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Practical
Forensic
Psychiatry
Edited by Tom Clark and
Dharjinder Singh Rooprai
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2011 by Taylor & Francis Group, LLC

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 Contents
Contributors v
Preface vi
Abbreviations vii

1. The Development of Forensic Psychiatric Services 1

James Reed
2. Entry into Secure Care 12
Helen Whitworth
3. Treatment and Outcomes in Secure Care 25
Leela Sivaprasad
4. Challenging Issues in Secure Care 43
Rebekah Bourne
5. Leaving Secure Care and Community Follow-up 56
Dharjinder Singh Rooprai
6. Risk of Violence Assessment 68
Tom Clark and Muthusamy Natarajan
7. Psychosis and Offending 82
Tom Clark and Muthusamy Natarajan
8. Mood Disorders, Neuroses and Offending 96
Clare Oakley
9. Personality Disorders and Offending 105
Clare Oakley
10. Learning Disability, Autistic Spectrum Disorders and Offending 117
Dharjinder Singh Rooprai
11. Women in Secure Care 130
John Croft
12. Children and Adolescents in Secure Care 143
Leela Sivaprasad
13. Sex Offenders, Stalkers and Fire Setters 156
Rebekah Bourne
14. Crime and Criminology 170
Renarta Rowe
iii
 Contents

15. The Criminal Law and Sentencing 183

James Reed
16. Psychiatry and the Police 197
Renarta Rowe
17. Psychiatry and the Criminal Justice System 211
Helen Whitworth
18. Prisons and Prisoners 227
Dharjinder Singh Rooprai and Tom Clark
19. Mental Health Care in Prisons 243
Tom Clark and Dharjinder Singh Rooprai
20. Psychiatric Issues in Criminal Courts 254
Tom Clark
21. Providing Expert Evidence to Criminal Courts 268
Tom Clark

iv
 Contributors
Rebekah Bourne MBChB MRCPsych DipMedEd
specialty registrar in forensic psychiatry, Birmingham & Solihull Mental Health NHS
Foundation Trust; honorary clinical teacher to the Birmingham MRCPsych Course
Tom Clark MBChB LLM MRCPsych
consultant forensic psychiatrist, Reaside Clinic, Birmingham & Solihull Mental Health NHS
Trust; honorary senior clinical lecturer in forensic psychiatry, University of Birmingham
training programme director for forensic psychiatry, West Midlands School of Psychiatry;
visiting forensic psychiatrist, HMP Birmingham
John Croft MBChB MRCPysch
consultant forensic psychiatrist, Ardenleigh Womens Forensic Mental health Service,
Birmingham & Solihull Mental Health NHS Foundation Trust
Muthusamy Natarajan MBBS MRCPsych
consultant forensic psychiatrist, William Wake House, St Andrew’s Healthcare, Billing Road,
Northampton
Clare Oakley MBChB MRCPsych
clinical research worker, St Andrew’s Academic Centre, Institute of Psychiatry, King’s
College London
James Reed MBChB BMedSci LLM MRCPsych
locum consultant forensic psychiatrist, Reaside Clinic, Birmingham & Solihull Mental Health
NHS Foundation Trust
Dharjinder Singh Rooprai MBBS LLM MRCPsych
consultant forensic psychiatrist (forensic LD, ASD and ABI), Fromeside, Avon and Wiltshire
Mental Health Partnership NHS Trust, West of England Forensic Mental Health Service
Renarta Rowe MBChB MSc MRCPsych
consultant forensic psychiatrist, Reaside Clinic, Birmingham & Solihull Mental Health NHS
Foundation Trust
Leela Sivaprasad MBBS DPM MRCPsych
consultant forensic psychiatrist, Reaside Clinic, Birmingham & Solihull Mental Health NHS
Foundation Trust
Helen Whitworth MBChB MSc MRCPsych Cert MHS
clinical lecturer, Keele University, visiting lecturer, Coventry University; consultant forensic
psychiatrist, Hatherton Centre, South Staffordshire and Shropshire Healthcare NHS
Foundation Trust

v
 Preface
We conceived this book with two broad aims in mind. Firstly, we wanted to present key fac-
tual information in a concise, readily retrievable format, with a relative absence of opinion
and debate. Of course the occasional opinion has crept in, and we think that the book is
more interesting and thought provoking for that, but it remains a densely factual book. Sec-
ondly, as a ‘jobbing’ consultant and, at the time, higher trainee respectively, we wanted to
provide practical guidance on the day-to-day tasks that a forensic psychiatrist is required to
deal with. This is particularly aimed at forensic trainees and psychiatrists working in other
fields, for whom forensic matters are so often relevant.
The book is unashamedly aimed at psychiatrists. While forensic psychiatric services are
necessarily multidisciplinary, we think that there is value in focusing on the role of the
psychiatrist, allowing a more pithy and direct approach, and enabling the role of the psy-
chiatrist to be set more clearly within its proper place as but one part of the team. At the
risk of appearing to try to eat our cake, we hope that those working in other disciplines and
in other types of mental health services will also find the information and clinical guidance
presented here useful. Most forensic patients used to be general psychiatric patients and
will be so again, and much of the interface between the criminal justice system and mental
health services is served by general rather than forensic psychiatry, and often by nurses
rather than doctors.
We are aware of gaps and areas of clinical practice that might have warranted more space
than we have been able to give. In particular we have not tried to cover the law in juris-
dictions other than England and Wales. More weighty and comprehensive textbooks are
available; our book is conceived more as a vade mecum. We have tried to point the reader
in the direction of further reading that might fill some of these gaps. Those references that
we consider to be particularly important are marked with an asterisk. Our view would be
that a higher trainee in forensic psychiatry should read all of these key references during the
course of their training, though it is by no means an exhaustive list.
Preparing a rather stylized yet multiple author book is a harder task than we imagined. We
are very grateful to our contributors, each chosen for their particular experience or know-
ledge in relation to some aspect or other of forensic clinical practice, for producing such val-
uable chapters while tolerating our editorial interference in the pursuit of a consistent style.

TC & DSR

vi
 Abbreviations
AC approved clinician
ACCT assessment, care in custody and teamwork
ADOS Autism Diagnostic Observation Schedule
AESOP Aetiology and Ethnicity of Schizophrenia and Other Psychoses
AMHP approved mental health professional
AOT assertive outreach team
ARA(I) actuarial risk assessment (instrument)
ASBO antisocial behaviour order
ASD autistic spectrum disorder
AUC area under the curve
AWOL absent without leave (from MHA detention) or absent without official leave
BCS British Crime Survey
BME black and minority ethnic
CAMHS Child and Adolescent Mental Health Services
CAMCOG Cambridge Cognitive Exam
CANFOR Camberwell Assessment of Needs – forensic version
CARATS counselling assessment referral advice and throughcare Service
CATIE Clinical Antipsychotic Trials of Intervention Effectiveness
CBT cognitive–behavioural therapy
CCRC Criminal Cases Review Commission
CIS-R Clinical Interview Schedule – Revised
CJA 2003 Criminal Justice Act 2003
CJA 2009 Coroners and Justice Act 2009
CJCSA 2000 Criminal Justice and Court Service Act 2000
CJS criminal justice system
CLDT community learning disability team
CMHT community mental health team
CPS Crown Prosecution Service
CoP Code of Practice to the Mental Health Act 1983
CPA care programme approach
CPIA Criminal Procedure (Insanity) Act 1969
CPN community psychiatric nurse
CrimPR Criminal Procedure Rules
CSA childhood sexual abuse
CTO community treatment order
DCR discretionary conditional release
DH Department of Health
DHSS Department of Health and Society Security
DPP detention for public protection

vii
 Abbreviations

DSH deliberate self-harm

DSM Diagnostic and Statistical Manual of Mental Disorders
DSPD dangerous and severe personality disorder
DTO Detention and Training Order
DVCVA 2004 Domestic Violence, Crime and Victims Act 2004
ECA Epidemiological Catchment Area Survey
ECHR European Convention on Human Rights
ERASOR estimate of risk of adolescent sexual offence recidivism
FME forensic medical examiner
GDP gross domestic product
HCR-20 Historical Clinical Risk-20
HMIP Her Majesty’s Inspectorate of Prisons
HoNOS Health of the Nation Outcome Scales
ICD International Classification of Diseases
ICT iterative classification tree
IMB independent monitoring board
IMCA independent mental capacity advocate
IPDE international personality disorder examination
imprisonment for public protection or indeterminate sentence for public
IPP
protection
LD learning disability
LHRH luteinizing hormone-releasing hormone
LSC Legal Services Commission
MAPPA multi-agency public protection arrangement
MAPPP multi-agency public protection panel
MCA 2005 Mental Capacity Act 2005
MDT multidisciplinary team
MDO mentally disordered offender
MEAMS Middlesex Elderly Assessment of Mental State
MHA 1983 Mental Health Act 1983
MHA 2007 Mental Health Act 2007
MHU Mental Health Unit (of the MoJ)
MMSE Mini-Mental State Examination
MoJ Ministry of Justice
MSU medium secure unit
NGBROI not guilty by reason of insanity
NICE National Institute for Health and Clinical Excellence
NOMS National Offender Management Service
OABH occasioning actual bodily harm
OASys Offender Assessment System
OBP offending behaviour programme
OCD obsessive–compulsive disorder
OGP OASys General reoffending Predictor
OGRS Offender Group Reconviction Scale
OM offender manager
OR odds ratio
OT occupational therapy

viii
 Abbreviations

OVP OASys Violence Predictor

PACE 1984 Police and Criminal Evidence Act 1984
PANSS Positive and Negative Syndrome Scale (for schizophrenia)
PAR population attributable risk
PCCA Powers of Criminal Courts Act 2000
PCL-R Psychopathy Checklist – Revised
PCL-SV Psychopathy Checklist – Screening Version
PCL-YV Psychopathy Checklist – Youth Version
PCT primary care trust
PD personality disorder
PED parole eligibility date
PICU psychiatric intensive care unit
PIPES psychologically informed planned environment
PPG penile plethysmography
PSR pre-sentence report
PTSD post-traumatic stress disorder
RC responsible clinician
RCP Royal College of Physicians
RCPsych Royal College of Psychiatrists
RM2000 Risk Matrix 2000
RMO responsible medical officer
RMP registered medical practitioner
ROC receiver operator characteristics
ROSH risk of serious harm (according to OASys)
RRASOR rapid risk assessment for sex offender recidivism
RSU regional secure unit
RSVP Risk of Sexual Violence Protocol
SAPROF Structured Assessment of Protective Factors for violence risk
SAVRY Structured Assessment of Violence Risk in Youth
SCA structured clinical assessment
SCAN Schedules for Clinical Assessment in Neuropsychiatry
SCID-II Structured Clinical Interview for DSM-IV axis II diagnoses
SCMH Sainsbury Centre for Mental Health
SCT supervised community treatment
SHA strategic health authority
SI statutory instrument
SMB strategic management board (for MAPPA)
SNASA Salford Needs Assessment Schedule for Adolescents
SOPO sex offender prevention order
SORAG sex offender risk appraisal guide
SOTP sex offender treatment programme
SPJ structured professional judgement
SSRI selective serotonin reuptake inhibitor
START short-term assessment of risk and treatability
TC therapeutic community
TCO threat control over-ride
ViSOR Violent and Sexual Offenders Register

ix
 Abbreviations

VLU victim liaison unit

VORAS Violent Offender Risk Assessment Scale
VRAG Violence Risk Appraisal Guide
WAIS Weschler Adult Intelligence Scale
WHO World Health Organization
wte whole-time equivalent
YJB Youth Justice Board
YOI young offenders’ institution
YOT Youth Offending Team

x
 1
The Development of
Forensic Psychiatric
Services
● Historical Background
Offenders with mental illness have always posed unique difficulties for the criminal justice
system and psychiatrists. Prior to the nineteenth century there were no specific facilities
for dealing with them, although in practice they were usually compulsorily committed to
hospital by the courts.

The need for secure hospitals

In 1800 James Hadfield tried to kill King George III and was found not guilty by reason of
insanity:
• He was transferred to Bethlem Hospital from prison, but escaped in 1802 before being recaptured
and sent back to prison.
• The ‘Report from the Select Committee Appointed to Enquire into the State of Lunatics’ criticized
the practice of admitting ‘criminal lunatics’ to ‘a common gaol’:
– inadequate security of asylums and uncertainties about funding were both cited as significant
problems
– recommended ‘separate confinement’ for ‘insane offenders’ funded by parishes.
• ‘Criminal wings’ were constructed at the Government’s expense at Bethlem Hospital in 1816:
– 60 beds (45 male, 15 female), extended in 1837 by 30 male beds.
• Patients with less serious offences were routinely detained in county asylums.

The development of criminal asylums

• Dundrum Central Criminal Asylum in Ireland opened in 1850 (120 beds)
• Broadmoor Criminal Lunatic Asylum in Berkshire opened in 1863 (500 beds):
– repeatedly extended due to overcrowding and demand
• Rampton Criminal Lunatic Asylum in Nottinghamshire opened in 1912
• Ashworth Hospital was created in 1989 by merging two adjacent high secure hospitals:
– Moss Side Hospital had opened in 1914
– Park Lane Hospital had opened in 1974.
1
 The Development of Forensic Psychiatric Services

These were known collectively as ‘special hospitals’ and later ‘high secure services’. They
became part of the NHS in 1948 but remained geographically and professionally isolated
from general psychiatric services.

The birth of forensic psychiatry

A series of reports beginning in the early 1960s heralded the emergence of forensic psychia-
try and began to foresee possibilities for secure services on a more local footing. The large
special hospitals remained remote, and there were concerns about the numbers of beds and
the conditions within the hospitals.

The Emery Report (Ministry of Health, 1961)

• The Mental Health Act 1959 began a trend of reducing restrictive practices and security in general
psychiatric hospitals:
– led to a reduction in mentally disordered offenders admitted.
• A working party on special hospitals was set up to consider the role of special hospitals in managing
these patients.
• Proposed provision of secure beds by regional health bodies to relieve pressure on special hospitals.
• No resources were provided and there was little tangible result.

The Gwynne Report (Ministry of Health, 1964)

• Examined the state of medical services in prisons (then separate from the NHS).
• Recommended appointing ‘forensic psychiatrists’ jointly between prison medical services and the
NHS as a response to the clear lack of psychiatric expertise within prisons.
• Seven consultant posts founded between 1966 and 1975.
• Worked in prisons and with liaison and assessment, but had no secure hospital beds available.

The Glancy Report (DHSS, 1974)

• Lack of secure beds as proposed by Emery was causing great difficulties:
– ongoing problems of managing those with mental disorder within the prison system
– special hospitals overcrowded, although Park Lane Hospital in development at that time.
• Working party commissioned to revisit the issues raised by Emery, and consider existing security
provisions and make recommendations for future provision.
• Recommended that regional health authorities provide secure beds on a regional level:
– 1000 beds for England and Wales proposed.

The Butler Committee on mentally abnormal offenders

By the early 1970s there was serious overcrowding in the special hospitals, an increasing
awareness of the difficulties posed in attempting to manage the mentally ill in prison and a
general downgrading of the security provided in general psychiatric hospitals.
The Butler Committee was established in 1972 following the conviction of Graham
Young, who had poisoned a large number of people (killing three) after discharge from
Broadmoor Hospital (see Bowden, 1996, for a full account of the case).The committee was
charged with considering the criminal law relating to mentally disordered offenders, and
making recommendations about facilities and treatment provided.
An interim report was published (Home Office and DHSS, 1974) given the urgency of
the problem of a lack of secure beds:
• Set a framework for the development and expansion of forensic psychiatry:
2
 Historical Background

– increasing numbers of consultant appointments

– all psychiatric trainees to have experience in the specialty.
• Recommended immediate construction of ‘regional secure units’ (RSUs):
– to be financed by direct allocation of Government money
– proposed initially 1000 beds, rising to 2000 over time
– not to be used for long-stay admissions – suggested indicative admissions of 18 months
– interim secure units (ISUs) to be opened while RSUs constructed.

