Broadmoor revealed: working with dangerous minds
Understanding the complex history and new beginnings bound for Broadmoor.
In a pretty English village in the leafy, affluent Royal County of Berkshire live some of the most complex and high-risk mental health patients in the country.
Their home, Broadmoor Hospital – a name with mythical associations – is one of only three high-security psychiatric hospitals in England, and the oldest and best known.
With an international reputation in forensic medicine, the hospital is light years from its founding days as the Broadmoor Criminal Lunatic Asylum – first opened in 1863.
Not a prison
But more than 150 years later, Broadmoor struggles against misunderstanding and misrepresentation; its many locked doors shrouding the place in mystery.
In the public imagination, the hospital’s associations with savage and irreparable criminality endures. High profile patients have kept media interest high and years of sensational tabloid stories have instilled an inherent wariness in allowing the press inside Broadmoor’s legendary walls.
But for those who believe the place to be a terminal dumping ground for the country’s most broken men – the reality can confound.
The main misconception is that Broadmoor is a prison; an idea deputy director of nursing Jimmy Noak is keen to dispel, emphasising instead its therapeutic environment.
‘Not all patients have committed a criminal offence, but all are subject to the Mental Health Act,’ he explains.
Broadmoor in numbers
- Approximately 63% of patients come from prisons, 37% from medium secure units
- Around 60% of patients are from the south of England
- There are 15 wards that house eight to 20 patients each
- The hospital treats 210 patients with a turnover of around 40 to 50 each year
- It employs 267 registered nurses and 181 healthcare assistants
- The average length of stay is five years
In fact the ‘vast majority’ of patients will respond to treatment and ultimately be transferred to less secure psychiatric environments, or back to prison.
‘Our patients come from the courts, prison services, medium secure units and sometimes the independent sector,’ Mr Noak says.
‘But patients presenting the biggest challenge are often not the ones who have committed the serious offences or biggest crimes.’
The 210 male patients committed to Broadmoor under hospital orders have psychiatric conditions, such as schizophrenia, or complex personality disorders.
‘A lot of patients have dramatic histories and there might be commonality in groups of patients, but I don’t think there is an “average Broadmoor patient”,’ says Mr Noak.
Working in the hospital is ‘no more dangerous’ than an acute mental health facility he contends, because of the extensive training staff receive in preventing and managing violence and aggression.
‘I don’t worry when I come to work,’ Mr Noak says. ‘We know all of our patients very well.
‘It is far harder in an acute ward when you don’t know who is going to walk in the door – whereas we have got very good structures and processes to manage risk.’
Caring for highly disturbed patients
Clinical nurse manager Ken Wakatama has spent 20 years working at the hospital and is in charge of the 11-bedded intensive care unit, known as the Cranfield Ward.
‘We are dealing with some of the most disturbed patients in the hospital,’ Mr Wakamata says, explaining most are managed through long-term seclusion or segregation.
‘A number of patients cannot mix with others at all because of the acuity of risk to each other and themselves.’
Mr Wakamata describes how every new intervention has to be planned: staff have to sit down, discuss the patient’s presentation and make a decision on changing risk. ‘You don’t just open a door,’ he laughs. ‘Getting a patient from his room – that has to be planned.’
Despite these challenges, nurses try to work collaboratively with the patients, although the most challenging patients might require six staff to move them.
‘Risk is always a two-way process,’ says Mr Wakamata. ‘If patients know we are caring for them, and our intentions are good and we are treating their illness: that lowers risk.’
The risks, to staff or patients, include breaking furniture and using it as a weapon, self-harm, or strangulation by hanging from a ligature point. Working in a high-risk ward can be draining.
‘As a manager, I am constantly assessing my staff and checking how they are both physically and psychologically – we also have robust occupational health care.’
Mr Wakamata says his job is rewarding and gives him a greater sense of purpose than he believes other vocations would have done.
‘We are in the business of changing lives,’ he says.
He is also conscious of a need to address the stigma around mental health to stop people being treated as ‘sub-human’ as he describes it.
‘It is about reminding others these are everyday people: somebody’s brother, father or son, and that always shocks me and brings me back to reality.’
Nursing the notorious
Caring for people who have committed violent crimes could create an ethical conundrum for some.
Nurse consultant Terry Fegan says it can be all too easy to be judgemental, but it is important not to dwell on a patient’s past and instead look at working with current issues.
‘For me, it’s about being non-judgemental and understanding what has gone on for that person before and how they arrived there,’ says Mr Fegan.
Practice development nurse Marcia Tharp agrees.
‘It is about looking at the person, and not what they have done,’ Ms Tharp explains.
‘We say to staff “the courts have done their job already” and that is the essence: it is not our job to judge; it is our job to get on with people and give them the best care.
‘Some people I have worked with haven’t had the opportunities that I have had, not just with work but also with family,’ she adds.
‘To experience what some of these patients have experienced… well, that’s why we are here; we have got to help them with that.’
