Kevin Murray: The future of high secure services over the next 50 years

In the past 50 years mental healthcare has been transformed in ways few could imagine in 1964. Fifty years ago Broadmoor Hospital had nearly 1000 patients who stayed an average of 20 years each at what is arguably the world’s most famous high secure hospital for mentally disordered offenders. Today it has some 195 patients who stay an average of five years.

Much improved drug therapy for psychosis and depression, a growing evidence base of clinically proven psychological treatments, and a developing understanding of the biochemistry of the brain thanks largely to neuroimaging have been transforming mental healthcare since then. Recovery principles and the value of “occupation” and leisure are also better understood. But what will we see in the next 50 years?

Last week, as part of Broadmoor Hospital’s 150th anniversary, clinicians hosted a seminar that focused on the challenges of the next 50 years from a high secure service perspective.

A former nursing officer for mental health and forensic psychiatry at the Department of Health, Malcolm Rae OBE, said the next five decades posed many unknown challenges for forensic nursing ethics. One that is causing growing concern among clinicians is the increasing numbers of cases of children who are victims of violence.

This is a “frightening” development, he said, as we do not know what impact exposure to violence is having on our young people and indeed what mental health problems it could lead to in their later life.

His views are backed up by a study, led by Izaskun Orue from the University of Duesto in Spain. It found, from a sample of nearly 800 children aged between 8 and 12, that seeing violence, whether at home, school, on TV, or as a victim, made it seem common and acceptable, and believing that agression was normal, led to more instances of it.

Malcolm’s views were echoed by Gisli Gudjonsson PhD, CBE, emeritus professor of forensic psychology at King’s College, London, who introduced his predictions with an illustrated anecdote about his summer job as a fortune teller at a children’s summer camp. He also cited the effects of stressful childhood life events, early trauma, head injury, and severe mental illness on offending, adding that treatment responsiveness needs to be better understood.

Gisli explained that clinicians would need to consider the development, implementation, and evaluation of psychological therapies in the context of genetic research, biological factors, improved drug treatment, and more sophisticated real time feedback, which new smart devices would support. He also believed that psychological therapies will become more individualised, refined, and effective at treating major mental illness as well as offending behaviour, particularly violence reduction and sexual offending.

We also welcomed Robin Murray—one of the world’s most influential researchers in psychiatry and in schizophrenia research.

In his enormously entertaining presentation, Robin made serious points about the most widely replicated risk factor for schizophrenia being a family history of the disorder in a first-degree relative. Twin and adoption studies have shown that this is largely due to genetic factors rather than family environment. He said that the risk to the identical co-twin of a schizophrenic individual was about 50%.

In a tongue in cheek section, Robin also speculated about “salience psychosis”—which may replace schizophrenia as a diagnosis and how this would be more common in cities—especially socially fragmented areas. He anticipated how “salience psychosis” would be seen as an indicator of the health of cities, and how cities would compete with each other to publish lower rates.

There were also very thought provoking contributions from Lucy Scott Moncrieff, a recent past president of the Law Society, on mental health legislation in the 21st century; from Saimo Chahal, a leading human rights lawyer, on the risks to patients on exiting the European Convention on Human Rights; from Mike Harris, on Rampton’s next 50 years as it approached its 150th anniversary, and the possible impact of financial pressures on effective care; and finally from Nick Caldwell, the architect of the new hospital, on designing for humanity and anticipating changes in clinical use and climate over the next 50 years.

Clearly there are many challenges that lie ahead for us over the next 50 years in high secure and forensic mental health services. Effective clinical leadership though will be key to the future success of forensic services, shaping and protecting front line services while bringing about satisfactory patient outcomes and safeguarding the public. However, there is clearly a strong need to safeguard our children from violence in every form to ensure they don’t become the Broadmoor patients of tomorrow.

Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I have the following  interests to declare: I am employed by WLMHT who manage Broadmoor Hospital.

Kevin Murray is clinical director at Broadmoor Hospital.