The final report (DHSS, 1975) was presented to Parliament in October 1975 and made
numerous recommendations:
• Reiterated the need for secure accommodation and noted that little progress had yet been made.

The Butler Report set the agenda for forensic psychiatry to be provided outside of custodial
settings and in purpose-built hospitals. Contemporaneously, some (Scott, 1974) argued that
it would be better to develop facilities within the prison system, rather than invest in new
provision which would inevitably leave prison health care as a poor relation.

The development of regional secure units

Interim secure units were set up within general hospitals while regional health authorities
developed plans for constructing RSUs.
The RSU programme was subject to considerable delays (Snowden, 1985):
• Reluctance among health authorities to proceed, despite money being available.
• Concerns about the cost of staffing and running the units long term, after construction costs met.
• Had to combat significant opposition from unions, local residents, lobbyists, MPs, etc.:
– a review of reports into serious untoward incidents from four RSUs over 4 years found no
measurable effect on serious crime rates in the local community (Gradillas et al., 2007).
• Problems with staffing and running costs.
• Forensic psychiatrists were often not involved in construction or service development until late
stages.
• Ideas about models of care provision changed with experience, but often too late to change plans
that were already in the late stages of development.

The first RSU opened in Middlesbrough in 1980, followed by units in Devon, Trent and
Mersey in 1983:
• By 1990, 600 of the 1000 proposed had been opened.

Eventually RSUs became established, and regional forensic psychiatry services built up
around them, providing a broad range of services:
• Psychiatric input in prisons.
• Court liaison and diversion schemes.
• Providing management advice to general psychiatry.
• Community follow-up in some cases.

The Reed Review

The broad remit for the Reed Review was to examine the health and social services pro-
vided to mentally disordered offenders (MDOs) and those non-offenders with similar needs.
This was in the context of changes in the structure of the NHS, along with ongoing con-
cerns about the difficulties in dealing with such offenders.
3
 The Development of Forensic Psychiatric Services

The review proposed important guiding principles to underpin care of these patients:
• Patients should be cared for as far as possible in the community, rather than institutional settings.
• Conditions of security should be no greater than could be justified by the danger posed to
themselves or to others.
• Care should be provided as near as possible to the patient’s home or family.

The final report (Department of Health and Home Office, 1992) made nearly 300 recom-
mendations:
• Formal arrangements for cooperation between the various agencies involved (health, social care,
criminal justice) should be put in place.
• Specialized teams for dealing with mentally disordered offenders should be established, with a
broad multidisciplinary staff.
• The application of the care programme approach (CPA) to mentally disordered offenders, including
those released from prison and those returned to prison after hospital treatment.
• Effort should be made to address the over-representation of ethnic minorities among MDOs.
• A new national target of 1500 medium secure beds proposed, with expansion in training and
recruitment of forensic psychiatrists and related professions.

Impact of the Reed recommendations

• Raised awareness of the issue and Government-acknowledged need.
• Some court diversion schemes established at a local level.
• Increased funding for medium secure beds:
– Butler target of 1000 beds was met in 1996
– approximately 2000 beds by 1999, 500 of which were provided outside the NHS (Coid et al.,
2001).

● Principles of Security
The Reed Report described three domains of security:
• Physical security:
– aspects of environment and building design that support containment and safety
– includes the secure perimeter, design and management of the entry point, locking of doors,
window design, alarm systems, etc.
• Relational security:
– the quality of the relationship between patient and carers, enabling a detailed and in-depth
knowledge of patients, their history, their reason for admission and progress to date
– allows early detection of alterations in presentation which might herald increased risk
– security and treatment closely linked.
• Procedural security:
– ‘The methodology or systems by which patients are managed and safe security maintained’
(Exworthy and Gunn, 2003)
– policies and practices governing patient movement and observation, such as maintaining a list
of contraband items, restricting access to potential weapons (‘sharps’), screening and approving
visitors, searching patients before and after leave, routine searches of wards for contraband items
– also includes higher level clinical and professional governance arrangements, major incident
planning, investigation of serious incidents, communication of lessons learned, etc.

The distinction between levels of security is shown in Table 1.1 and discussed further in
Kennedy (2002) and Crichton (2009).
4
 Principles of Security

Table 1.1 Security characteristics at different levels of security

Low Medium High
Physical National Standards Guidance Traditionally designed to be Equivalent to a category
gives considerable latitude ‘escape-retardant’; current B prison – designed to be
depending on the population expectations are to deter all escape-proof
served, but all security but the most determined
measures should be discreet escapers
Standard hospital perimeter, 5.2 m high perimeter – close- 6 m high wall
with enclosed garden mesh fence or connecting
buildings
Daily checks of the perimeter
Dedicated entry point, not Entry through an ‘air lock’, Entry through dedicated
through rest of hospital; controlled by reception gate lodge, including X-ray
airlock is recommended machine and metal detector
Clear lines of sight, and Staff electronic keys may allow CCTV covering entire site
appropriate space/door size monitoring of movement.
for physical interventions May have some CCTV
Solid-core, outward opening Doors secured with standard All doors secured with prison
doors, mostly lockable. locks or magnetic locking specification locks
Window opening restricted to device
less than 125 mm
Wall-mounted alarms and/or Individual personal alarms provided for all staff
personal alarms for staff
Procedural Dedicated security staff Some units have a dedicated Dedicated security team
unlikely security team supporting clinical teams
Rub down searching may take place on return from Routine use of rub-down
community leave, otherwise not used routinely searches
No routine monitoring of telephone calls and no Mental Routine monitoring of patient
Health Act (MHA) power to interfere with mail telephone calls and mail
Fewer restrictions on items Tight restrictions on items Tight restrictions on items
and those with a specific allowed in the hospital allowed within the secure
purpose in rehabilitation (potential weapons, com- perimeter
(e.g. access to computers munication devices, etc.). There
or mobile phones) may be may be some flexibility for
permitted staff and in non-clinical areas
Visiting controlled as in Visitors subject to approval Visiting restricted with careful
general hospital-locked wards process, but generally less vetting beforehand. Visits are
rigorous than high security. closely supervised by security
Visits supervised by nursing staff
staff
Depending on the nature Many patients will have Relatively few patients have
of the unit, patients may regular leave outside the leave outside the hospital
have considerable access to hospital, either escorted or perimeter except for essential
community unescorted visits (e.g. hospital
appointments)
Relational Lower nursing numbers than Increased nurse : patient ratio
medium and high security
Detailed documentation Relatively long admissions Dedicated security team
and regular meetings of all allow more detailed collects security-related data
clinical team members to knowledge of patients over and information
discuss cases time to be accrued Long admissions allow
The range of environment detailed knowledge of a
within medium security, from patient to be gathered,
acute or intensive care wards albeit only within a highly
to rehab wards with extensive controlled environment
community leave, provides a
particularly rich knowledge
5
 The Development of Forensic Psychiatric Services

The differential impact of ‘security creep’

The last 10 years has seen an incremental increase in the level of security provided in secure
hospitals, together with, for medium secure units, a reduction in the level of political/mana-
gerial tolerance for escapes and absconds. In particular:
• The Tilt Report (Tilt et al., 2000) made recommendations to increase the physical and procedural
security at the three high secure hospitals.
• The national specification for medium secure services (Department of Health, 2007) has increased
the physical security requirements for medium secure services.

This inexorable shift in the direction of increased security should be seen in the context of
the changing socio-political climate, with increased risk-aversion, more punitive sentenc-
ing, and the political drive to increase rates of MHA detention for those deemed dangerous.
Reports, inquiries and managers tend to give greater emphasis to physical and procedural
than to relational security measures. Physical and procedural security measures are:
• conceptually simpler and more tangible
• easier to articulate and therefore recommend
• easier to achieve
• easier to measure, audit and demonstrate.

Increasing physical and procedural security risks less effective relational security, because:
• the range of environments in which the patient is managed is more limited
• there are fewer opportunities for therapeutic risk taking and testing out
• an over-emphasis on demonstrating readily auditable physical and procedural security reduces the
attention given to relational security.

Consequently, medium secure care environments have become more restrictive and less like
the community. The gap that must be bridged by rehabilitation has become wider.
• Low secure units, originally conceived as providing primarily long-term care, have begun to seek to
fill that rehabilitative gap.
• This forensic version of functionalization in itself has important implications for continuity of care
and relational security.

● Current Secure Hospital Provision

Recent figures for the size of the forensic population/secure bed provision include:
• Forensic patient population increased from 2650 in 1997 to nearly 4000 in July 2007.
• In 2005, 2886 NHS beds and 1827 independent sector secure beds (Rutherford and Duggan, 2007).
• In 2007, 3022 NHS and 1913 independent sector secure beds (BBC, 2008).
• In 2009 there were a daily average of 3438 secure NHS beds available across all three levels
of security (figures available at http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/
Performancedataandstatistics/Beds/DH_083781).

High secure services

The three high secure hospitals are:
• Ashworth Hospital, Maghull, Liverpool; approx 275 beds
• Rampton Hospital, Retford, Nottinghamshire; approx 370 beds:
– includes the national high secure services for women, learning disability and the deaf.
6
 Current Secure Hospital Provision

• Broadmoor Hospital, Crowthorne, Berkshire; 260 beds.

Patients are admitted to high security when they are considered to pose a ‘grave and im-
mediate danger’ to the public. This decision may be based on:
• having been charged with or convicted of a grave offence, including those with sadistic or sexual
motive
• the immediacy of risk to others if they were at large
• evidence of a capacity to coordinate an organized escape attempt, or engage in subversion of
staff.

Cases with a high national profile are also likely to be admitted to high security, on the
basis that an ‘abscond from hospital would seriously undermine confidence in the criminal
justice system’.
In previous years the high secure hospitals were subjected to much criticism, the prob-
lems perhaps resulting in part from the nature of the patient group and the professional and
managerial isolation from other parts of the NHS. In particular, at Ashworth Hospital:
• The Blom-Cooper Report in 1992 (Blom-Cooper et al., 1992) was highly critical of the culture and
abusive practices that were uncovered. It found evidence of systematic mistreatment and abuse of
patients, and failures of management throughout the organization.
• The Fallon Inquiry report in 1994 (Department of Health, 1994) identified severe shortcomings
in the running of the personality disorder service. Patients were discovered to have been dealing
in drugs, alcohol and pornography and security had been compromised to a large extent. There
was also evidence of widespread corruption. The report again strongly criticized the management
of the service and the hospital and recommended its complete closure, although this did not take
place.

Since then, the management of each high secure hospital has been brought into that of the
local NHS provider; the high secure services are managed as one part of a range of secure
services in that region. There has also been significant retraction in services since 2000
(Abbott et al., 2005):
• due to projections of reduced need for high secure care as a result of increased provision in medium
security
• high secure beds reduced from 1276 in 2000 to 879 in 2009 (Hansard, 2010)
• movement of patients into regional services for long-term care
• rehabilitation of patients through medium and low secure services where appropriate.

Medium secure services

There are currently in the region of 3500 medium secure beds across NHS and independent
sector providers. Medium secure units provide the mainstay of forensic psychiatric inpatient
care, and are often the regional centres in which other forensic outreach, prison inreach and
liaison services are based.
The original expectation that admissions would be for 18 months to 2 years is no longer
valid:
• Long-term medium secure beds have been provided for those patients who require long-term care
in such conditions, including some previously housed in high security.
• For others the duration of admission has increased significantly beyond this.

The Department of Health has issued a formal specification for medium secure services
(Department of Health, 2007):
7
 The Development of Forensic Psychiatric Services

• Seven key domains – safety, clinical and cost-effectiveness, governance, patient focus, accessible
and responsive care, care environment and amenities, public health.
• For each domain a number of specific quality principles, with specified measures of performance
and evidence required.
• Used as a basis for the evaluation of quality of care provided in medium secure services.

The Royal College of Psychiatrists has established a ‘Quality Network for Foren-
sic Mental Health Services’ which provides a peer review process based on the Depart-
ment of Health standards (http://www.rcpsych.ac.uk/quality/quality,accreditationaudit/
forensicmentalhealth.aspx)
Bed numbers have continued to increase and more specialized services developed:
• Provided by a mixture of NHS and independent sector providers.
• Specialized services for women, forensic CAMHS, older adults, autistic spectrum disorder (ASD),
etc.

Low secure services

In contrast to medium secure units, low secure provision has developed organically, without
any clear statement of need or policy, mostly over the last 10–15 years.
• There are no reliable data on numbers, and the services provided in low security are diverse.

National minimum standards for psychiatric intensive care units (PICUs) and low security
developed by the Department of Health (2002):
• Defined as services delivering ‘intensive, comprehensive and multidisciplinary treatment and care
by qualified staff for patients who demonstrate disturbed behaviour in the context of a serious
mental disorder and who require the provision of security’.
• Set standards for all aspects of the units including physical design and layout, service structure,
involvement of patients and carers, policies and procedures, clinical audit, etc.
• Envisioned to provide longer-term care (around 2 years) as compared with 8 weeks for PICUs.

Low secure services have evolved into a combination of active rehabilitation and long-term
facilities, providing
• a step-down from medium security into the community, allowing for extended community
rehabilitation
• long-term care for those in medium security who are unlikely to be successfully discharged into the
community due to the nature of their illness and ongoing risks
• a sideways move from PICUs for those who require longer-term care in such conditions.

Recent papers have suggested that a large expansion in low secure bed numbers is needed to
match the expansion in medium security and provide suitable pathways into the community
(Beer, 2008; O’Grady, 2008; Turner and Salter, 2008).

● Forensic Community Services

The Reed Report recommended the development of forensic community services but gener-
ally this lagged behind the RSU programme.
In contrast to general, psychiatric, functionalized community teams there are no agreed
standards for forensic community teams, and there is considerable variation in service
model between forensic services:
8
 Commissioning Arrangements and the Independent Sector

• No community service, all inpatients passing from secure care to general psychiatric teams for
community follow-up, either with or without an intervening period of general psychiatric inpatient
care.
• Parallel model, in which a distinct forensic community team carries care programme approach
(CPA) responsibility for a defined case load of patients. This provides the clearest demarcation of
roles and responsibilities.
• Integrated model, in which the forensic community team works within general psychiatric
community teams, supporting them in managing their ‘forensic’ patients:
– may reduce stigma associated with being a forensic patient
– encourages development of skills in general psychiatric teams (Whittle and Scally, 1998).
• Consultation and liaison models. Most forensic services provide this service to general psychiatric
colleagues either on a traditional medical referral basis, or in the form of a distinct and specifically
commissioned forensic liaison service:
– the development of such services was given renewed impetus by the Bradley Report (Department
of Health, 2009).

● Commissioning Arrangements and the

Independent Sector
Commissioning is the process by which most services in the NHS are developed and funded:
• Defined by the Audit Commission as ‘the process of securing and monitoring services to meet
individuals’ needs at a strategic level’.
• ‘Purchasers’ are given control of money.
• Services for patients are purchased from ‘providers’ (usually NHS organizations, but also includes
independent sector).

Up until 2011, the purchasers for most services were primary care trusts (PCTs). However,
most secure services were classed as specialist services:
• Regional Specialized Commissioning Teams, based within strategic health authorities (SHAs),
negotiated with all the purchasers within the region to commission a regional service.
• This means that the provider does not have to negotiate with a series of different purchasers at
once.
• In most cases the ‘preferred provider’ is the NHS service, but where necessary due to capacity
issues or a particular clinical need, the commissioning teams also negotiate and agree contracts
with independent sector providers.
• The commissioning team has a responsibility to ensure that the services provided to the patients of
that region is of high quality.

Some particularly specialist services, were commissioned nationally due to the relatively
small demand and high complexity:
• The National Commissioning Group (NCG) was responsible for this (http://www.ncg.nhs.uk).
• Mostly complex medical and surgical problems (pancreas transplants, amyloidosis, etc.).
• Secure forensic mental health services for young people (otherwise known as forensic CAMHS) were
commissioned on this basis by the NCG.

