Criminal wings at the Bethlem

Criminal lunatics were proving to be unsafe both in prison and in the Bethlem and they needed their own special provision. Although a separate State criminal lunatic asylum was proposed, the government preferred to fund two new criminal wings at the Bethlem. These opened in 1816 and provided 45 male and 15 female beds. Hence, the first planned provision in Britain for criminal lunatics was within a mental hospital, albeit in a segregated and separate part of it. The patients were under the care of Bethlem doctors and keepers (later known as attendants and, still later, as nurses) and managed according to regulations stipulated by the Bethlem governors, though admission and discharge were determined by Royal warrant or direction of the Secretary of State.

An enduring difference from the outset was evident between the general patients at the Bethlem and elsewhere and the criminal patients. Pauper lunatics could be discharged once sanity had returned, but discharge of criminal lunatics had to take account of their potential for relapse if in the community. The nature of the mental disorder was as relevant as its severity or degree. The longer stays of the criminal group was, and is, underpinned by this difference in emphasis.

The Bethlem criminal wings were probably the first forensic psychiatric facilities in the world. But the government’s policy was that the Bethlem would take only the most dangerous criminal lunatics, the remainder being admitted to county and borough asylums. But who qualified as a criminal lunatic evolved over time. The 1800 Act had included those found not guilty by reason of insanity to a charge of a felony and those found insane on arraignment (what later was known as unfit to plead): a group dubbed His Majesty’s Pleasure patients. From 1816, the Act also included those found to be insane during a prison sentence and transferred to asylums. In contrast to His Majesty’s Pleasure patients, they were subject to a transfer warrant by the Secretary of State and were referred to as Secretary of State patients. Unlike His Majesty’s Pleasure patients, Secretary of State patients could be transferred back to prison if they recovered their sanity. In 1840, a finding of not guilty by reason of insanity could be reached following not only felonies but also less serious misdemeanours.

Both groups were therefore criminal lunatics, but it was the Secretary of State patients who proved more troublesome, probably as their personalities were more antisocial. Many His Majesty’s Pleasure patients who had committed a homicide had little, if any, prior criminal record, whereas many Secretary of State patients who had not been convicted of homicide nonetheless had extensive histories of criminality and antisocial behaviour. They were often unwelcome even in the Bethlem criminal wings. Dr William Hood, Medical Superintendent of Bethlem from 1852, regretted that there were not special units in prisons for insane sentenced prisoners, some of whom he felt had feigned insanity in prison to be transferred out to Bethlem (Reference HoodHood 1854). But the clinical reality may not in practice have been so simple. In some cases, insanity may have been incubating at the time of the index offence but not yet evident and only manifest itself during the prison sentence. In others, defendants though insane pleaded guilty, preferring a prison sentence to an indefinite admission to an asylum.

State criminal lunatic asylums, Broadmoor and Rampton

The opening of the Bethlem criminal wings did not provide a facility for the admission of all criminal lunatics. Preferable no doubt to a death sentence or perhaps to a sentence of transportation, most His Majesty’s Pleasure patients in Bethlem stayed until they died, although a few were discharged. The male criminal wards were therefore usually full, though vacancies were available on the female side. In 1836 the male wing was enlarged by 30 beds and in 1849 the Home Office funded a criminal wing for less dangerous criminal lunatics at Fisherton House, a private licensed house in Wiltshire (Reference O'DonoghueO’Donoghue 1914). The role of the private sector has already been noted in the case of Mary Lamb, and its contribution to the treatment of mentally disordered offenders is therefore not a new phenomenon. In 1850 the first separate State criminal lunatic asylum opened in Dundrum, Dublin, Ireland, which paved the way for the opening in England of Broadmoor in 1863 for female and 1864 for male patients (Reference GordonGordon 2012). In Scotland, a different approach was followed. Asylums there also objected to receiving criminal lunatics (Reference ThompsonThompson 1867). From 1846 lunatic wings were established in Perth Prison for insane sentenced prisoners and, in 1857, a criminal lunatic department was opened for those found not guilty by reason of insanity or insane on arraignment (Reference BairdBaird 1984).

With 500 beds at the time, Broadmoor was much larger than the Bethlem provision. However, by the end of the 19th century it was already full and another criminal lunatic asylum was required. In 1906 Parkhurst Prison opened a criminal lunatic wing for insane sentenced prisoners, but this closed in 1912 when Rampton opened as a branch of Broadmoor.

With a new focus on the provision of facilities for the mentally deficient, Rampton in 1920 became a State institution for mental defectives (Reference JonesJones 1960).

