discharged by his/her doctor alone. Discharge is either by a tribunal, headed by a judge, or by agreement with the Home Office. The Home Office have the right to make submissions to a tribunal, but the decision to release is for the tribunal alone.

If a "high profile" prisoner requires treatment for a mental disorder during a prison sentence, when he/she recovers, it is likely that he/she will be remitted to prison by the Home Office. There are circumstances, usually towards the end of the sentence, when instead of being remitted to prison, the transferred prisoner will be allowed to be released subject to quite stringent conditions.

I listened with great interest to the broadcast on the issue of Broadmoor today. Do you think that the patients who are in Broadmoor for sexual offences are curable? Do you offer a comprehensive sex offenders treatment program as some prisons do?

Dr Kevin Murray
I think the first point is that "sex offending" isn't a diagnosis, any more than arson or violence is a diagnosis. Sex offending may occur in the context of various forms of mental disorder, and so the first issue is the treatment of the underlying disorder. Beyond that, if there are specific disorders of sexual preference, we aim to bring the patient to a better understanding of their behaviour and its consequences and how to adapt to a lower risk way of living.

Within the hospital sex offenders receive both specific treatment, often of a cognitive behavioural type as well as treatments in the other modalities eg drama therapy as I mentioned below.

With Munchausen's Syndrome by proxy in the news at the moment, is this a problem common within the forensic hospital arena and if so, is it an easily (successfully) treated problem. As it is generally a problem suffered by women (I think!) is it more likely to result in a woman going to prison rather than hospital? (And should that be the case?)

You raise an important issue and one common misunderstanding about psychiatric diagnosis like Munchausen syndrome by proxy is that there is much less certainty about whether or not someone has a diagnosis as there is no definitive diagnostic aid, for example a blood test. The only way to make a diagnosis is by clinical observation, interviewing the patient and speaking to informants. It is no surprise that many cases of MSBP are controversial; the issue people forget is that often in the absence of a blood test there will be huge uncertainty. The recent controversy over MSBP doesn't take away from the fact the diagnosis definitely exists and many childrens' lives have been saved by doctors who have correctly made the diagnosis.

Carolyne (via text)
Do you think that prisoners consider Broadmoor to be an easy option, as mentioned in one of your interviews? Is the system being abused?

Dr Kevin Murray
I think your question represents quite a common concern. The extent of assessment which referred prisoners undergo before admission to Broadmoor is such that the likelihood of someone coming in "for an easy option" is tiny. Having worked as visiting psychiatrist at one of the London prisons for some years, I know that the general prison culture is quite hostile to acknowledgement of mental disorder, and prisoners generally resent psychiatric referrals being made.

Where there is any doubt, it is usual to admit prisoners for assessment at Broadmoor for up to a year before giving definitive recommendations to the court.

Having worked for many years as a Forensic Social Worker in a medium secure and community setting, I was disappointed that today's programme made no mention of the role of the social worker as part of the multi-disciplinary team caring for this difficult and challenging client group. In my experience The social workers role in the assessment, treatment and rehabilitation of patients is intrinsic to the concept of integrating the world outside the walls of the secure hospitals with the life before admission and the prospect of discharge at a later stage. Having worked with the social work department at Broadmoor, I am aware that the social histories collated by them at the point of admission are a pivotal part of the treatment planning process. I could go on at great length detailing my view of the important part that social workers play in the assessment, treatment and management of this group of people in the various settings in which they find themselves. Suffice to say that it is unfortunate that an opportunity to enlighten the general public, even if superficially, to the role that social workers have in the care and management of people with mental health problems was lost. Again we are the hidden profession - until something goes wrong.

Dr Kevin Murray
I entirely agree with the points you make. You're obviously aware of how central the social work role is at Broadmoor. As we admit patients from 40% of the UK, an enormous catchment area, continued liaison with patients' families is vital.

Angharad Law, All in the Mind Producer
Unfortunately due to the time constraints of a 28 minute programme, we could not include interviews with everybody we spoke to. For example, we could not fit in an interview with an occupational therapist or a psychologist. It was a very hard programme to edit together.