Reorganizations are frequent, mostly varying the nature of the purchasers:

• The 2011 reforms (Department of Health, 2010) proposed abolition of PCTs, which had previously
commissioned most services, and SHAs which had commissioned specialist services such as secure
psychiatric care:
9
 The Development of Forensic Psychiatric Services

– establishment of GP consortia to take over as the main commissioners

– secure psychiatric care would continue to be commissioned regionally, through the central NHS
Commissioning Board.

The relationship between the NHS and independent sector

According to Murphy and Sugarman (2010) the independent sector now provides more
than half of the medium secure beds nationally:
• Mostly generic secure mental illness services, but also include services for personality disorder and
some other specialist needs.

The regional NHS service usually provides a ‘gate-keeping’ service to the commissioning
team, carrying out clinical assessments of the needs of patients referred for secure care.
Where the NHS service either lacks capacity, or cannot address some particular need, an
alternative independent provider is sought. Historically, independent sector placements
tended to be more expensive than the NHS, but this difference has declined in recent years.
NHS services continue, generally, to provide a more comprehensive service than inde-
pendent providers, who tend to concentrate just on inpatient care. For some, the establish-
ment of the independent sector as providing a major contribution to forensic psychiatric
services in the UK is a matter of political or economic concern. See Murphy and Sugarman
(2010) and Pollock (2010).

References
Abbott P, Davenport S, Davies S, Nimmagadda SR, O’Halloran A, Tattan T. (2005) Potential effects of
retractions of the high-security hospitals. Psychiatric Bulletin 29, 403–6
BBC. (2008) Today Program, ‘Mental Health Care Escapes “horrifying”’, 9 September 2008
Beer D. (2008) Psychiatric intensive care and low secure units: where are we now? Psychiatric Bulletin
32(12), 441–3
Blom-Cooper L, Brown M, Dolan R, Murphy E. (1992) Report of the Committee of Inquiry into com-
plaints about Ashworth Hospital. Cmnd 202. London: HMSO
Bowden P. (1996) Graham Young (1947–90); the St Albans poisoner: his life and times. Criminal
Behaviour and Mental Health 6, 17–24
Coid J, Nadji K, Gault S, Cook A, Jarman B. (2001) Medium secure forensic psychiatry services. Com-
parison of seven English health regions. British Journal of Psychiatry 178, 55–61
*Crichton JHM. (2009) Defining high, medium, and low security in forensic mental healthcare: the
development of the Matrix of Security in Scotland. Journal of Forensic Psychiatry and Psychology
20(3), 333–53
Department of Health. (1994) Report of the Committee of Inquiry into the Personality Disorder Unit,
Ashworth Special Hospital (The Fallon Inquiry). London: The Stationery Office
Department of Health. (2002) Mental Health Policy Implementation Guide. National Minimum
Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure
Environments. London: Department of Health
*Department of Health. (2007) Best Practice Guidance: Specification for adult medium-secure serv-
ices. London: Department of Health
Department of Health. (2009) The Bradley Report: Lord Bradley’s review of people with mental
health problems or learning disabilities in the Criminal Justice System. London: Department of
Health
10
 Commissioning Arrangements and the Independent Sector

Department of Health. (2010) Equity and Excellence: Liberating the NHS. London: The Stationery
Office
*Department of Health and the Home Office. (1992) Review of Health and Social Services for Men-
tally Disordered Offenders and Others Requiring Similar Services (The Reed Report). Cm 2088.
London: HMSO
Department of Health and Social Security. (1974) Revised Report of the Working Party of Security in
NHS Psychiatric Hospitals (Glancy Report). London: HMSO
Department of Health and Social Security. (1975) Report of the Committee of Mentally Abnormal
Offenders (Butler Report). London: HMSO
Exworthy T, Gunn J. (2003) Taking another tilt at high security hospitals. British Journal of Psychiatry
182, 469–71
Gradillas V, Williams A, Walsh E, Fahy T. (2007) Do forensic inpatient units pose a risk to local com-
munities? Journal of Forensic Psychiatry and Psychology 18(2), 261–5
Hansard. (2010) HC vol 505 col 1046W, 10 February 2010
Home Office and DHSS. (1974) Interim Report of the Committee on Mentally Abnormal Offenders
(Butler Report). London: HMSO
Kennedy HG. (2002) Therapeutic uses of security: mapping forensic mental health services by strati-
fying risk. Advances in Psychiatric Treatment 8, 433–43
Ministry of Health. (1961) Special Hospitals: Report of a Working Party (Emery Report). London:
Ministry of Health.
Ministry of Health. (1964) Report of the Working Party on the Organisation of the Prison Medical
Service (Gwynne Report). London: Ministry of Health.
Murphy E, Sugarman P. (2010) Should mental health services fear the independent sector: no. British
Medical Journal 341, 5385
O’Grady J. (2008) Time to talk. Commentary on … forensic psychiatry and general psychiatry. Psy-
chiatric Bulletin 32(1), 6–7
Pollock A. (2010) Should mental health services fear the independent sector: yes. British Medical
Journal 341, c5382
Rutherford M, Duggan S. (2007) ‘Forensic Factfile 2007’: Forensic Mental Health Services: Facts and
figures on current provision. Sainsbury Centre for Mental Health. Available at: http://www.centre-
formentalhealth.org.uk/publications/forensic.aspx?ID=526
Scott P. (1974) Solutions to the problem of the dangerous offender. British Medical Journal 4(5495),
640–1
Snowden P. (1985) A survey of the Regional Secure Unit Programme. British Journal of Psychiatry
147, 499–507
Tilt R, Perry B, Martin C. (2000) Report of the Review of Security at the High Security Hospitals.
London: Department of Health.
Turner T, Salter M. (2008) Forensic psychiatry and general psychiatry: re-examining the relationship.
Psychiatric Bulletin 32(1), 2–6.
Whittle M, Scally M. (1998) Model of forensic community care. Psychiatric Bulletin 22, 748–50

11
 2
Entry into
Secure Care
Mental health problems are common, and offending is common:
• In 2006, 15% of people (24% of males, 6% of females) between 10 and 52 years had at least
one conviction.
• Of males born in 1973, 29% had been convicted before the age of 30 (Ministry of Justice, 2010a).

Overlap is inevitable.
There is no agreed definition of a ‘forensic patient’, the specialty having developed prag-
matically, driven by clinicians and public policy, rather than from a cohesive body of research,
a treatment approach or a defining pathology. Movement between forensic and general psy-
chiatric services is fluid, and often dependent on local provision and organization:
• Assertive outreach team (AOT) patients have many criminogenic needs in terms of socio-economic
disadvantage, substance misuse and a history of offending (Priebe et al., 2003).
• In a small European study Hodgins et al. (2006) found no difference between discharged forensic
and general psychiatric patients on HCR-20 or PCL-R scores. A history of serious physical violence
towards others, including violent crimes and physical violence which had not resulted in legal
sanction, seemed to distinguish the forensic group.

● Sources of Referrals
Referrals to forensic services may be:
• for diversion from the criminal justice system (CJS) (prisons, courts, police stations)
• to consider movement between levels of security:
– up, usually from general psychiatric wards
– down, from high security or medium security, or
– sideways between services to address some specific need
• for ‘gate-keeping’ assessments for specialist services within or outside of the NHS
• for a second opinion on diagnosis/risk/management.

Admission rates to high and medium secure hospitals demonstrate a linear correlation with
levels of socio-economic deprivation in patients’ catchment areas of origin (Coid, 1998):
• So demands on urban forensic services will be higher.

Most patients entering secure care are diverted from a custodial setting:
• Coid and Kahtan (2001) described a sample of 2608 admissions to 7 regional secure units (RSUs)
between 1988 and 1994. The pre-admission locations were:
12
 Diversion from CJS

– 39–65% from prison

– 11–26% from psychiatric hospitals
– 3–40% from community, including police stations
– 6–19% from high secure hospitals.
• It is likely that there has been some change in these patterns in the intervening years. Anecdotally,
the proportion of patients admitted to medium security from prison is higher now than it was then.
• Jamieson et al. (2000) looked at high secure admissions between 1986 and 1995. Women were
more likely than men to be admitted from other hospitals than as prison transfers:

Source of referral Male (%) Female (%)

Prison 41 21
Courts 35 37
Hospital 21 40

Table 2.1 Some factors relevant to deciding the appropriate level of security (adapted from
Department of Health, 2007; Kennedy, 2002)
High secure Medium secure Low secure/psychiatric intensive
care unit (PICU)
Grave offence, especially Serious offence or past failed History of non-violent offending
sadistic or sexual placements at lower level behaviour
Immediate danger to others if Danger to others would be less immediate
in community
Risk is predominantly to others Mix of risk to others/challenging
behaviour/deliberate self-harm
Significant capacity to Significant risk of escape or Low risk of absconding
coordinate outside help for an absconding, or
escape attempt or absconding Pre-sentence for serious charge
would undermine confidence
in the criminal justice system
Unpredictable relationship Recovery likely to be prolonged, Acute illness, likely to respond
between risk and mental state some risks remain even when well promptly to treatment
Previously unmanageable in Previously unmanageable in low Previously unmanageable on open
medium security security/PICU ward

● Diversion from CJS

The policy objective of diversion from custody encourages the removal of people with men-
tal disorders from the CJS to a suitable hospital or community placement where they can
receive treatment:
• This reflects a social consensus that sick people should be treated rather than punished (James et
al., 2002).
Contemporary diversion policy began with Home Office Circular 66/90:
• Set out the Government’s policy to divert mentally disordered persons from the CJS in cases where
the public interest did not require a prosecution.
• Non-penal disposals were encouraged where a prosecution was necessary.

Subsequently:
• The Reed Report (Department of Health and Home Office, 1992):
– recommended nationwide provision of court diversion schemes
– recommended alternative community provisions for mentally disordered offenders
– led to an increase in the number of prisoner transfers to hospital.
13
 Entry into Secure Care

Box 2.1 Assessment of referrals for admission from a setting of

lower security or CJS
Before the assessment it is important to ensure that the funding stream is established and allocation of
the case is correct. Establishing the relevant commissioner is explained for prison transfers in Department
of Health (2007), and is based on, in order:
• the patient’s GP or their address if unregistered
• the area in which their offence occurred if they had no address/GP
• the area in which the prison is located if usually resident outside the UK.
Ensure that you know what the referrer wants:
• It is common for a referral letter to seek a general ‘forensic opinion’, without explicating what the refer-
ring team is really hoping for. This is especially likely to be true where a trainee has written the letter.
• Speak to the referring consultant, so that you know what the real issues are and understand the urgency
of the referral.
Consider:
• Whether there is additional information that needs to be supplied in advance of the assessment.
• Who should carry out the assessment and whether more than one discipline is required.
• The need for a collateral history and facilitate this if possible – for example, by asking the patient to
bring a carer to an outpatient appointment, or ensuring that their keyworker will be present when you
assess an inpatient.
Before seeing the patient:
• Review the case notes, noting in particular incidents and precipitants of violence/aggression, apparent
changes in mental state, periods of leave, use of drugs/alcohol, medication changes, level of engage-
ment in treatment, subversive behaviours.
• Discuss these areas of inquiry with nursing staff, and understand any dynamic issues with particular
staff, with other individual patients, or relating to the current mix of patients on the ward as a whole.
• Consider safety issues relating to interviewing this patient, and the interview room itself. Make any
adjustments that you consider necessary.
The interview needs to be flexible and adaptable according to the presentation/mental state of the
patient and the desired outcome:
• For assessments already in secure services, make use of existing detailed reports for background history
and concentrate on current clinical and dynamic factors important to your decision-making.
• Particularly concentrate on the level of insight and understanding of mental illness and offending, the
level of engagement in treatment and likely motivations, their aims for the future and their conceptual-
ization of a pathway to achieve these.
• Assessments of patients in the CJS are more likely to require a full background history from the patient
and other informants.
Always remember to make an entry in the case notes to record your assessment and ensure that any
immediate concerns , either related to mental state or risk, are effectively communicated to those with
ongoing responsibility for the patient’s care.
After the assessment take your time to assimilate all the information and discuss within the multi-
disciplinary team. You need to consider:
• The patient’s diagnosis, the likely effectiveness of treatment in the current setting and the impact that
this will have on risk behaviours.
• Risks of violence to others (see Chapter 6) but also to self, of absconding/escaping and perhaps other
idiosyncratic risks.
• What enhanced measures might be employed in the current setting to manage these risks.
• Whether they are manageable within the current setting until treatment is likely to have been effective.
• The likely effectiveness of treatment within the proposed setting.
• Any idiosyncratic treatment needs that would require specific planning or referral to a specialist service.

14
 Diversion from CJS

Deciding on whether a patient (1) should be admitted and (2) if no to what level of security are complex
clinical judgements with no simple determining factors:
• therefore your opinion should be circumspect, open-minded and, where appropriate, should specify the
circumstances in which you would want to review the case.

Assessing a referral for transfer from higher security

This follows the same principles as described above and many of the same issues are relevant. In relation
to incidents of violence, other risk behaviours and subversion, you need to make a judgement about
whether an apparent decline or cessation is due to positive clinical change or simply due to the highly
restricted environment:
• A period of testing at lower security may still be appropriate if it seems to be the latter, but you are likely
to proceed more cautiously.
You need particularly to consider the likely cost of escape or absconding, which will become considerably
more possible with a move down to medium or low security:
• You must understand how much leave they have had and how restrictive this has been.
There should be adequate background history already available. Use your assessment to:
• clarify any gaps or queries in their background, or changes in how they see their history consequent to
therapy in hospital
• understand exactly what therapy they have engaged in, and what impact this has had
• understand their current clinical state, particularly their level of engagement and degree of insight into
their disorder and offending
• formulate any change in risk behaviours that is evident
• think about and specify outstanding rehabilitative needs.

• The All-Party Parliamentary Group on Prison Health (2006) concluded that ‘a fundamental shift in
thinking’ was required to decriminalize the mentally ill, transferring their care from the CJS to health.
• The Bradley Report (Department of Health, 2009) recommended nationwide provision of court
diversion schemes and the establishment of Criminal Justice Mental Health Teams (CJMHTs) to:
– ensure continuity of care for individuals in contact with CJS
– identify and divert mentally disordered offenders (MDOs) as early as possible.
• The policy drive of the 2010 Coalition Government to reduce overcrowding in prisons was often
justified by the need to divert the mentally disordered out of the CJS.

The evidence is that the ‘organizational embedding’ of diversion and liaison schemes is
often poor, leading to doubts about the sustainability of individual schemes (Pakes and
Winstone, 2010).
There has sometimes been a tendency to dichotomize the ill and the criminals, such
that psychiatric treatment and prosecution are seen as mutually exclusive. This is discussed
further in relation to prosecuting inpatient violence in Chapter 16.
• Always remember that diversion does not require the discontinuation of criminal proceedings.
• Very often both treatment and prosecution should proceed in parallel.

Diversion in practice
An MDO may be diverted from:
• the police station (at the point of arrest)
• the magistrates’ court
• prison.
15
 Entry into Secure Care

Diversion from the police station is discussed in Chapter 16. Most such cases will not re-
quire secure care and will be admitted to PICUs or open wards.

Court diversion schemes

Magistrates’ courts are a good point for diversion because they are a filter through which all
charged cases must pass at an early stage (James, 1999):
• On the recommendation of the Reed Report a number of schemes were set up locally, but without
any central commissioning or framework.
• So nationwide coverage has not been achieved and services have developed in a piecemeal and
haphazard way (Sainsbury Centre for Mental Health, 2009).
• The Bradley Report (Department of Health, 2009) provided a further impetus, again without
provision of funds.
Potential effects of a court diversion scheme include:
• reduced reoffending and improved mental health outcomes:
– savings of >£20 000 per case in reduced CJS costs and reduction in reoffending (Sainsbury
Centre for Mental Health, 2009)
• reduced delay in receiving treatment:
– identification at court reduced the mean time between arrest and admission from 50 days to 8
days (James and Hamilton, 1992)
• increased admissions to hospital from court (four-fold for James and Hamilton, 1992), leading to an
increased demand for beds.
According to Joseph (1994), psychiatric assessment at court has other advantages:
• More information is available to the psychiatrist.
• There is greater liaison with other professionals (e.g. solicitors and probation officers).
• There is the opportunity to discuss the possibility of discontinuance with the CPS where a seriously
mentally ill individual has been charged with a relatively minor offence.
Most patients diverted from court do not require a secure service. Kingham and Corfe (2005)
reported that the need for a secure bed led to an 8- to 12-week delay in hospitalization.
An early court diversion scheme in central London was described by Joseph and Potter
(1990, 1993). They reported that, of 201 psychiatric examinations:
• 75% had previously been detained in hospital
• 77% had a previous criminal record, more than half of whom had previously been imprisoned
• Schizophrenia was the most common diagnosis (39%)
• 34% were considered unfit to plead
• 65 patients were admitted to hospital, 1 to an RSU and the rest to unlocked wards, from where
46% absconded.
They concluded that:
• admissions should generally be to locked wards
• psychotic patients benefitted most from diversion.