Patients’ group work programmes might explore ‘very difficult things’ related to offending behaviour, points out Mr Noak, which can be tough on staff.
‘I think everybody has to have their own processes, we have individual ways of coping and being resilient.’
Staff have training on managing boundaries, backed up by supervision and reflective practice, helping to ensure they are not manipulated by certain patients. And each staff member has to find their own ways to relax and unwind.
Band five staff nurse Amber Doyle first came to Broadmoor on a four-week elective placement during her pre-registration nursing studies at the University of Essex. Before qualifying and starting her preceptorship last year, Ms Doyle worked on the hospital’s staff bank as a healthcare assistant
‘It is very welcoming here and I wanted to get to know the hospital and my ward and patients before starting.’
She says interacting with the patients gives her huge job satisfaction.
‘I’ve always had an interest in forensic nursing,’ she says. ‘I have worked quite a lot with personality disorder wards and people who can be very challenging at times.’ Ms Doyle has now finished her period of preceptorship and has taken part in a band five to six development programme at the hospital.
‘In the future, I’d like to work as a team leader and coordinate taking care of members of staff as well as patients.’ She adds that she would encourage other nursing students to come and visit to understand that Broadmoor is a therapeutic environment, not a prison.
Ms Tharp and Mr Fegan both began their careers at Broadmoor in the early 1990s as nursing assistants and both praise the opportunities they have had to develop.
Mr Fegan says: ‘I feel very lucky to have done a degree, and an MSc.
‘I’ve been abroad to present work we are doing here and I realised this place is seen as the pinnacle of mental health care.’
What’s in a name?
Often staff choose not to tell people they work at Broadmoor as the response is often a lurid interest in notorious inmates.
Ms Tharp, who has worked at the hospital since 1993 when she joined as a nursing assistant, says if people discover where she works she can be bombarded with questions. She emphasises confidentiality by asking overly curious people how they would feel to discover a sensitive conversation they’d had with a nurse was later shared.
‘Sometimes it can kill conversations, but people are either incredibly interested or not interested at all.’
Work is going on to build a new hospital as the current one was ruled not fit for purpose by the Care Quality Commission in 2009.
Early next year, staff and patients will move next door into a new purpose-built hospital, which has been created with very good sight lines to ease observation of patients, and direct access to gardens.The replacement of Broadmoor’s Victorian building with a 21st century hospital may help to reduce the myths about the hospital, but it will definitely provide an improved environment for staff.
Patients are admitted to one of three 12-bed wards where they will be assessed and a care pathway determined. Wards range from the highest risk, which is intensive care, to high dependency, medium dependency and, for those ready for a final step, to "assertive rehabilitation".
Treatment options include:
- Cognitive behavioural therapy.
- Dialectical behaviour therapy.
- Group work, including the homicide group, substance misuse group etc.
- Talking therapies.
- Work with mental health restoration.
- Risk reduction.
- Offence related work.
- Pharmacological interventions.
Once the patient is ready to move on, they either go back to prison, or to a medium secure unit, which is the next step before moving into a community setting.
Nurse consultant Terry Fegan says a key challenge is keeping up to date with national and international guidelines on mental health. ‘It is easy to say “we can’t do that, we’re high security,” whereas in reality, it is contemporary practice,’ says Mr Fegan. ‘Whatever guideline comes out, we will be able to achieve it.’
A patient’s story
Gary was sent to prison after being convicted for making threats to kill. He spent long periods of time in solitary confinement.
‘My behaviour was causing problems, I had been fighting with prison staff and become very assaultative,’ he reflects.
‘I spent quite a bit of time in solitary confinement and they called in psychiatrists to conduct an assessment who diagnosed a personality disorder and mental illness.’
Gary was sent to Broadmoor where he says over the next six years his life was changed.
‘The first thing I remember is how warm the staff were, they called me by my first name and it was a relaxed and friendly environment.’
Arriving in a ‘body belt’ with his hands strapped to handcuffs, Broadmoor staff told him, ‘you can take that off.’ ‘I was used to solitary confinement: an hour’s exercise, a phone call, a shower – all of a sudden there were 19 other people to bounce off and talk to,’ he says.
During his time at Broadmoor Gary became a user representative, taking issues for patients to raise at forums for discussion.
Nurse consultant Terry Fegan says: ‘Gary was really high risk, but it is not unusual for us to see patients who have been incredibly violent in prison and see that violence stop.’
Gary moved on from Broadmoor into a medium secure unit and then back into the community. Now, he works for the hospital and is involved in mandatory induction training for staff about safe therapy services and involved in a ‘moving on’ group for patients.
This, he says, demonstrates an inclusive and supportive ethos, which he feels is representative of the hospital. ‘They are willing to work with people and promote independence and engagement with service users – it is credit to them,’ he says. ‘This is my opportunity to give something back.’
But, Gary also enjoys going back to Broadmoor. ‘The staff are all very supportive and positive and experienced; in terms of recovery, it is all about the people on the frontline and they really encourage people.
‘I really enjoyed my time there from the start.’