From Anon
What criteria determine a patient as unsuitable for rehabilitation and how do you help those patients to come to terms with the knowledge that they will never be released? What are they then able to contribute socially within Broadmoor?

Dr Kevin Murray
I'm not sure that we would ever take the view that an individual patient is unsuitable for rehabilitation. We do have patients, as I've mentioned, with severe, relatively treatment-resistant psychotic illnesses, and we do have patients with severe persistent personality disorders. It is our responsibility to use all proven available treatments, and to be at the forefront of research, to develop effective treatment programmes for these most challenging patients.

We do recognise that some patients will spend many years with us - but only those for whom our current treatments have not reduced the risks that they pose to a level which allows their safe onward movement. For those patients, it is our responsibility to provide the best quality of life which we can, consistent with the restrictions implicit in high-secure care.

People often seem to think that Broadmoor patients are desperate to escape at all costs, but do you ever find patients who are scared about living in the outside world and readjusting when released, having been inside for a long time?

Dr Kevin Murray
Thank you for making a most helpful point. Many of the patients in Broadmoor have the most damaging forms of schizophrenia which erode their ability to cope with change - the phenomenon of "institutionalisation" which is well recognised in psychiatric literature. It can become very difficult to support anxious patients in the transition to more appropriate local services as part of that rehabilitative process.

It was mentioned in the broadcast that most patients suffered from schizophrenia.I have always thought that this term was rather broad and unhelpful. What are the criteria used at Broadmoor in diagnosing someone as schizophrenic?

This is a question which is currently of much interest to researchers. There is a lot of controversy around the idea that people with schizophrenia are of higher risk in becoming violent. While there is some evidence that this is the case and it is indeed striking that schizophrenia is such a common diagnosis in Broadmoor, the problem is the statistics are complex. Another way of looking at the problem is to ask the question how much of total violence in the community in society can be attributed to people with schizophrenia. The research evidence is that this figure is between to 2 to 4%. This means that if we want to reduce violence in society there are many other areas we should target rather than schizophrenia or severe mental illness. Within the diagnosis of schizophrenia there is increasing interest in the idea that the issue isn't your diagnosis but particular symptoms and aspects of lifestyle. For example, if you have schizophrenia and you abuse drugs or alcohol your risk of violence increases substantially. Particularly symptoms like certain kinds of hallucinations are also associated with higher risk of violence.

Since by definition you have some of the most mentally disturbed patients, you may be in a position to do original research into the nature of extreme disorders and perhaps into the nature of "evil", whatever that is, with an eventual view to prevention and cure.

Is this in fact pursued at Broadmoor?

Dr Kevin Murray
I'm not sure that it's for a doctor to pronounce on the subject of "evil". It is interesting to speculate whether this is a quality of an action or of an individual. As a clinical service, it is our responsibility to identify and treat mental disorder. Issues of moral judgements are perhaps for others. I'm not sure, therefore, whether a "disease model" of prevention and cure is applicable.

The patient interviewed by Raj seemed very happy with doctors and other staff. this seemed different from what i might expect. Do patients try to "hoodwink" their way to release by appearing to be compliant?

Many are convinced that psychiatrists and doctors are regularly hoodwinked by patients. As if experienced forensic psychiatrists who have been working with some of the most manipulative people on the planet for many decades, and for whom there would be professional grave consequences, might never have considered the possibility of being duped by patients! In my experience the hoodwinking that goes on is the way the media portrays the expertise of psychiatrists and psychologists. There are many notable drama series where forensic psychiatry plays a high profile role on TV where the portrayal of how forensic psychiatrists work is totally fallacious.

Clitheroe Royal Grammar School
Do the patients have 'new identities' once they have left Broadmoor? How are you chosen to go to Broadmoor? Are there distinctive class differences between the patients? Do the patients families attend 're-hab' sessions? Thanks.