Although they are often conflated, diversion should be distinguished from liaison:
• Diversion schemes require the active participation of at least one psychiatrist (and an approval
mental health professional [AMHP] for civil detention)
• Liaison schemes are often nurse-led and aim to:
– identify offenders who require diversion, and
– liaise with secondary mental health providers who will undertake diversion.
16
 Diversion from CJS

Prison transfers
The provision of mental health care in prisons is discussed in Chapter 19. Despite the great
improvements in prison health care over the last 10 years, prisoners with severe mental ill-
ness generally require to be transferred out to a hospital setting.

• According to the Sainsbury Centre for Mental Health (2009) 97% of restricted transferred prisoners
are admitted to medium or high security.
• The increased frequency of transfers reported by Hotopf et al. (2000) may have been due to:
– increasing size of the prison population
– more psychiatrists visiting prisons
– limited availability making it is easier to coordinate admissions to secure beds from prison than
court (Birmingham, 2001).

As a result of these pressures, waiting times for admission have increased:

• 42 prisoners per quarter waited more than 3 months for transfer from prison to hospital in England
in 2006 (Sainsbury Centre for Mental Health, 2009).
• A pilot study investigating the feasibility of a 14-day transfer standard (Royal College of
Psychiatrists, 2010) found:
– the mean waiting time for transfer was 29 days; the median was 18 days.
• An observational study at HMP Brixton (Forrester et al., 2009) found:
– mean wait of 102 days
– 20% were referred, assessed and transferred within a month.

The Bradley Report (Department of Health, 2009) recommended a minimum target of 14

days for the transfer of prisoners with severe mental illness.

Transfers late in sentence

It is common for professionals in prison to become concerned about a prisoner’s mental
health or risk close to the point at which they are to be released:

• The prospect of release sensitizes professionals to risk.

• Pre-release assessments may uncover a previously undetected problem.
• The prospect of release may be a stressor for some, leading to deterioration in mental health.

Clinically, detention close to expected release is undesirable, because it is likely negatively

to affect initial engagement with treatment.
Transfers to hospital should not be sought in order to prolong an individual’s time in
detention on risk grounds:

• In R (on the application of TF) v Secretary of State for Justice [2008] EWCA Civ 1457, the Court of
Appeal held, in relation to a young offender with personality disorder, that:

if the decision is being taken … right at the end of sentence … a decision to direct transfer
cannot simply be taken on the grounds that a convicted person will be a danger to the
public if released … but can only be taken on the grounds that his medical condition & its
treatability … justify the decision.

• In response to this judgment, the Mental Health Unit will turn down requests for transfers late in
sentence unless there is good evidence that hospital treatment will be of benefit to the prisoner and
there are good reasons why transfer could not have been achieved earlier in sentence (e.g. recent
deterioration in a patient’s condition or recent onset of serious mental illness).
17
 Entry into Secure Care

• Such cases may be dealt with by detention under s2 or s3:

– the papers may be completed in advance of release from prison
– the prison authority is able to transfer to hospital.

● Admissions Under Part 3 of the Mental Health

Act 1983
Amendments introduced by the Mental Health Act 2007
Part 3 of the Act was not significantly amended itself, but some changes impact upon the
detention of those concerned in criminal proceedings or under sentence. In particular:
• A single definition of mental disorder replaces the previous four categories, and removes the
exclusion of sexual deviance.
• Mental disorder means ‘any disorder or disability of mind’, but:
– dependence on alcohol or drugs is not considered a mental disorder
– a learning-disabled person is not mentally disordered unless their disability is associated with
‘abnormally aggressive or seriously irresponsible conduct’.
• Abolition of the ‘treatability’ test:
– The introduction of the ‘appropriate medical treatment’ test, together with the broad definition
of medical treatment in ss3(4) and 145(4), which preserves existing case law, means that this
change is of limited impact.
• The responsible medical officer (RMO) is replaced by the responsible clinician (RC), who need no
longer be a registered medical practitioner (RMP).

Admissions by court order prior to sentencing

Section 35 – Remand to hospital for report
A defendant convicted of or awaiting trial for an offence punishable with imprisonment
(unless convicted of murder).
Magistrates’ or Crown court:
• is satisfied on the written or oral evidence of one s12(2) approved RMP that there is ‘reason to
suspect that the accused person is suffering from mental disorder’
• ‘It would be impracticable for a report … to be made … on bail’
• is satisfied on the evidence of the RC or representative of the managers of the hospital that the
patient will be admitted within 7 days

Duration of 28 days, renewable on the evidence of the RC, up to maximum of 12 weeks. Not
subject to consent to treatment, so there is no power to treat compulsorily.

Section 36 – Remand to hospital for treatment

A defendant in custody awaiting trial or sentencing for an offence punishable with impris-
onment (other than murder).
A Crown court is satisfied:
• on the written or oral evidence of two RMPs, one s12(2) approved:
– that ‘he is suffering from mental disorder of a nature or degree which makes it appropriate for
him to be detained in a hospital for medical treatment’, and
– appropriate medical treatment is available
• on the evidence of the RC or representative of the managers of the hospital that they will be
admitted within 7 days.
18
 Admissions Under Part 3 of the Mental Health Act 1983

Duration of 28 days, renewable on the evidence of the RC, up to maximum of 12 weeks.

Subject to consent to treatment provisions of the Act.

Section 38 – interim hospital order

A defendant who has been convicted of an offence punishable with imprisonment (other
than murder).
A Crown court is satisfied:
• on the written or oral evidence of two RMPs, one s12(2) approved, one of whom is employed in the
admitting hospital:
– ‘that the offender is suffering from mental disorder’, and
– there is reason to suppose that it ‘is such that it may be appropriate for a hospital order to be
made’
• on the evidence of the RC or representative of the managers of the hospital that they will be
admitted within 28 days.

Maximum initial duration of 12 weeks, renewable for 28-day periods, on the evidence of the
RC, to maximum of 1 year. Subject to consent to treatment.

For ss35, 36 and 38:

• patients are not required to attend court for renewal hearings, so long as they are legally
represented
• the court may direct that the person be taken to a place of safety, pending admission within the
statutory period.

Section 44 – Committal to hospital under section 43 hospital order

Where a magistrates’ court refers a case to the Crown court for the purpose of making a
restriction order, and is satisfied that the criteria for a hospital order are in place, the court
may direct the offender to be admitted until the Crown court deals with the case.
The patient is treated as though detained under s37/41.

MHA sentences available to criminal courts

Section 37 – Hospital order
A defendant convicted of an offence punishable with imprisonment, other than murder:
• Note s37(3), which provides that a magistrates’ court may make such an order without convicting
him, if it is satisfied that he ‘did the act or made the omission charged’.

A magistrates’ or Crown court:

• is satisfied on the written or oral evidence of two RMPs, one s12(2) approved:
– ‘that the offender is suffering from mental disorder’
– ‘of a nature or degree which makes it appropriate for him to be detained in a hospital for medical
treatment, and
– appropriate medical treatment is available for him’
• ‘is of the opinion, having regard to all the circumstances including the nature of the offence and
the character and antecedents of the offender … that the most suitable method of disposing of
the case’ is a hospital order
• is satisfied on the evidence of the RC or representative of the managers of the hospital that he will
be admitted within 28 days.
19
 Entry into Secure Care

A restriction order under s41 may or may not be added. Once it has been made, an unre-
stricted hospital order operates much as a section 3, except that there is no right of appeal to
the first tier tribunal in the first 6 months and the nearest relative has no power to discharge.
• It may be renewed for 6 months in the first instance, and then annually.

Section 45A – Hospital direction and limitation direction

A defendant convicted of an offence punishable with imprisonment, other than murder.
Where a Crown court ‘considers making a hospital order … before deciding to impose a
sentence of imprisonment’, and:
• is satisfied on the written or oral evidence of two RMPs, one s12(2) approved, and one of whom
gives oral evidence:
– ‘that the offender is suffering from mental disorder’
– ‘of a nature or degree which makes it appropriate for him to be detained in hospital for medical
treatment’ and
– appropriate treatment is available for him
• is satisfied on the evidence of the RC or representative of the managers of the hospital that they
will be admitted within 28 days.

A hospital direction cannot be given without a limitation direction, which has much the
same effect as a restriction order under s41.
For both s37 and s45A, if it appears not practicable for them to be admitted to the
specified hospital, the Secretary of State may vary the hospital to which they will be
admitted.

Transfers from custody by warrant

Sentenced prisoners, or remand prisoners who require hospital treatment urgently, may be
transferred by warrant of the Secretary of State for Justice.

Section 47 – Removal to hospital of a sentenced prisoner

If the Secretary of State:
• is satisfied by reports from two RMPs, one s12(2) approved:
– that the offender is suffering from mental disorder
– ‘of a nature or degree which makes it appropriate for him to be detained in hospital for medical
treatment’, and
– appropriate treatment is available for him
• they may issue a transfer direction, which expires after 14 days.

If a restriction direction is made, it ends automatically on the day that the patient would
have been entitled to be released from custody:
• If the patient remains detained under a ‘notional s37’, which operates in the same way as an s3,
the patient may still be liable to detention in hospital under s47 of the MHA. This is equivalent to
being detained under s37 of the Act and is known as a ‘notional s37 hospital order’.

Section 48 – Removal to hospital of an unsentenced prisoner

Applicable to prisoners on remand from magistrates’ or Crown courts, immigration detain-
ees, and civil prisoners.
If the Secretary of State:
20
 Admissions Under Part 3 of the Mental Health Act 1983

• is satisfied by reports from two RMPs, one s12(2) approved:

– that the offender is suffering from mental disorder
– ‘of a nature or degree which makes it appropriate for him to be detained in hospital for medical
treatment’
– he is in urgent need of such treatment
– appropriate treatment is available for him
• they may issue a transfer direction, which expires after 14 days.

A restriction direction (s49) must be made in the case of a remand prisoner, and may be
made for civil or immigration detainees.
The transfer direction ends automatically when the case is disposed of by the court
• If there is concern that an s48 patient may be released by the court, they may be made subject to
an s3 concurrently and prophylactically.

For both ss47 and 48:

• warrants under ss47 and 48 each expire after 14 days – admission must be completed within that
time or a fresh warrant will be required
• if a restriction direction is made, the transfer direction can specify that the patient be admitted to a
particular unit of a hospital
• the Ministry of Justice requires that:
– the warrant is issued within 2 months of the date of the medical reports, and
– the reports are dated within 2 weeks of the examination of the patient.

Restriction orders and restriction directions

Section 41 – Restriction order
A Crown court may add a restriction order to a hospital order:
• where ‘It appears to the court … that it is necessary for the “protection of the public from serious
harm”’
• after hearing oral evidence from one of the RMPs who recommended the hospital order.

A magistrates’ court may not make a restriction order, but it may commit a case to Crown
court where it is of the opinion that a restriction order should be made (s43 of the MHA
1983). The criteria for making a restriction order are considered in Chapter 20, in the con-
text of providing oral evidence.
The effect of the restriction order is that:
• the Part 2 rules relating to duration, renewal and expiration of the authority to detain do not apply
• provisions relating to SCT do not apply
• there are no nearest relatives powers
• leave of absence, transfer or discharge may only be granted by the RC or the hospital managers
with the consent of the Secretary of State
• the RC must provide at least annual reports to the Secretary of State.

Section 49 – Restriction direction

This has the same effect as s41, and is attached to an s47 or s48.

Limitation direction
A limitation direction (under s45A) is different from a restriction order in three respects:
21
 Entry into Secure Care

• It ends when the patient would have been entitled to be released from prison (the hospital
direction may continue).
• While a limitation direction is in force, the offender may be removed to prison (criteria as for
remission of s47/48 – see Chapter 5).
• While a limitation direction is in force, discharge by the tribunal requires the consent of the
Secretary of State.

● Mental Health Act Statistics

The NHS Information Centre (2009) reported on rates of admissions to NHS and inde-
pendent sector beds in England for 2008–9. There were 28 673 admissions under the MHA,
2138 of which were under Part 3:

Section s35 s36 s37 s37/41 s45A s47 s47/49 s48 s48/49
Number 119 19 392 565 3 74 433 4 341

Use of part 3 of the MHA has been increasing in recent years, as shown in Figures 2.1 and
2.2.
The rate of increase in the prevalence of detained restricted patients has been greater
than in new admissions, implying that restricted patients are staying in hospital for longer.
In the calendar year 2008:
• there were 1501 new restricted admissions to hospital, of which 110 (7%) were to high secure
hospital
• these included 442 under s47, 484 under s48, 343 under s37/41, 2 under s45A, and 190 recalled
patients.

On 31 December 2008 there were a total of 3937 restricted patients in hospital:

• 88% were male
• including 703 under s47, 234 under s48, 2678 under s37/41, and 13 under s45A
• 3% were under 21, 49% were 21–39, 40% were 40–59, 8% were 60 years and above.

