Psychotherapist to the dangerously disturbed

The Independent has a revealing article on the working life of Dr Gwen Adshead, a forensic psychiatrist and psychotherapist at Broadmoor Hospital, one of the few very high security hospital dedicated to the most dangerous psychiatric patients in the UK.

As a consultant forensic psychotherapist – a rare breed in medicine – she spends her working life in the company of men at Broadmoor whom others would dismiss with a single word – evil. Her aim is to make them safer – safe enough, ultimately, to be released from Britain’s highest security institution for mentally disordered offenders – and to achieve that they must understand the full import of the crime they have committed.

“My job is to help a man become more articulate about what he has done, about his illness and about why that might be important for his future. Even if a cure is not possible, recovery of some identity is possible. My work involves talking to them and getting them to become more self-reflective. Violence is more likely to occur when people are not thinking straight.”

Admission to Broadmoor is granted only to members of an exclusive club: the violent insane. The Yorkshire Ripper, Peter Sutcliffe, is here, convicted in 1981 of murdering 13 prostitutes; Kenneth Erskine, the Stockwell strangler who murdered seven elderly people in 1986; and London nail bomber David Copeland who targeted blacks, Bangladeshis and gays, killing three people and injuring 129, of whom four lost limbs.

The article characterises the patients Adshead works with as the ‘violent insane’ although it’s worth noting that not all will be ‘insane’ in the popular or even traditional sense of the term – that is, affected by psychosis that includes delusions and hallucinations.

Some will be ‘diagnosed’ with Dangerous and Severe Personality Disorder. I put ‘diagnosed’ in scare quotes because you may notice that no such condition is listed in either the DSM or ICD diagnostic manuals – it has been created by the UK government and on the basis of this label a patient can be locked-up indefinitely.

Unlike psychosis, personality disorder doesn’t involve any significant ‘loss of contact with reality’ (although it may be diagnosed alongside it). This is why the journalist comments that the patient he bumps into who makes “a passionate denunciation” of his detention doesn’t seem to be ‘insane’.

This is not to say he’s just a regular chap – a diagnosis of personality disorder signifies his day-to-day functioning is quite impaired because of difficulties relating to others – while the ‘dangerous and severe’ prefix is based on a still-not-very-accurate risk assessment that the person is likely to be violent in the near future.

The Broadmoor DSPD unit has now been in existence for 10 years and still lacks good evidence that it is effective in helping the patients or reducing risk. Needless to say, it is likely to remain controversial.

The Independent article is a good insight into the difficulties of working with (the very few) psychiatric patients who are dangerous, regardless of diagnosis, although do ignore the sensationalist and irrelevant headline. Apart from that, well worth a read.

Link to Independent on Adhead and Broadmoor.

3 thoughts on “Psychotherapist to the dangerously disturbed”

  1. Interesting post, worried that you came close to representing ‘dangerously severe’ personalty disorder, a political diagnosis, and DSM or ICD recognised PD – which certainly consumes a significant amount of my clinical time (and personal time as personality disordered patients can evoke a great deal of emotion in clinical staff and are quite frequently discussed in our weekly reflection groups!)

  2. ROFL at the implication that the British Government should be bound by the often arbitrary decisions of a group of American psychiatrists as to what labels they can use.

  3. Dr. Adshead was interviewed on BBC Radio 4’s “Desert Island Discs” back in the summer. She was marvellous, not at all condemnatory, just pointing out that there’s a reason that her charges are the way they are and making me think about how sad these cases are on almost every level.

    The programme is still available on iPlayer at, though if you’re outside the UK it’s going to be difficult to circumvent the protection.

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