An interest in mental disorder in prisons was already well established, but from the 1930s a degree of emphasis was placed on treatment in prison, albeit in a context of realism regarding the risk of recidivism. A prominent prison psychiatrist and administrator William Norwood East described how some prisoners were psychopaths who were ‘non-sane, non-insane’, implying that sanity and insanity were on a continuum rather than there being a distinct boundary between mental disorder and normality (Reference EastEast 1945).

From lunatic to patient

The term ‘lunatic’ was replaced with ‘patient’ by the 1930 Mental Treatment Act. The term ‘criminal lunatic’ was, however, more enduring, the Criminal Justice Act of 1948 replacing it with the confusing term ‘Broadmoor patient’. It was confusing as it referred to any insane offender, whether detained in Broadmoor or in a local mental hospital. The 1948 Act also renamed Broadmoor Criminal Lunatic Asylum as Broadmoor Institution. Criminal lunatics no longer officially existed, although the term is still occasionally heard today, albeit misplaced. Broadmoor also ceased to be designated an asylum, but it did not assume as yet the status of mental hospital as had been the case with local asylums since the Local Government Act of 1929. Following the Mental Health Act 1959, Broadmoor became a Special Hospital, along with Rampton and Moss Side, with separate legislation for the State Hospital, Scotland.

Separating of pauper and criminal lunatics

By the 1850s there seemed to be a consensus that mixing pauper and criminal lunatics was entirely undesirable. The underlying reason for that view was that local asylums should function as havens of recovery and should not be associated with the vice of criminality, which required stricter custody along the lines of a prison. In 1845 the Commissioners in Lunacy had replaced their Metropolitan predecessors and in 1852 their Chairman, Lord Shaftesbury, rejuvenated the call for a separate State criminal lunatic asylum for England and Wales. Bethlem’s new medical superintendent, Dr William Hood, initially opposed the plan, preferring the improvement of Bethlem and retention of the practice of county asylums taking criminal lunatics who had committed minor offences. Dr John Bucknill, an occasional medical superintendent of Devon County Asylum, though offering no praise for the Bethlem criminal wings, nonetheless also felt that the local asylums should continue to accept the less dangerous criminal lunatics. Dr Bucknill stated that he had not noticed any particular problems with the relatively small numbers of criminal lunatics admitted. He noted that there were some pauper lunatics who were dangerous and some criminal lunatics who were relatively harmless. He felt that a State criminal lunatic asylum should take patients who were dangerous, irrespective of their legal status (Reference BucknillBucknill 1851). However, the view in Devon may have been more determined by Dr Bucknill himself, as when he left the asylum in 1862 antipathy to the admission of criminal lunatics there increased (Reference Melling, Forsythe, Adair, Bartlett and WrightMelling 1999).

Indeed, serious violence, including homicides, did occur in local asylums, carried out by pauper lunatics. From the opening of Broadmoor in 1863 until the Mental Health Act 1959 took effect in November 1960, 82 male and 11 female patients who had killed in local asylums were subsequently admitted to Broadmoor (Reference GordonGordon 2012). Many Victorian psychiatrists thought that there was a mental illness known as homicidal insanity (Reference MaudsleyMaudsley 1897), although in fact homicidal urges can occur in patients with various mental disorders. Despite serious risk posed not only by some criminal lunatics, but also by some pauper lunatics, during the passage of the 1860 Act that authorised the building of Broadmoor, it was declared ‘an evil’ to mix pauper with criminal lunatics.

By the end of the 1860s, two-thirds of all criminal lunatics in England and Wales were in Broadmoor, a proportion much higher than in Bethlem’s criminal wings and local asylums (Table 2). Some ambiguity occurred as to whether all criminal lunatics needed to be in a criminal lunatic asylum. A survey by the Commissioners in Lunacy of criminal lunatics in local asylums concluded that criminal lunatics who were less dangerous or for whom family visiting might prove difficult need not be transferred to Broadmoor (Commissioners in Lunacy 1863).

TabLE 2 Criminal lunatics in England and Wales 1843–1960

In 1867, further legislation caused much concern for county and borough asylums. The Criminal Lunatics Act 1867 declared that all Secretary of State patients in Broadmoor at the end of their prison sentence would have to be transferred to local asylums if still insane. A criminal lunatic asylum was not for those who were no longer criminals and were now essentially ex-criminal lunatics. Indeed, some psychiatrists referred to Secretary of State patients not as criminal lunatics but as lunatic criminals (Reference BraynBrayn 1901). The end of their prison sentence did not mean the end of their criminal propensities and the local asylums found them troublesome. But so did everywhere else. The prisons wanted their insane prisoners in an asylum, whilst even Broadmoor attributed most of its early escape attempts and some of its more difficult patient behaviour to that group. In fact, Broadmoor did retain a few such patients at the end of their prison sentences, if they were dangerous or unfit to travel, by arranging for a civil or justice order to be made, though the threshold for that was much higher than that preferred by the local asylums.