600
s37 (no s41)
s37/41
500 s47
s48
Number of detentions

400

300

200

100

0
2003–4 2004–5 2005–6 2006–7 2007–8 2008–9
Figure 2.1 Numbers of detentions under part 3 per year (data from the NHS Information Centre,
2009)
22
 Mental Health Act Statistics

4500
No. of restricted patients in hospital
4000
No. of new restricted admissions
3500
Number of patients

3000

2500

2000

1500

1000

500

0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Figure 2.2 Restricted patients detained in hospital (Ministry of Justice, 2010b)

References
All-Party Parliamentary Group on Prison Health. (2006) The Mental Health Problem in UK HM Pris-
ons. London: House of Commons. Available at: http://nacro.org.uk/data/files/nacro-2006110801-
352.pdf
Birmingham L. (2001) Diversion from custody. Advances in Psychiatric Treatment 7,198–207
Coid JW. (1998) Socio-economic deprivation and admission rates to secure forensic services Psychi-
atric Bulletin 22, 294–7
Coid J, Kahtan N. (2001) Medium secure forensic psychiatry services; comparison of seven English
health regions. British Journal of Psychiatry 178, 55–61
*Department of Health. (2007) Procedure for Transferring Prisoners to and from Hospital under Sec-
tions 47 & 48 of the Mental Health Act (1983). Available at: http://www.dh.gov.uk/prod_consum_
dh/groups/dh_digitalassets/documents/digitalasset/dh_081262.pdf
Department of Health. (2009) The Bradley Report: Lord Bradley’s review of people with mental
health problems or learning disabilities in the Criminal Justice System. London: Department of
Health
Department of Health and the Home Office. (1992) Review of Health and Social Services for Men-
tally Disordered Offenders and Others Requiring Similar Services (Reed Report). London: HMSO
Forrester A, Henderson C, Wilson S, Cumming I, Spyrou M, Parrott J. (2009) A suitable waiting room?
Hospital transfer outcomes & delays from two London prisons. Psychiatric Bulletin B, 409–12
Hodgins S, Muller-Isberner R, Allaire J-F. (2006) Attempting to understand the increase in numbers of
forensic beds in Europe: a multi-site study of patients in forensic and general psychiatric services.
International Journal of Forensic Mental Health 5(2), 173–84
Hotopf M, Wall S, Buchanan A, Wessely S, Churchill R. (2000) Changing patterns in the use of the
Mental Health Act 1983 in England, 1984–1996. British Journal of Psychiatry 176, 479–84
James D. (1999) Court diversion at 10 years: can it work, does it work and has it a future? Journal of
Forensic Psychiatry 10, 507–24
James DV, Hamilton LW. (1992) Setting up psychiatric liaison schemes to magistrates’ courts: prob-
lems and practicalities. Medicine Science & the Law 32,167–76
23
 Entry into Secure Care

James D, Farnham F, Moorey H, Lloyd H, Hill K, Blizard R, Barnes TRE. (2002) Outcomes of Psychiatric
Admissions through the Courts. Home Office RDS Occasional paper 79. London: Home Office
Jamieson E, Butwell M, Taylor P, Leese M. (2000) Trends in special (high secure) hospitals: referrals
and admissions. British Journal of Psychiatry, 176, 253–9
Joseph P. (1994) Psychiatric assessment at the magistrates’ court: early intervention is needed in the
remand process. British Journal of Psychiatry 164, 722–4
Joseph P, Potter M. (1990) Mentally disordered homeless offenders – diversion from custody. Health
Trends 22, 51–3
Joseph P, Potter M. (1993) Diversion from custody II: effect on hospital and prison resources. British
Journal of Psychiatry 162, 330–4
Kennedy HG. (2002) Therapeutic uses of security: mapping forensic mental health services by strati-
fying risk. Advances in Psychiatric Treatment 8, 433–43
Kingham M, Corfe M. (2005) Experiences of a mixed court diversion and liaison scheme. Psychiatric
Bulletin 29, 137–40
Ministry of Justice. (2010a) Conviction Histories of Offenders between the Ages of 10 and 52. Avail-
able at: http://www.justice.gov.uk/criminal-histories-bulletin.pdf
Ministry of Justice. (2010b) Statistics of Mentally Disordered Offenders 2008 England and Wales.
Available at: http://www.justice.gov.uk/publications/mentally-disordered-offenders.htm
NHS Information Centre. (2009) In-patients Formally Detained in Hospitals under the Mental Health
Act 1983 and Patients Subject to Supervised Community Treatment: 1998–99 to 2008–09. Avail-
able at: http://www.ic.nhs.uk
Pakes F, Winstone J. (2010) A site visit of 101 mental health liaison and diversion schemes in Eng-
land. Journal of Forensic Psychiatry and Psychology 21(6), 873–86
Priebe S, Fakhoury W, Watts J, Bebbington P, Burns T, Johnson S, et al. (2003) Assertive outreach
teams in London: patient characteristics and outcomes. British Journal of Psychiatry 183, 148–54
Royal College of Psychiatrists. (2010) Briefing Note: Consultation on Clinicians’ Experiences of Prison
Transfers. London: RCPsych.
Sainsbury Centre for Mental Health. (2009) Diversion: a better way for criminal justice & mental
health. Available at: http://www.centreformentalhealth.org.uk/criminal_justice/a_better_way.
aspx

24
 3
Treatment and
Outcomes in Secure Care
The principles of providing psychiatric treatment in secure hospitals are no different from
providing psychiatric treatment in general psychiatric services.
Differences in emphasis in forensic services include:
• the patients tend to have a multiplicity of interdependent needs
• a greater awareness of risk of harm to others
• a greater prominence of legal issues, with more external restrictions on the patient
• inpatient treatment tends to be longer term, including both acute treatment and prolonged
rehabilitation
• progress is made in small graduated steps, with testing out at each one
• an emphasis on continuity of care rather than functionalization of care
• greater availability of psychological treatment
• more prominent security, which has a complex relationship with therapy
• greater need to work with other agencies (particularly MAPPA agencies and the Ministry of Justice),
which demands an acute sensitivity to confidentiality and medical ethics
• staff may require different forms of support because of the complexities of:
– the patients
– combining both a therapeutic and a custodian role.

● The Needs and Characteristics of Patients in

Secure Settings
Secure settings have an overwhelmingly male population:
• overall 88% of patients in secure hospitals are male (Rutherford and Duggan, 2007)
• 88% of restricted patients in 2008 were male (Ministry of Justice, 2010).

BME populations are over-represented in secure services (Rutherford and Duggan, 2007):

Patients in forensic services (%) Prison General

s37 s47 s48 population (%) population (%)
Non-white British ethnic origin 33 29 56 25 7.9
Black or black British 18 12 20 15 2
Asian or Asian British 4 4 7 6 4

The distribution of legal classification among all restricted patients prior to the Mental
Health Act (MHA) 2007 was (Rutherford and Duggan, 2007):
25
 Treatment and Outcomes in Secure Care

• mental illness 76%

• psychopathic disorder 12%
• mental impairment 5%
• unclassified/other 7%.

It is often argued that these figures underestimate the rate of personality disorder (PD),
because many of those detained for mental illness will have co-morbid PDs.
Structured and standardized assessments of need (or measures of outcome) sometimes
used in forensic services include:
• Camberwell Assessment of Needs – forensic version (CANFOR – Thomas et al., 2003):
– the forensic version of the Cambridge Assessment of Needs
– separate staff and patient ratings in 25 domains
• Health of the Nation Outcome Scores (HoNOS) secure:
– required as part of the minimum data set for services
– quick and easy to use, but uncertain validity and reliability (Dickens et al., 2007)
• Recovery-Star (see http://www.mhpf.org.uk):
– 10 domains are rated collaboratively by patient and a professional.

Surveys of patients in medium security

A survey of patients from one inner London health authority found that of 183 patients in
secure psychiatric care (Lelliot et al., 2001):
• 87% were men
• mean age 36 (range 17–64)
• 93% were unemployed prior to admission
• 93% had psychosis or bipolar affective disorder
• 10% had a primary or secondary diagnosis of PD
• half the patients had multiple previous admissions over many years.

In 2007, a similar picture was found in a cross-sectional survey of the inpatient population
at Reaside Clinic medium secure unit (MSU), Birmingham. Of 80 male patients:
• the mean age was 37 years (range 21–71)
• 65% were admitted from prison, 15% from community, 10% from another secure setting,
10% from a general psychiatric setting
• most were subject to MHA detention:
– 56% were detained under s37/41
– 14% under a civil section
– 4% s37
– 12.5% s47/49
– 6.3% s48/49
• index offences included:
– 25% homicide/attempted murder
– 29% wounding
– 20% assault
– 10% sexual offence
– 7.5% arson
• most suffered from a severe mental illness:
– 86% schizophrenia or schizoaffective disorder
– 5% bipolar affective disorder

26
 The Multidisciplinary Team

– 1% persistent delusional disorder

• 85% had a history of problematic use of alcohol or drugs:
– most commonly alcohol or cannabis
• the mean number of years since first psychiatric contact was 14:
– 56% had a history of disengagement from follow-up
– 70% had a history of non-adherence to pharmacological treatment.

There is a group of patients in medium security who require secure care for consider-
ably longer than the original expectation of up to 2 years (see Chapter 1). Jacques et al.
(2010) found that 21% of men in their medium secure service had been in hospital for
more than 5 years and separated them into two groups based on needs identified by the
CANFOR:
• Chronic challenging behaviour, treatment-resistant mental illness and considerable daily support
needs.
• A more able group who were dependent on the hospital.

Surveys of patients in high security

A survey of 1255 patients in high security found that 85% were men (Harty et al., 2004):
• The men had a mean age of 40 (range 19–84) and a mean duration of admission of 9.8 years
(range 0–54).
• The women were younger, with a mean age of 37.
• 57% were classified under the MHA category of mental illness, 25% under psychopathic disorder
and 10% were dually classified:
– 61% had schizophrenia
– 45% had a personality disorder
– 10% had learning disability.
• CANFOR needs domains that were commonly unmet included daytime activities, sexual offending
(especially among men), arson (especially among women), drugs and alcohol.

● The Multidisciplinary Team

For forensic services in particular, the multidisciplinary team (MDT) is the cornerstone on
which effective and safe clinical care is founded:
• Most clinical decisions will be made at the MDT clinical meeting.

The patient sits at the centre of a complex arrangement of multiple agencies (Figure 3.1):
• These agencies have differing agendas and approaches, which commonly overlap but occasionally
conflict.
• This is particularly important in forensic services because of the practical and ethical complexities of
the therapy/risk dynamic.
• The MDT as a whole, and the RC in particular, must be able to manage the interagency dynamics in
a properly balanced way, and bearing in mind issues of confidentiality.

The role of a forensic psychiatrist

While there may be occasional variation, in most services at present, leadership of the MDT
is provided by the responsible clinician (RC), who is usually a psychiatrist:
27
 Treatment and Outcomes in Secure Care

• For the patient, their detention and the associated parameters of restriction are often paramount.
So the patient tends to see the RC as being ‘in charge’.
• As yet there has not been a wholesale expansion of the RC role to other disciplines following the
MHA 2007. Forensic services tend to be relatively conservative, so, if this change happens, it is likely
to happen gradually.

Core roles of the forensic psychiatrist (variously delegated to juniors) in an inpatient setting
include:
• providing leadership to the MDT, and accepting responsibility for the governance of team
functioning
• holding overall responsibility for each patient’s detention, care and treatment
• assessing psychopathology, using appropriate medical investigations and arriving at diagnoses
• deciding on pharmacological and other medical interventions
• ensuring that the physical health needs of patients are addressed
• carrying out the statutory functions required by the MHA:
– renewal of detention
– consent to treatment
– providing evidence to courts or tribunals
– reporting to the MoJ on restricted patients.

Clinical MDT
Patient Ward
advocacy nursing
services staff

Voluntary The
sector
agencies
patient MoJ

CJS,
Statutory
probation,
agencies
Carers police
(e.g. LA)
&
families

Figure 3.1 Agencies working with patients in secure services (CJS = criminal justice system, LA = local
authority, MDT = multidisciplinary team, MoJ = Ministry of Justice)
28
 The Multidisciplinary Team

Other key roles within forensic MDTs

Other key roles within forensic MDTs are described in Table 3.1.
Table 3.1 Key roles within forensic multidisciplinary teams (MDTs)
Psychologist Clinical and forensic psychologists have differing professional backgrounds, the former
tending to have trained in a health environment and the latter more likely to have
trained in a penal environment
Conducting psychometric assessments relating to intellectual function and personality
style
Delivering group and individual psychological interventions (see below)
Developing individual formulations of risk and mental disorder
Providing a psychologically informed perspective to MDT functioning
Nurses Manage the day-to-day care of the patient within the ward environment, and liaise
with the MDT when necessary
Includes both traditional therapeutic nursing roles and security roles such as searching
of patients, rooms and possessions, drug testing and maintaining ward security
Managing observations, leave, visits and other patient activities
Managing incidents of aggression and violence or of self-harm
Managing the ward environment, patient interactions, and observing for changes in
mental state, conduct and risk
Social workers Statutory functions relating to the Mental Health Act
Family and carer liaison
Liaison with local authority, may lead on child protection or adult safeguarding issues,
including child visitors
May lead on liaison with probation, victim liaison unit and multi-agency public
protection arrangement
Providing a sociological or situational perspective to the MDT
Occupational Providing assessments and interventions aimed at potentiating an individual’s
therapists occupational function
Standardized assessments such as the Model of Human Occupation Screening Tool
(Parkinson et al., 2005) provide consistency
Providing and encouraging participation in activities, to enable assessment and
foster ability to structure time
Assessing and developing independent living skills
Supporting and facilitating access to educational, vocational or leisure activities
Delivering cognitive–behavioural therapy-based interventions
Pharmacists Patients often have long histories of pharmacological treatment and complex
treatment-resistant illnesses
Compiling reviews of a patient’s medication history
Providing information to patients on their treatment

Conflict within teams

Individuals working in MDTs have loyalties both to the team and to their profession (Mason
and Vivian-Byrne, 2002).
• In an effective team these are balanced, bringing a creative tension to team discussions, in which
the eclectic richness of approach and practice is used productively.
• Where there is too great an identification with the team, that creative tension may be lost.
• Where there is too great an identification with profession, the intra-team conflict may become
obstructive.

It might be that, in forensic MDTs, conflict is heightened by:

• the complexities of the patient’s psychopathology, leading to conflicting formulations
• the particular psychopathology of some patients, especially those with damaged attachment
styles, leading to splitting within teams
29
 Treatment and Outcomes in Secure Care

Box 3.1 The psychiatrist, the patient and the Ministry of Justice (MoJ)
Traditionally, forensic services have tended to adopt a paternalistic approach, founded on a predominantly
medical model of treating illness and the authority of clinicians:
• In some cases this fosters dependence on the part of patients, and it is sometimes through a
dependent relationship that risk is effectively managed.
• Reducing offending was often a welcome consequence of establishing mental health, rather than an
end in its own right.
More recently risk reduction has come to occupy equal billing in the prioritized aims of forensic clinicians,
leading to a more explicit focus on criminogenic needs themselves.
• Interestingly criminal justice system (CJS) offending behaviour programmes (OBPs) have begun to
recognize and emphasize the importance of collaboration with the offender in risk reduction, adopting
engagement strategies from health.
The MoJ carries a yet more explicit authority than the clinicians, creating a complex triangle of care/control.
• For the clinician, it is sometimes useful to locate the controlling aspect of the therapeutic relationship in
the MoJ, enabling the development of a collaboration with the patient to satisfy the MoJ.
• The risk of this approach lies in disingenuously, or seemingly, denying the clinician’s custodian/public
protection/authoritarian role, leading to the patient feeling cheated or let down when it reappears.
In recent years, the patient advocacy movement and a trend in emphasis away from curing illness to
enhancing strengths, well-being and self-acceptance have begun to change the way in which forensic
services work with their patients.
• This improves the degree to which forensic services are patient-centred, and benefits are likely.
• There may be costs too, because some patients have done well with a traditional forensic approach.
• Mezey et al. (2010) describe some of the obstacles to embracing a recovery approach in forensic
services.

• the primacy of risk, requiring formulation, management and therapeutic risk taking.

While all clinical teams work differently, in principle effective team functioning can be
maintained by:
• regular multidisciplinary meetings and good communication within teams
• engaging in debate and discussion within the team, while presenting a coherent team approach to
patients and carers
• respecting individual team members’ roles
• involving the team in most decisions – few issues cannot wait until the next team meeting
• developing an agreed formulation of the patient’s engagement with the team
• ensuring effective intra-discipline support
• consciously acknowledging the challenges of MDT working in secure environments
• regular team awaydays/practice development days, perhaps with external facilitation
• acknowledging problems relating to particular patients and accessing psychotherapeutic
supervision or assessment to understand the psychopathology/dynamics further.

● The Patient Journey in Secure Care

The characteristics of treatment within secure services vary greatly among different levels
of security and different patient groups. In general terms, patients should move in the direc-
tion shown in Figure 3.2.
30
 The Patient Journey in Secure Care

Uncontrolled mental disorder Stabilization of mental state

External controls on behaviour Internal behavioural controls

Treatment under coercion Collaboration in treatment

Lack of engagement in treatment Active engagement

Lack of self-awareness Capacity to introspect

Figure 3.2 General objectives of treatment in secure care

Admission to secure care

Prior to admission:
• the responsible clinician, clinical team and care coordinator should be identified
• an initial care plan and risk assessment with immediate and short-term plans and goals is agreed
• the patient’s room is searched and cleaned.

On admission, according to local policies and procedures:

• an effective handover from escorting staff to ward staff is essential
• the patient is greeted and searched:
– belongings are recorded on a property list
– the list of contraband items may vary among units and security levels
• detention papers are checked by medical records staff
• the patient is orientated to the ward and provided with:
– written and/or oral information about the ward routine, basic policies and procedures
(particularly meal times, smoking arrangements, visits, etc.)
– the patient is informed of their MHA rights
• an initial nursing assessment is followed by formal medical clerking
• nursing staff will complete a patient profile including:
– a physical description and perhaps a photograph
– individuals at risk and to be contacted in the event of the patient being absent without leave.
• the initial care plan will at least include:
– observation level
– mental and physical state
– keyworker sessions
– leave and visitors
– initial medication, both regular and as required sedative medication where necessary.