Dr Kevin Murray
The first answer is no, patients do not have "new identities". In fact, as you might see, it is of the greatest importance that the clinical services responsible for patients when they've moved on are very well-versed in their patients' backgrounds. Patients are "chosen" following assessments by forensic psychiatric services up and down the country, and their concerns that in an individual case admission to Broadmoor is appropriate. The patient (or often prisoner) is then assessed by staff from Broadmoor and we come to a conclusion with our colleagues at regional services as to where treatment should be offered.

Most patients who come to Broadmoor have a background of major social disadvantage: broken homes, periods in care, significant substance misuse, violent and sexual abuse as they are growing up etc. However, there are patients from stable and well-to-do backgrounds, although these are a minority. Mental illness is no respecter of social class.

Families do not attend re-hab sessions as such. It is sadly the case that for many of our patients they are not in touch with their families. However where there is active family contact families are invited to attend care-planning meetings and often have very valuable contributions to make.

How quickly are Broadmoor patients moved on when it is discovered that they have been admitted with a misdiagnosis? I know that several years ago patients who were admitted to Broadmoor with an original diagnosis of Schizophrenia have since been diagnosed as having Asperger Syndrome which is not a mental condition nor, in many cases, a learning disability. Surely someone with AS should be moved to a more appropriate placement immediately. Are AS people forced to endure a prolonged stay at Broadmoor because there simply are not services in place for them?

Dr Kevin Murray
It is more common for patients with a combination of Asperger's syndrome and an additional mental disorder eg schizophrenia to be admitted than for patients with Asperger's syndrome alone. Although there is some controversy in this area, the conventional classifications of mental disorder include Asperger's and Autism as mental disorders. There are, rarely, patients with these disorders who either offend and for whom the courts require advice on placement, or who are being treated in other services but whose behaviour is so disturbed that they cannot be safely managed there. In these circumstances, admission to high secure hospital may follow.

As regards moving such patients on, we actively involve specialist services where appropriate and as with all other patients, seek to transfer them as soon as it is safe and practicable to do so.

I am very concerned to hear no mention of the women detained in Broadmoor or the fact that very few of them have any contact with the criminal justice system. I am a former Broadmoor patient, deeply stigmatised by public opinion which this programme will serve to re-enforce. What a missed opportunity.

It is true that there are women patients at Broadmoor and that this issue was not fully explored in our broadcast. However, remember we only had half an hour in which to cover a vast amount of material. We conducted a large number of interviews we were unable to broadcast due to time constraints. For example we went to the education centre, the gym, and the art centre amongst many other locations but unfortunately we had to make some tough decisions about what we could keep in the programme. The issue of women in Broadmoor is complex, particularly as there are plans to move the women out of Broadmoor in the near future. The treatment of women has often in the past been a particularly controversial part of the experience of Broadmoor. Ironically women were the very first residents of Broadmoor when it was founded in the mid-nineteeth century. The treatment of women in forensic environments has long been problematic; there is a tension between trying to create as normal an environment as possible in these places and protecting women from the inappropriate attentions of some male residents.

I live very close to Broadmoor and can hear the alarms go off every Monday morning. Could you please tell me if it has ever been necessary to use these alarms. Have there been any recent escapes and what happens when an emergency of this kind occurs? How should the local community react?

Dr Kevin Murray
I hope that my previous answer covered much of your question. To the best of my knowledge, it is more than 10 years since the last escape from Broadmoor, and very much longer since any escape was followed by a violent event.

I was wondering why the farm closed, and if it was purely arable, or had livestock. Caring for someone or something is an important part of our make-up and surely would be of great benefit to patients. Do animals play any part in the hospital?