The financial burden of Broadmoor

Studies in the Victorian era and beyond have shown that local asylums preferred not to accept criminal lunatics (Reference HearderHearder 1898; Reference Lord and BartlettLord 1913; Reference SaundersSaunders 1988). Broadmoor had been open only 12 years when, in 1876, local asylums complained of the cost of running it, due essentially to the higher staff-to-patient ratios necessary to maintain safety and prevent escape (Reference CrossCross 1876). Key parameters such as the mortality rate and rate of escape of criminal lunatics were considerably lower in Broadmoor than in local asylums (Reference OrangeOrange 1883). In 1882, a Commission on Criminal Lunacy confirmed the necessity of retaining a State criminal lunatic asylum (Criminal Lunacy (Departmental) Commission 1882). It also considered the need for local asylums to make provision for their more dangerous pauper lunatics, although no special arrangements were subsequently made. The 1882 Commission report did, however, note as necessary the higher cost of running Broadmoor and to some extent opened a debate on the need for local special provision for more dangerous patients, which would be revisited some 80 years later.

Criminal lunatics unwelcome in local asylums

The disinclination of the local asylums to accept criminal lunatics continued into the 20th century. Most were Secretary of State patients transferred during a prison sentence, though a small proportion were what had previously been dubbed His Majesty’s Pleasure patients who had carried out less serious offences. Most such patients in Broadmoor who had sufficiently improved were conditionally discharged to the community, and only a minority were transferred to local asylums. In 1913, medical superintendents of county and borough asylums reiterated their view that it was undesirable for them to have to accept criminal lunatics. Accordingly, the Medico-Psychological Association (a precursor of the Royal College of Psychiatrists), supported by the Commissioners in Lunacy, so advised the Home Secretary (Journal of Mental Science 1913). In the same year, the Home Office issued a document in which it acknowledged that local asylums were institutions for treatment that should avoid any return to excessive custodial practice. It noted that there was a good deal of prejudice among the public against criminal lunatics, and that local authorities and local asylums were reluctant to accept them. There were no precise rules determining whether a criminal lunatic went to Broadmoor or to a local asylum. However, the main deciding factors were the nature of the offence, the nature of the patient’s lunacy, the level of potential dangerousness and, for insane sentenced prisoners, the length of the sentence (Home Office 1913).

New possibilities of treatment

As the 20th century progressed, especially from the 1930s, an increased level of confidence developed in the treatment of those termed psychopaths. Whether that therapeutic optimism was well grounded remains a disputed issue. The number of such patients with personality disorder admitted to Broadmoor began to rise even before the legal recognition of psychopathic disorder that came with the Mental Health Act of 1959. Out of the ruins of the Second World War emerged a National Health Service in 1948 in which mental health services were part of a wider, comprehensive system of healthcare provision (Reference JonesJones 1960).

The remit of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency (1957) (the Percy Commission) did not include mentally disordered offenders. However, the Royal Medico-Psychological Association submitted that less serious offender patients should continue to be admitted to local mental hospitals, but subject to agreement by the hospital’s medical superintendent. Broadmoor had hitherto conditionally discharged its patients when stable directly to the community. Now increasingly it would transfer most of its patients to local mental hospitals. The Mental Health Act 1959 was effectively the birth of the modern era in mental healthcare, its underlying principles having largely remained unchanged by the 1983 Act and its amendments in 2007.

Regional medium secure units

The notion of some form of regional security, at least for civil patients, had first been proposed in 1882 by the Commission on Criminal Lunacy. The idea resurfaced in 1961 for offender patients (Ministry of Health 1961). A decade later, galvanisation of the proposal followed homicides committed by Graham Young a year after he had been conditionally discharged from Broadmoor. The Report of the Committee on Mentally Abnormal Offenders (the Butler Report; Home Office 1975) noted divided opinion in general psychiatric hospitals regarding the feasibility of treating offender patients, open-door conditions conflicting with the need for security, and consultant psychiatrists not welcoming the loss of autonomy involved in the treatment of patients subject to a restriction order, whose transfer or discharge required the approval of the Home Office. The first interim medium secure unit in England opened in 1976, and by a generation later there was comprehensive national provision. The interface between general and forensic psychiatry now focuses on the relationship between general psychiatric hospitals and medium secure units (and, more recently, low secure units), with an overall protective envelope provided by what are now called the high secure hospitals. A new forensic ‘intraface’ has evolved between high security and medium security, which is characterised by both collaboration and tension. But whether in high, medium or low security, most patients have previously been treated in general psychiatric services and are likely to return to them at some stage (Reference TaylorTaylor 1997).