The acute phase of treatment

The key aims for the acute phase of treatment are:
• to carry out initial assessments and risk management
• to confirm the diagnoses
31
 Treatment and Outcomes in Secure Care

• to stabilize the mental state

• to decide on the initial care pathway and work through the criminal justice process.

At the ward level, this phase is characterized by:

• close observation levels ranging from constant observation by one or more staff to intermittent
observations at a frequency of between 5 minutes to an hour
• close observation of mental state, behaviour and interactions with other patients and staff
• regular physical observations including weight checks and drug testing
• regular and random searches of a patient’s personal and living environment
• facilitating and monitoring personal and professional visits
• gradually reducing restrictions, contingent on risk behaviours and mental state:
– reducing observation level
– increasing leave within the building
– access to kitchen (e.g. for hot drinks), use of sharps on the ward (e.g. for shaving) and other
freedoms according to local policies and practice.

At the team level:

• building a therapeutic relationship with the patient
• frequent mental state examination to document current psychopathology
• detailed history taking and collation of information from other sources
• engagement of carers and relatives
• establishment of initial pharmacological treatment
• specific standard initial assessments of, for example, problematic substance use, IQ, personality
style, occupational needs
• liaison with courts and solicitors over ongoing legal proceedings and provision of reports
• dealing with issues relating to previous accommodation, benefits and debts.

Rehabilitation in secure care

A patient may move to the rehabilitation phase once:
• there is some stability of their mental state
• there is a relatively sustained cessation of risk behaviours, indicating improved internal controls
• they are showing some positive engagement and collaboration in their care.

The key aims are:

• to maintain mental state stability, enabling psychosocial rehabilitation
• to provide further psychological assessment and treatment
• to develop a shared formulation of the mental disorder, risk behaviours and the relationship
between them, encompassing where relevant:
– problematic substance use
– interpersonal relationships
– situational factors
• to develop a shared relapse prevention plan
• systematic assessment of psychosocial needs, perhaps using a structured instrument, and tailored
interventions to meet them
• to reintroduce the patient to a community setting gradually, allowing assessment at each step.

This phase is characterized by:

• some relaxation of procedural security, though not relational security:
– generally reduced frequency of observations and searching
32
 Treating Aggression

– more permitted possessions

– increased freedom to move around within the hospital
• ongoing assessment and treatment in more varied settings:
– including individual and group work, in the occupational therapy department and social activities
– progression to leave within the hospital grounds and then the community
• greater responsibility for treatment:
– self-medication regimes
• development of relationships with families, relatives, carers and friends
• increased emphasis on occupational and educational as well as leisure activity, developing the
patient’s ability to structure time
• ongoing formulation of mental disorder and risk, and development of a relapse prevention plan:
– sharing this with other agencies or carers as and when appropriate
• establishing accommodation needs and options
• preparation for a tribunal, or other discharge mechanism.

● Pharmacological Treatment in Secure Care

Pharmacological treatment for mental disorder is no different in forensic services from that
in other settings. The association of serious risk with mental ill-health brings an added
impetus to preventing relapse or detecting relapse early, thus enabling intervention.
For Patel and David (2005) long-acting injectable antipsychotics have advantages over
oral preparations in the treatment of schizophrenia.
• improved treatment adherence
• abolition of covert treatment non-adherence:
– probably the most important pragmatic advantage among high-risk patients
– non-adherence may be both a cause and a consequence of relapse
• improved global outcome and reduced rate of hospitalization (Robert and Geppert, 2004)
• more predictable and consistent pharmacodynamics and pharmacokinetics
• dose changes are more gradual, reducing risk of sudden relapse
• reduced risk of overdose.

They consider that many of the disadvantages of depots may be construed as perception
problems:
• stigmatizing and disempowering/coercive:
– there is no intrinsic reason why this should be so
• reduced patient acceptability:
– often an individual matter – some patients prefer depots; many do not
• potential for increased side effects:
– specific side effects may include pain and local inflammation at the injection site
– otherwise there is little evidence for greater side effects with depots, when comparing like drugs
– improved pharmacodynamics may lead to a better side-effect profile for depots
• dose changes are more gradual, reducing the ability to respond promptly to side effects or patient
choice.

● Treating Aggression
The literature on the pharmacological treatment of violence is small and the evidence is
conflicting. A Cochrane Review of the use of antiepileptics in treating aggression and asso-
ciated impulsivity (Huban et al., 2010) identified 14 studies involving 672 subjects:
33
 Treatment and Outcomes in Secure Care

• The subjects differed between studies, and there were both positive and negative findings.
• No firm conclusions could be drawn on effectiveness.

Recent structured reviews (Volavka and Citrome, 2008; Topiwala and Fazel, 2011) of the
available evidence for treating aggression in patients with schizophrenia have reached the
following conclusions:
• There is good evidence that clozapine reduces levels of aggression, and that this effect is
independent of impact on psychotic symptoms.
• Otherwise, there is no convincing evidence that any specific antipsychotic confers added benefit in
comparison to the others.
• The evidence on mood stabilizers is inconsistent:
– controlled studies do not support efficacy of valproate
– carbamazepine may reduce agitation, but little anti-aggression effect
– no evidence to support the use of lithium or lamotrigine.
• There is limited evidence for the use of adjunctive beta blockers, but they may not be well tolerated.

● Physical Health of Patients in Secure Care

The standardized mortality ratio is 1.5 for those with mental disorder generally, and 3–4 for
those with schizophrenia. Being an inpatient in secure care may be associated with:
• a generally sedentary lifestyle
• reduced opportunities for exercise
• effects of psychotropic medication
• boredom, leading to compensatory behaviours such as snacking and smoking cigarettes
• reduced motivation for self-care.

Psychiatrists must accept responsibility for the physical health of their patients, but the evi-
dence suggests that dedicated primary care services offer benefits within long-term inpatient
settings (Cormac et al., 2004). Practice, supported by policy, should address (Royal College
of Psychiatrists, 2009):
• schedules for physical monitoring, with reference to prescribed medication and other risk factors:
– including especially weight/body mass index (BMI), blood pressure (BP), smoking status, lipids,
random/fasting glucose, electrocardiogram (ECG)
• health promotion and education
• encouragement of healthy exercise
• diet and nutrition
• weight management
• infectious diseases and sexual health
• addictions and alcohol use:
– including particularly tobacco use, secure units increasingly becoming smoke-free environments.

● Management of Disturbed/Violent Behaviour

The short-term management of disturbed/violent behaviour may be considered in three
stages (National Institute for Health and Clinical Excellence, 2005):
• Prediction:
– including risk assessment and searching.
• Prevention:
– using de-escalation techniques and observations
34
 Management of Disturbed/Violent Behaviour

– managing the environment to reduce stimulation, consider use of designated room for ‘time
out’; this should not routinely be the seclusion room
– discussing issues in calm manner, aiming to develop rapport while maintaining an awareness of
cues and body language.
• Interventions for continued management:
– rapid tranquillization (see National Institute for Health and Clinical Excellence, 2005, and local
policies)
– seclusion
– physical intervention.

There is little empirical evidence that seclusion or any other form of physical intervention
is more effective than the other. The relative use of different types of intervention varies
greatly internationally, due to cultural and historical practice issues rather than an evi-
dence base. Bowers et al. (2005) compared methods of containment of disturbed behaviour
between the UK, Greece and Italy, and showed more use of seclusion in the UK, and more
use of physical restraints on the Continent.
NICE guidelines (2005) recommend that teams should work with patients to prepare
advance directives of preferences for interventions in the event of violent or disturbed
behaviour. This practice is widely used in intensive care units in all levels of security.

Seclusion
There is no definitive international definition of seclusion. For example:
• the UK MHA CoP (Department of Health, 2008) defines seclusion as:
– ‘The supervised confinement of a patient in a room, which may be locked. Its sole aim is to
contain severely disturbed behaviour which is likely to cause harm to others’
• mental health legislation of the Australian State of Victoria uses:
– ‘sole confinement of a person at any hour of the day or night in a room of which the doors and
windows are locked from the outside’.

Seclusion areas should be specially built and designed to be a safe and secure, low-stimulus
environment. However, seclusion is not defined by the area in which it occurs. If a patient
is confined elsewhere, their bedroom, for example, this is still seclusion.
Each unit will have its own policies and procedures regarding the seclusion of patients.
Generally these will include the following factors:
• The decision to seclude a patient should be made by a senior clinician or the professional in charge
of the ward.
• There should be a regular review of the need for seclusion to continue, including regular
multidisciplinary review.
• There should be a suitably trained professional within sight of the seclusion room at all times.

Ching et al. (2010) discuss the negative aspects of seclusion, which should be seen as a meas-
ure of last resort. They describe a successful strategy to reduce the use of seclusion within a
forensic service.

Physical intervention
All physical interventions should be seen as a last resort, to be avoided if possible and de-
escalation techniques should be used continuously throughout a period of restraint. Such
interventions carry a risk of injury to patient and to staff.
35
 Treatment and Outcomes in Secure Care

Manual holding
• The most commonly used method in the UK.
• Requires specific training and uses a team approach, each individual having a particular
responsibility, one person having responsibility for protecting the patient’s head and neck.

There have been incidents of patient deaths occurring while in restraint, the most well-
known case being that of David Bennett, who was manually restrained for over half an hour
in the prone position. NICE guidelines state that during physical restraint at no time should
pressure be applied to the patient’s neck, thorax, back, abdomen or pelvic area. They also
recommend that cardiopulmonary resuscitation equipment be available within 3 minutes of
the setting where these interventions are being used.

Mechanical restraints
Restraints such as body belts, straps or straitjackets are rarely used in the UK but are more
widely used in other countries (including continental Europe and the USA). There are
some circumstances where mechanical restraints are used in this country:
• Handcuffs are used routinely by prisons, including when transferring prisoners to hospital. Use
of handcuffs has become more common in secure psychiatric hospitals in recent years, for
transporting high-risk patients to attend court or general hospitals.
– There is no clinical evidence base to support this, and handcuffs may be extremely stigmatizing,
particularly in a general health-care setting.
• The use of some mechanical restraints in high secure hospitals. This is generally for short periods, at
times of extremely disturbed behaviour when transferring patients from one care area to another.
• The use of mechanical restraints in prisons. Again these are used for short periods of time when
other interventions would not be appropriate.

● Psychological Treatment in Secure Care

Traditionally, forensic services tended to take an individualistic approach to treatment:
• An individual formulation was key.
• Interventions tended to be delivered on an individual basis to reflect this individual formulation,
the effects of psychosis in particular being seen as too idiosyncratic to allow a more programmatic
approach.
• Individual interventions adopted a variety of approaches, including both treatments based on
cognitive–behavioural therapy and more dynamically orientated approaches.
• Often the chosen approach was dependent primarily on the professional background of the
therapist.

In more recent years:

• psychological interventions have tended to become more programmatic and group-based
• forensic psychotherapy has begun to create a more defined role within mental illness-dominated
medium secure units (MSUs).

Individual assessment, formulation and treatment remain crucial for effective clinical care
and risk management because:
• group interventions cannot provide sufficient responsivity, to take account of the patient’s
individual needs, particularly the idiosyncratic effects of psychosis
• it is necessary to engage difficult-to-engage patients, and sometimes this is best done individually
36
 Psychological Treatment in Secure Care

• relapse prevention plans and risk management plans are necessarily individual
• confidentiality issues may obstruct group work for some.

The approach used in individual treatment is flexible, and may be determined by both pro-
fessional and patient factors.
Group-based interventions may be:
• traditionally delivered psychoeducation or CBT-based interventions, targeting mental health needs,
such as:
– mental health awareness
– problematic substance use
– hearing voices
– recovering from psychosis
• interventions targeting criminogenic needs, often based on accredited offending behaviour
programmes, such as:
– reasoning and rehabilitation
– anger management
– fire setting groups
– sex offender treatment programmes.

Howells et al. (2004) discuss the application of the ‘What Works’ principles (Risk, Needs,
Responsivity) to psychiatric settings. The recently developing literature about group-based
interventions in forensic settings is nevertheless limited:
• It has not yet moved beyond parochial descriptions of individual interventions in single units.
• Such interventions generally have high face validity.
• Demonstrating positive outcomes consequent to a particular intervention that is delivered within
the context of a much wider care package in a secure setting is a considerable challenge (see, for
example, Swain et al., 2010).

In reporting the results of an audit of psychology provision in a forensic service, Gudjonsson

and Young (2007):
• draw attention to the tendency for direct treatment to be subordinated to assessment and indirect
patient care
• contrast risk management models with strength-based models
• describe the service model for psychological intervention that their service has adopted.

Forensic psychotherapy
Psychotherapy within secure settings and prisons has a long history, and is established in:
• high security, where treatment for PD is also established
• the small number of MSUs which specifically provide treatment for those with PD
• a few prisons, notably HMP Gendon (see Chapter 18)
• some outpatient services, notably the Portman Clinic, London.

Current provision within mental illness-focused MSUs is limited and variable. McGauley
and Humphrey (2003) describe the role of forensic psychotherapy in secure units:
• Direct clinical work:
– providing assessments to inform understanding of the patient
– providing treatment, individual or group.
• Supervisory work:
– either of other professionals doing direct clinical work, or
37
 Treatment and Outcomes in Secure Care

– regarding psychodynamic processes of an institution.

• Clinical meetings:
– case conferences, clinical team meetings and patient reviews.
• Consultation or institutional supervision:
– provided to an institution from outside.

Through reflective practice groups, supervisory work may particularly seek to improve staff’s
awareness of the unconscious dynamics among the triad of:
• the patient
• the staff
• the institution.

For further reading see Cordess and Cox (1998) and, particularly, Bartlett and McGauley
(2009).

● Leave for Restricted Patients

Restricted patients may only be given leave of absence (LOA) under s17 MHA with the
permission of the Secretary of State for Justice. Three standard types of LOA may be con-
sidered, a patient generally being expected to move through them sequentially prior to
discharge:
• escorted community leave (ECL)
• unescorted community leave (UCL)
• overnight leave (ONL):
– usually to a proposed discharge address.

Other types of leave include:

• compassionate leave:
– a leave required at short notice, usually due to serious illness or death in a close relative
– specific permission should be sought even where the patient has already been granted ECL or
UCL
• leave to attend hospital:
– MoJ permission is not required for escorted leave to attend hospital for medical examination or
other urgent treatment
– The MoJ should be informed in advance if possible for s48 patients, and immediately afterwards
for all others.
• leave to attend court:
– permission is not required for escorted leave to attend criminal court in relation to alleged offences.

For patients transferring between hospitals, leave status:

• does not usually transfer with a patient moving from high security
• may or may not transfer from medium to low security
• usually does transfer between hospitals of the same level of security.

Section 48 patients are not normally granted s17 leave. For s47 patients:
• UCL will usually only be considered within 2 years of their parole eligibility date (PED), or once they
have served half their custodial sentence, whichever is the later.
• ONL will be considered within 3 months of their PED.
• For life sentenced prisoners, ECL will be considered on its merits, and UCL may be considered within
3 years of the tariff date.
38
 Outcomes of Treatment in Secure Care

Box 3.2 Liaising with the Ministry of Justice (MoJ) in relation to leave
Each type of leave requires a separate application:
• The responsible clinician (RC) must apply using a standardized form available on the MoJ website.
• The MoJ aims to respond to leave requests within 3 weeks.
Leave is usually granted at the discretion of the RC, with a report required after 3 months:
• The RC may decide upon the duration and destination of each leave.
• Occasionally restrictions will be added, relating to restriction zones, for example.
• It is usual for the next stage of leave not to be considered until such a report has been made.
A small naturalistic study suggested that clinical leave decisions are often based on implicit shared
knowledge which may not be voiced, and may be less focused on risk than on humanity (Lyall and Bartlett,
2010):
• The risk of absconding should be considered explicitly in terms of both likelihood and likely cost.
Remember that the presence of a nursing escort does not prevent a determined absconder. The escort
can only:
• try to dissuade the patient from absconding
• try to keep an absconding patient in sight
• raise the alarm promptly.
The MoJ should always be informed immediately if changes are made to leave status at a clinical level.
Where the RC has rescinded leave, the MoJ will inform the RC if further permission is required to reinstate
it.