I think this is a very good question. In fact it was very common in the large Victorian asylums 2 centuries ago for there to be a farm as part of the grounds. These farms were often quite substantial affairs with livestock and vegetables being produced for the patients table. I think for all sorts of reasons, contact with nature, gardening, and contact with animals, there are many aspects of the farm experience with would be therapeutic. But even more importantly making a hospital self sufficient with the patients contributing to the upkeep helps them develop a more active role in the institution and the current passive role they play I am convinced is not helpful. Broadmoor does in fact contain a kitchen garden where patients can grow vegetables for use in the hospital. I suspect the managers of private and public hospitals all around the world have so much on their plate in terms of the basic running of these complex institutions that the thought of introducing a farm to add to their hassle ensures this has a low priority. I hope however, like so much in psychiatry, that in the future we will come full circle yet again and reintroduce farms into hospitals because the Victorians actually knew a thing or too about creating viable institutions.

Could Dr Murray comment on the multi million pound development of Broadmoor's physical security (fences etc). Why was this money spent? Is it because patients have escaped from Broadmoor. What are the views of staff & patients about the increased security?

Dr Kevin Murray
The large investment in security at Broadmoor, and at Rampton and Ashworth, followed the recommendations of Sir Richard Tilt, who was commissioned by the Government to review security at the high security hospitals following "Fallon" report on Ashworth hospital five years ago. It is the case that as the oldest of the special hospitals, there may have been more to do at Broadmoor than the others. It is also the case that the amount of investment is seen as disproportionate by some colleagues, particularly outside the hospital. My own view is that, if this is necessary to reassure the public that we are taking security seriously, and this allows the courts to continue to send high-risk mentally disordered offenders to hospital for treatment rather than to prison, I am perfectly willing to work within these constraints. It is not a local response to any event.

Many of the people you must treat have done terrible things to others, yet do not feel the responsibility of these actions. How do you go about awakening an insight in them that they are the owner of these actions and so begin the healing process.

Dr Kevin Murray
Hello Steve. Yes it is the case that admission to Broadmoor does on occasion follow the most serious of offences. In essence, there are two parts to treatment, firstly the underlying mental disorder then secondly the circumstances leading to admission, commonly a violent offence. We have a range of professional skills which you heard in the programme - psychotherapy, art therapy, music therapy, cognitive behavioural therapy and others which are designed to better understand and take forward the areas around offending and risk, both retrospectively and prospectively.

It was mentioned toward the end of your broadcast on Tuesday evening that psychotherapy for patients was, though enormously beneficial, too late in the sense that it only took place after a crime had been committed. To what extent do you think psychotherapy for the emotionally disturbed in their childhood might have a preventative effect in reducing crime rates? Also, what provision for child psychotherapy is provided by the NHS?

Many thanks for your question. Preventing mental illness is a special interest of mine. I'm not sure that for the emotionally disturbed in their childhood to receive psychotherapy would be the answer. Though in many cases, particularly children who come from very disturbed backgrounds would benefit. The key thing, perhaps, is to create healthier childhood environments and this means better parenting education. I am a passionate believer that mental illness can be prevented by the teaching of the best coping skills as discovered by psychiatric scientific research.

If you know the right coping skills and how to implement them when you face even catastrophic stress you can remain resilient and not go under with a mental illness. The real causes of most psychological difficulties are not severe stresses but severe stress combined with poor coping.

Colin Webster
I was the Director of Nursing at Broadmoor Hospital from 1986 through into the nineties (while the hospital was still managed directly by the Department of Health) so I listened to "All in the Mind" this week with great interest.

After many years of failure to improve the hospital's image, and in view of its unmanageable size, are you still confident that perceptions can be changed?

Should it not now be recognised that this anachronistic institution needs to be closed and replaced by smaller, more manageable local units?

Dr Kevin Murray
Hello Colin. I hope that Broadmoor has progressed since your involvement there some years ago. The hospital is now significantly smaller - about 320 patients compared with over 400 a decade ago. In part this is due to the development of more, smaller local units as you suggest, but there is still a need for a number of beds in higher security than can be provided at these units. The reduction in Broadmoor's size has meant that we have been able to reduce ward sizes down to about a maximum of 20 and to provide more focused treatment regimes. I agree that there is still a job of work to do in respect of public perception, and I hope today's programme is part of that process.


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