● Outcomes of Treatment in Secure Care

Reconviction rates are the most commonly used outcome measure for research, probably
because reconviction may be detected reliably. But:
• official rates are likely to underestimate the true rate of offending, particularly among the mentally
disordered
• patients may be institutionalized for significant periods after discharge from secure care, limiting
the opportunity for offending
• reconviction rates may not be a good measure of mental health outcomes.

For restricted patients, rates of reoffending within 2 years of first discharge are (Ministry of
Justice, 2010):
• all offences 7%
• sexual or violent offence 2%
• grave offence 1%:
– homicide, serious wounding, rape, buggery, arson, robbery, aggravated burglary.

Reconviction following discharge from high security

Buchanan (1998) studied a cohort of 425 consecutive discharges from all UK high secure
hospitals in 1982–83, without accounting for post-discharge setting.

Prevalence of reoffending (%)

5½ years 10½ years
Violent offence 9 7.5
Sexual offence 5 15
Any offence 26 34

39
Another random document with
no related content on Scribd:
 What were the citizens doing while Henry III and his dear wife
ruined the bridge by confiscating her revenues? Did they believe that
everybody’s affair was nobody’s business, and that they would be
asked to mend the bridge if they drew attention to her condition? As
to Edward I, he kept his hand away from his own pocket, and
personated charity that for ever begs. “Each for Himself” was a
policy that suited Edward; and his orders to the clergy proved that
he knew it to be a policy which his loyal subjects followed as a habit.
Hence the “pious exhortations,” with indulgences also, we may rest
assured. The whole story is pitifully ironic. London had no other
bridge over the Thames, yet the people looked on while a king and
his wife played the part of bridge wreckers. Some protest there must
have been, for London Bridge—a great street of timber houses—was
more populous than many a village; and the tenants, like other
Englishmen of those days, had no wish to be plunged into cold
water. According to Stow’s “Annals,” five arches fell, so many houses
also were lost, perhaps with their inmates.
M. Jusserand believes that during the Middle Ages our English
highways fared no better than London Bridge. His verdict runs thus:
“Though there were roads, though property was burdened with
obligatory services for their upkeep, though laws every now and
again recalled their obligations to the possessors of the soil, though
from time to time the private interest of lords and of monks, in
addition to the public interest, suggested and directed repairs, yet
the fate of a traveller in a fall of snow or in a thaw was very
precarious. The Church might well have pity on the wayfarer; and
him she specified, together with the sick and the captive, among
those unfortunates whom she recommended to the daily prayers of
pious souls.”
There is a great deal of evidence to justify this verdict, but
evidence in history depends on its choice; and in Thorold Rogers
there are other facts that leave England with some efficient
mediæval roads, along which horsemen could travel rapidly. Perhaps
Rogers may have set too much store by his data; but when we study
all the evidence, when we balance it carefully, and visualise all its
pictures of well-tested negligence and crime, one thing is beyond all
doubt: that the social rule, “Each for All, yet Each for Himself,” was a
national catastrophe. Its first principle had a very precarious life,
though incessant compulsion tried to drive it home to the people’s
fear of revengeful laws; whereas the second principle—“Each for
Himself”—was so popular as a creed that even the divine mysteries
beyond death were assailed by egoists, who thought they could buy
a place in heaven by giving lands and goods to the Church, no
matter what harm they had done in a brief life upon earth. Study
Erasmus in his wayfaring letters, and you will breathe the
atmosphere of the Middle Ages.

old london bridge, begun by peter colechurch in 1176, and finished by

a frenchman, called isembert, in the year 1209
 pont sidi rached at constantine, algeria. built in 1908-1912
The span of the great arch is 70 metres. The work illustrates the longevity of
custom and convention, being inspired partly by Roman aqueducts and partly by
the two famous bridges over the Tech at Céret, in France, one of which dates from
the year 1321. The span of its great arch is 45m. 45cm.

III
CUSTOM AND CONVENTION
Yet a pontist must be exceedingly careful when his tramps through
any period bring him in touch with ethical problems. He should try to
live on the highways of history, not in order to pass judgments on
vice and on crime, but because he wants to see clearly, under the
form of visual conception, why social concord and equity have never
fared well, even the best forms of civilization being only half-
educated barbarisms that allow their strife to be drilled by a vast
number of active laws. These phases of compulsion go on
increasing, yet they fail to resolve into harmony those rapacious
egotisms that compete against each other in the body social like
microbes in living tissues. As soon as a pontist understands his
wayfaring through history, as soon as he feels at home in the
general atmosphere of the human drama, he is glad to be a realist;
then nothing that societies do or have done seems unexampled and
inexplicable. To him, for example, the infanticide practised age after
age by savage tribesmen is not more terrible than the death of
babies in the slums of civilized towns, or than the degradation
brought before his mind by the alert philanthropy that saves little
English children from cruelties. To him, again, the slaughter on a
great battlefield is not more woeful than the annual sacrifice of lives
in street accidents, and railway smashes, and mine disasters, and
sea tragedies; as well as in games and sports, in nursing the sick,
and in all trades and professions. He is not scared by the fact that
the sum of human life is war, but he is scared by the primordial
customs and conventions that make the incessant war infinitely less
humane than it could be and ought to be. So a pontist in his attitude
to history is a sociologist, and not an abstract moralist. Each body
social and its systems of circulation are to him what patients are to
medical students in a hospital; he has to learn to be attentive to all
disease and to make his diagnoses thoughtfully. Even then frequent
mistakes will occur. One thing he must regard as his clinical
thermometer: it is the truth that civilizations in their intercourse with
right and wrong have been governed by habits and customs and
conventions, which have caused most men to be other men; so that
most human actions, whether studied in old history or in the current
routine of living, are mere quotations from other human actions,
instead of being like original ideas in a well-ordered composition. In
other words, the ordinary human brain has tried to be automatic, as
if to be in harmony with the rest of the vital organs.
Now the architecture of bridges, like that of huts and houses and
cottages, never fails to keep before our minds the awful slowness of
each reluctant advance from custom to custom, and from convention
to convention. I have no words to describe the terror that comes to
me when I find in daily use a type or species of bridge so aboriginal
in its poor workmanship that a forerunner not only similar to it, but
as rudely effective, may well have been employed by the earliest
Flint Men, whose delight in imitation was stimulated by all the
bridges which Nature had created. Even more, at this moment in
England, and even in busy Lancashire, where to-day’s machinery
abounds, there are primitive bridges which are not even primitively
structural; bridges which need in their making not more thought
than is given to a difficult sneeze when we are troubled by a cold (p.
60). When I look at them and think of the myriads of generations
which in different parts of the world have used bridges akin to these,
I am so awed with fear that I feel like a baby Gulliver in a new
Brobdingnag where everlasting conventions are impersonated by
brainless giants whose bodies are too vast for my eyes to focus.
Often, too, I say to myself: “In the presence of this dreadful
conservatism, this inept mimicry that endures unruffled by a thought
for many thousands of years, you are as futile as a single microbe
would be on a field of battle. Or imagine that the microbe is in
Westminster Abbey, and that it has a blurred sense that makes it
dimly conscious of all the many historic things there gathered
together; then you have a figure of yourself in your relation to the
mingled good and bad in history. For the Abbey shows in its
architecture that convention, though a bane to ordinary minds, is the
grammar of progress to the rare men of genius who from time to
time shake the world free from its bondage to fixed customs and
routines, and compel it to move on to other routines and customs,
where it will dawdle until other geniuses come out of the dark and
find in new mother-ideas a compulsive force that works a new
liberation.”
 old bridge over the clain, near poitiers

This, indeed, is the only encouragement that I am able to

perceive when I watch in history the periodical strife between
inveterate conventions and the mother-ideas of genius. In the case
of bridges, for example, the first mother-ideas were those that
enabled a primitive craftsman here and there to copy with success
the least difficult of Nature’s models. What this man achieved was
repeated by his tools, the ordinary men of his tribe; then other tribes
got wind of the discovery and began to make similar bridges, until at
last several conventions were formed, and they became widespread
and stereotyped. When a convention was very simple and also
effective for a given purpose, no one wished to see it developed, so
it entered that domain of infertile mimicry where stone tools and
weapons remained unpolished for years to be reckoned by scores of
thousands. If experience had shown that chipped flint in a rough
state would neither cut wood nor break human skulls, then at an
early date polishing would have been found out by a savage of
genius who yearned to prove that his invention could be made
useful; but rough-hewn stones were rudely efficient, so mankind
settled itself in a routine and plodded on and on automatically. And
thus it was also in the case of many primitive bridges which became
so firmly fixed in conventions that now they seem to be
contemporary with nearly all the ages of human strife. Not in any
other way can we explain their present use by many Europeans, as
well as by the natives of Asia, and Africa, and America (p. 145). On
the other hand, when a primeval bridge did not serve its purpose
efficiently, when it was useless in tribal wars and dangerous in rainy
seasons, then a mother-idea paid it a visit from time to time, as we
shall see in the next chapter.
Whence the idea came we do not know. It entered a mind that
was ready to receive it, coming unbidden from a place unknown like
an abiding quest from a spirit world. The mind that welcomed the
idea was neither masculine nor feminine, it was both, a thing
androgynous, for genius has ever been a single creative agent with a
double sex. The tools with which genius has worked—the selected
traditions and conventions, the acquired knowledge, the original
observation, and the handicrafts of social life—have ever been plain
enough, of course; but to see and admire tools is not to understand
the advent of those imperishable ideas which not only transform
history, but turn all ordinary men into their mimics and mechanics.
For instance, whenever we light a candle or a fire we obey the
genius of a Palæolithic savage, who, with sparks beaten from flint
into some inflammable grass or moss or fluff from cocoons, brought
into the world the earliest missionaries, artificial light and heat.
Similarly, whenever we walk across a timber bridge, whether old or
new, we are servants to the earliest savage who with a stone axe
cut down a tree, causing it to fall from bank to bank of a river or
chasm. Delete from history even two mother-ideas—the invention of
wheels, for example, and the evolution of arched bridges from
Nature’s models—and how many civilizations would you cancel? Omit
from the annals of our “modern democracy” not more than three
mother-ideas: the discovery of steam as a motive-power, the
discovery of microbes, and the use of metal in bridge building. In a
twinkling we go back to the middle of the eighteenth century, when
hospitals were cesspools, [14] when surgery and medicine were wild
empirics, when travellers in stage-coaches longed for the general
Turnpike Act (a boon delayed till 1773), and when England was
unspoiled by jerry-builders and a factory system. A pontist, then, if
he understands his subject, looks upon genius as the solar system of
human societies, hence he cannot be a willing servant to any mob-
rule or mob-worship.
On the contrary, he would gladly see in every town a fine church
dedicated to the men and women of genius who with great mother-
ideas have tried to better the strife of human adventure. For two
reasons I used the phrase “have tried to better.” In the first place,
the constituents of new knowledge, when mingled with the old
customs and conventions, lose much of their good invariably; and,
next, the amalgam thus formed may become explosive. At this
moment we see in our new art, the art of flying, how precarious is
the charity that mother-ideas bring into the battlefields of
competition. What aeroplanes can do in war is already the only
consideration that the mother-idea of mechanical flight receives from
the most alert minds; and very soon military engineers will be called
upon to invent bomb-proof covers for every strategic bridge which
cannot be displaced by a tunnel. So we compel airmanship to
torment us with visions of wrecked cities, when she ought to delight
us with bird’s-eye views of happier countries.
In brief, the more we study mother-ideas the more clearly we
perceive that they in themselves are phases of strife, for they have
power to do harm as well as good. Providence for ever tries to
quicken the inept human mind, since no blessing is granted to us
without its attendant bane. Electricity has dangers of its own, so has
fire; Pasteurism has dangers of its own, so has food; radium is
curative and very perilous, like the sea or the sun; and all other
good things ask us to pick our way with care between danger and
utility.
The most tragic element of all in human indiscretion is the
mindless routine which has deadened the brain of ordinary men.
There is in Lancashire, for example, a charming valley where six or
seven old bridges make a few minutes’ walk a very long pilgrimage
through the history of primitive conventions. Wycollar the valley is
called, and antiquaries and pontists ought to go there at once, but
not in motor-cars that devour topography as well as miles. One
bridge is exceedingly low in the scale of thought and skill; indeed, no
prehistoric tool or weapon stands below it. Even the Adam of
Evolution, if he ever lived in rock-strewn places, had common sense
enough probably to choose a flat stone and to lay it across a deep
rivulet, so as to save his children from danger. Such is the most
primeval of the Wycollar bridges: three schoolboys could make a
smaller one between two April showers. For the stone is not a huge
slab ten feet long by four wide, such as we find not far from
Fernworthy Bridge, Dartmoor; nor is it like the single slab over the
Walla Brook on Dartmoor. It is a long lintel-stone, and in eight or
nine strides a little girl would cross it easily.[15] If the stone were
new, and also alone in the valley, no one would think more of it than
of a plank used as a temporary bridge; but the stone is very old, and
lintel-bridges are ancient customs in the valley of Wycollar. If Nature
once in a century allowed bridges to tell their tales, I should expect
two of the Wycollar historians to trace their lineage through a great
many ancestors until at last they came to a time when the first
nomads hacked their way with flint axes through the undergrowth of
Lancashire forests, and cursed in primitive words or sounds at the
virile brambles whose thorns were sharper than pointed flints.
The second bridge of lintel-stones at Wycollar is a simple
adaptation from one of Nature’s bridges, the bridge of stepping-
stones littered over the beds of rivers by earthquakes and floods.
When the stepping-stones are long you turn them on end and use
them as piers; when they are short and squat you pile them up into
piers; then lintel-stones are put from pier to pier, and from pier to
each bankside. Here is the A B C of primitive bridge-making with
slabs, boulders, and fragments of rock. It needs very much less
mother-wit than that which enabled primitive men to survive
innumerable hardships, and to breed and rear those true artists who
in Palæolithic times, about 50,000 years ago, [16] turned a good
many European caves into the first public art galleries, famous for
their rock-paintings and for their sculpture and engravings. Thus the
Altamira Cavern, near Santander, in Northern Spain, and the La
Madeleine cave in the Dordogne (about eighty miles east of
Bordeaux), are among the prehistoric museums, or art galleries,
which have given us work very far in advance of the Wycollar lintel-
bridges; so far, indeed, that trees and shrubs in the valley ought to
blush with shame by keeping autumn tints in their leaves all the year
round. This hint from Dame Nature might awaken some little self-
reproach in the Lancashire weavers and peasants whose heavy clogs
clatter day after day over the lintel-stones, wearing them into
troughs where rainwater collects pretty pictures from the sky.
 in the valley of wycollar, lancashire: the weavers’ bridge

Not long ago a busy official mind in the neighbourhood was

troubled by one of the bridges at Wycollar, named the Weavers’
Bridge, a dull-witted primitivity made with three lintel-stones and
two rough piers in the water. Though the busy official mind was
troubled it did not suggest that the bridge should be put under glass
and kept with as much care as the perfect skeleton of a mastodon
would receive; nor did it wish to build a successor in the cheapest
style of industrial metal-work. No; what the official mind advertised
as a fortunate inspiration was a foolish little act of commonplace
vandalism. It set a mason to chisel out of existence the trough worn
in the lintel-stones by generations of clog-wearers! I have two
photographs, now historic, in which the trough can be seen
distinctly; but the poor weavers have no such consolation. Their
ancestors’ work has to be done all over again, and they know that
their great-grandchildren will find in the lintel-stones not a trough
but a vague hollow scarcely deep enough to hold a few raindrops.
Mr. Sargisson wrote to tell me this pathetic story of a crisis in
antiquarianism. But it is fair to add that the busy official mind was
content with one foolish act; it spared the rude pillar on the left
bank, though this rough stone looks like a small menhir and
completes the primeval bridge.
And now let us look at the survival of convention under a form
that is even more distressing. Is it true that in many times and lands
human beings have been sacrificed not to bridges, but to the spirits
of floods and storms which have been feared as destroyers of
bridges? One good reference to this question will be found in Francis
M. Crawford’s “Ave Roma Immortalis.” The most venerated bridge in
ancient Rome was the Pons Sublicius, whose history dated from the
time of Ancus Marcius, who reigned twenty-four years—b.c. 640-616.
In much later times, long after the good fight that made Horatius
Cocles famous for ever, strange ceremonies and superstitions
lingered around the Pons Sublicius. On the Ides of May, which were
celebrated on the fifteenth of the month, Pontiffs and Vestals came
in solemn state to the bridge, accompanied by men who carried
thirty effigies representing human bodies. The effigies were made of
bulrushes, and one by one they were thrown into the Tiber, while
the Vestals sang hymns or the priests chanted prayers. What did this
rite signify? A tradition popular in Rome taught children to believe
that the effigies took the place of human beings, once sacrificed to
the river in May. This tradition is attacked by Ovid, “but the
industrious Baracconi quotes Sextus Pompeius Festus to prove that
in very early times human victims were thrown into the Tiber for one
reason or another, and that human beings were otherwise sacrificed
until the year of the City 657, when, Cnæus Cornelius Lentulus and
Publius Licinius Crassus being consuls, the Senate made a law that
no man should be sacrificed thereafter.”
It is possible, if not, indeed, probable, that the effigies were made
at first in order to placate the common people who were indignant
over the loss of a festival. We can imagine what would be said to-
day if Cup-finals were stopped by Act of Parliament; and the
Romans, in their fool-fury over “sport” at second-hand, were always
glad to appease their curiosity with shows of bloodshed. Further, in
the folk-lore of later times bridges and rivers are connected with the
primitive rite of killing women and men as a sacrifice to evil spirits.
This dread tradition is related now in the Asiatic provinces of Turkey,
as I learn from Sir Mark Sykes, whose “Dar-Ul-Islam” is a book for
pontists to read. It was at Zakho that Sir Mark heard the following
legend:—
“Many years ago workmen under their master were set to
build the bridge; three times the bridge fell, and the workmen
said, ‘The bridge needs a life.’ And the master saw a beautiful
girl, accompanied by a bitch and her puppies, and he said,
‘We will give the first [life] that comes by.’ But the dog and
her little ones hung back, so the girl was built alive into the
bridge, and only her hand with a gold bracelet upon it was
left outside.
“At the foot of this bridge I found the local Agha, Yussuf
Pasha, superintending the collection of the sheep-tax, in
which as a large landowner he has an interest.”
Try to visualise in all their details these pictures, passing from to-
day’s tax-gatherer, a Pasha Lloyd George, into the drama of a very
terrible superstition. The workmen can be fitted with fairly good
primitive characters, for they do not suggest the sacrifice of a life
until the bridge has fallen thrice. As to their master, he is a fiend,
since he acts upon their suggestion at once, unmoved by the girl’s
beauty and the frisking springtime that accompanies her. A little
dead hand—and a gleaming bracelet—and the masons chanting at
their work, as bridge-builders chant now in Persia: so the drama
ends, or so it would end if we could not unite it with a similar legend
known almost everywhere in Europe.
Why in the Turkish story the workmen say, “The bridge needs a
life,” I do not know. Their superstition goes away from the river and
its evil spirits, and from those other demons, which in olden times
made winds so variable. Are we then to suppose that men have
defiled the charity of bridges with bad spirits other than those that
live in wilted conventions and in modern engineers? I prefer to
believe that a bridge that fell three times would muddle the
superstition of any workman. In fact, there are many bridges which
superstition—not modesty in men—has given to the Devil, and as a
rule they have been connected with the same legend, or bogie tale.
Mr. Baring-Gould takes a great interest in the bridges ascribed to the
Devil, and writes about them as follows in his “Book of South
Wales”:—

pont du diable, st. gotthard pass

“The Devil’s Bridge is twelve miles from Aberystwyth; it is

over the Afon Mynach just before its junction with the
Rheidol[17].... The original bridge was constructed by the
monks of Strata Florida, at what time is unknown, but legend
says it was built by the Devil.

Old Megan Llandunach, of Pont-y-Mynach,

Had lost her only cow;
Across the ravine the cow was seen,
But to get it she could not tell how.

“In this dilemma the Evil One appeared to her cowled as a

monk, and with a rosary at his belt, and offered to cast a
bridge across the chasm if she would promise him the first
living being that should pass over it when complete. To this
she gladly consented. The bridge was thrown across the
ravine, and the Evil One stood bowing and beckoning to the
old woman to come over and try it. But she was too clever to
do that. She had noticed his left leg as he was engaged on
the construction, and saw that the knee was behind in place
of in front, and for a foot he had a hoof.

In her pocket she fumbled, a crust out tumbled,

She called her little black cur;
The crust over she threw, the dog after it flew,
Says she, ‘The dog’s yours, crafty sir!’

“Precisely the same story is told of S. Cadoc’s Causeway in

Brittany; of the bridge over the Maine at Frankfort, and of
many and many another.
“How comes it that we have an almost identical tale in so
many parts of Europe? The reason is that in all such
structures a sacrifice was offered to the Spirits of Evil who
haunted the place. When a storm came down on the sea,
Jonah had to be flung overboard to allay it. When, in the old
English ballad, a ship remained stationary, though all sails
 were spread, and she could make no headway, the crew ‘cast
the black bullets,’ and the lot falls to the captain’s wife, and
she is thereupon thrown overboard. Vortigern sought to lay
the foundations of his castle in the blood of an orphan boy. A
dam broke in Holland in the seventeenth century; the
peasants could hardly be restrained from burying a living child
under it, when reconstructed, to ensure its stability.[18]
“When the [Cistercian] monks of Strata Florida threw the
daring arch over the chasm, they so far yielded to the popular
superstition as to bury a dog beneath the base of the arch, or
to fling one over the parapet.”
There! We have followed a superstition—a vile convention in
ignorance and cowardice—from the Pons Sublicius in Ancient Rome
to the Pont-y-Mynach in South Wales; and the best we can say of it
is that in Pagan Rome it went from human victims to effigies of men
and women, while in Christian times it passed from human victims to
dogs.[19] Mr. Baring-Gould has told us that in bridges, and “in all
such structures, a sacrifice was offered to the Spirits of Evil who
haunted the place.” Yet it was not in a structure—a finished building
—that Vortigern wished to offer his sacrifice; he “sought to lay the
foundations of his castle in the blood of an orphan boy,” so his aim
was to placate the Spirits of Evil before his castle was built. As to his
conception of the spiritual agencies to be appeased, it would mingle
his own passions with the fears bred by his primitive fanaticism. For,
as Darwin says, “savages would naturally attribute to spirits the
same passions, the same love of vengeance or simplest form of
justice, and the same affections which they themselves felt.”
Now in the case of bridges we have to identify primitive men with
the terror inspired by storms and floods; a terror difficult for us to
understand in our sheltered lives. Have you read Matthew Paris, who
lived in the reign of Henry III? If not, go to him and study the
tempests that he described, and see how villages were desolated by
winds and inundations. Amid these disasters the ignorant would
cling to ancient superstitions; fear would be pagan out of doors
whatever faith might say in church; and I have no doubt at all that
the many so-called Devil’s Bridges were as supernatural to the
mediæval peasant as were witches. The Dutch of the Middle Ages
were more advanced in domestic civilization than our own ancestors;
and yet at heart they were cruel pagans, even as late as the
seventeenth century, as Mr. Baring-Gould has shown. How very
humble human nature ought to be!
Let us pass on, then, to a convention that does not reek like a
stricken field. One of the best historians in architecture, Viollet-le-
Duc, found in the hills of Savoy a primeval bridge whose structure
had been changed very little, if at all, since the days when its
ancestors were described by Cæsar and used by the Gauls. It is a
timber bridge, known in France as un empilage, a thing piled
together rudely, and not constructed with art. Indeed, it needs no
carpentry, so it is far behind the social genius of prehistoric lake-
dwellers. To make a simple Gaulish bridge, as to-day in Savoy, we
must choose a deep-lying river with rugged banks; then with water-
worn boulders we make on each bank a rough foundation about
fifteen feet square, or more. Upon this we raise a criss-cross of tree
trunks, taking care that the horizontal trees jut out farther and
farther across the water, narrowing the gap to be bridged by four or
five pines. Each criss-cross must be “stiffened” or filled in with
pebbles and bits of rock; and across the unfinished road of pines
thick boards are nailed firmly. Viollet-le-Duc says:—
“Cette construction primitive ... rappelle singulièrement ces
ouvrages Gaulois dont parle César, et qui se composaient de
troncs d’arbres posés à l’angle droit par rangées, entre
lesquelles on bloquait des quartiers de roches. Ce procédé,
qui nest qu’un empilage, doit remonter à la plus haute
antiquité; nous le signalons ici pour faire connaître comment
certaines traditions se perpétuent à travers les siècles, malgré
les perfectionnements apportés par la civilisation, et combien
elles doivent toujours fixer l’attention de l’archéologue.”
 Does anyone suppose that Savoy would have been loyal to a
prehistoric bridge if all primitiveness had vanished from her social
life?
Not that Savoy is the only place where criss-cross bridges are still
in vogue. Much finer specimens are to be found in Kashmír, thrown
across the river Jhelum, the Hydaspes of Greek historians. At
Srínagar, the capital city, founded in the sixth century a.d., there is a
quite wonderful example, for it has many spans, and corbelled out
from the footway is a quaint little street of frail shops, rickety cabins
with gabled roofs, and so unequal in size that they are charmed with
an amusing inequality. I have several photographs of this bridge,
and in them I see always with a renewed pleasure its ancestry, its
descent from the prehistoric lake-villages, those heralds of Venice
and of Old London Bridge (p. 216). All the piers are made with
deodar logs piled up in the criss-cross manner; those that stretch
across the river are cut in varying lengths, and each succeeding row
is longer than the one beneath it, so the logs in a brace of piers
project towards each other farther and farther over the water, till at
last they form an arched shape; not an arch perfect in outline, of
course, since the head of it is flattened by the long bearing beams of
the roadway. Still, the arched shape is very noticeable.
A pontist should study these rude arches with care, and connect
them with similar arches in the Gaulish bridges of Savoy, and also
with the historic fact that the first arches built with voussoirs (i.e.
arch-stones) were evolved from vaults roughly constructed with
parallel courses of stone and layers of timber (p. 155). It is probable
that the parallel layers of timber or rows of logs came before the
parallel courses of stone, as the evolution of architecture passed
from wood to stone. Forests much more than rocks and quarries
have been an inspiration to primitive builders, as if the handling of
wood has quickened in human nature an arboreal instinct dating
from the family trees in the descent of man.
 at albi on the tarn, in france, showing on our right
the old houses, and on our left, beyond the bridge,
the great old church, famous for its fortifications

However, another criss-cross bridge in Kashmír ought to be

studied in photographs; it is carried on six piers over the Jhelum at
Baramula—quite close to the Himalayas; the piers rise from boat-
shaped platforms that meet the oncoming water as boats do, with
their blunt stems looking brave as rearguards. The parapet is a
simple latticework, and the abutments are masonry. Here we have a
type of bridge perhaps quite similar to the one from which the Gauls
got their rude methods, long after the craft of the lake-dwellers had
left its sheltered moorings and adventured across wide rivers.
Is there any concrete evidence to suggest that the bridge with
criss-cross piers has gone through many phases of change, of
growth or of decadence? Yes. At Archangel, in North Russia, the
criss-cross piers are more primitive; instead of being arched they are
upright and stiff; but as the bridge is nearly a quarter of a mile long,
and as it is taken down every spring (before the ice breaks up
noisily, and the Dwina thunders into a raging torrent), crude
workmanship in a hurried routine is excusable. The main point is
that a bridge akin to the Gaulish type and to the variation in Kashmir
exists in North Russia.
And another variation is met with at Bhutan, in India. Brangwyn
has drawn it, and we shall study it later in a page on gateway-
towers (p. 272). In the highlands of Eastern Kurdistan, the
borderland of Asiatic Turkey and Persia, travellers find a bridge akin
to the Bhutan variety. An excellent book on these highlands has
been published, [20] and its authors, very generously, have written
for me some valuable notes on the bridges. Before I quote them in
full, let me ask you to remember that in Eastern Kurdistan timber is
uncommon; hence the criss-cross bridge has been evolved into
another sort of primitive structure—a third cousin, several times
removed. A Kurdistan bridge is built as follows: “A site is selected, if
one can be found, where two immovable and flat-topped masses of
rock face one another across the stream to be bridged: an abutment
of unhewn stones is built on these, solid, until a height has been
reached sufficient to be safe from any flood.
“Then a bracket of four or more rows of poplar trunks is
constructed on each abutment; short stout trunks form the bottom
row, and those of each succeeding one are naturally longer than the
preceding. Unless the bridge is unusually wide in the footway four
poplars are enough to form a row, and the butts of the trees, which
are kept shore-wards, are weighted down with big stones as
counter-weights to hold them in place.
“The top of each row of trunks projects perhaps five feet beyond
the preceding one, so that when a bracket of four rows is
completed, it may project perhaps twenty feet over the stream.
“When the corresponding bracket has been completed, two long
poplar trunks are slung by withies from bracket end to bracket end,
a footway of withy hurdles, resting on faggots, is laid down over all,
and the bridge is complete. The length of this centre span is of
course limited by the height of the poplars available. I should think
fifty feet the extreme possible.
“If the width of the river makes it necessary, one or more piers of
stone,—I have seen as many as three,—are erected in midstream,
preferably on rock foundations. Each of these carries a bracket on
each side, but this double bracket is usually made of ‘whole trunks’
and these naturally need no counter-weighting.
“As a rule the footway is about four feet wide, and the whole
structure is very elastic, so that, as it is guiltless of handrails, it
requires a steady head in the passenger. Further, the central span
often acquires a pronounced ‘sag,’ and not seldom an equally
pronounced tilt to one side or other. Ancient rule says that the
passenger ought not to look down in crossing such a place, lest the
sight of water whirling below should unnerve him. In Kurdistan,
however, look down he must, and make the best of the hurdles that
form the footway; they abound in holes and other traps for the
unwary, and a stumble may mean disaster. These bridges, then,
though admirably planned (for they are true cantilevers), are not
built in the most convenient manner. It is characteristically Oriental,
this union of real fineness of design with great casualness in
construction and in upkeep. The piers are invariably of stone, never
of wood. Good timber is almost unknown in Kurdistan. The poplar
grows well, but it is at best only a good pole. Stone, on the other
hand, is embarrassingly abundant.
“Dry-stone arches are thrown over smaller streams, but their
builders, though acquainted with the principle of the vault, do not
venture on a span of more than thirty feet!”[21]
How do you like the antiquity of conventions? Does it not make
you feel that the greatest part of mankind has never shown a
particle of desire that its civil institutions should be improved? Note,
too, that convention among men is inferior to the instinct of animals,
for animals invariably repeat themselves with a passionate interest,
whereas we in our formulas grow more and more unfeeling and
automatic. Even rabbits when they dig their burrows seem to be
guided by inspiration, as if routine work with them is an appetite,
like love and hunger; so very different are they from the
conservative peasants of Savoy, whose dull routine has delivered
down through the centuries a primeval bridge which an hour’s
thought could have improved.
One day, let us hope, most men will realise that it is woefully
commonplace to be as other men; then conventions will go out of
vogue. Courts and clubs will invent new and good etiquettes every
year; no game will be stereotyped; and laws will command that such
and such things be altered and improved by given dates. For
example, if an Act of Parliament decreed that during the next ten
years all the railway bridges in England must be made less uncomely
and less at odds with the needs of military defence, I have no doubt
that compulsion, the scout of civil progress, would discover among
engineers more than enough invention.
Railway bridges have been built in obedience to a brace of
conventional arguments. It has been argued, first, that because
traffic and trade are the main considerations, therefore art is not a
matter to be considered; next, that because boards of directors have
to please their shareholders, therefore a most strenuous economy
must be advertised in a very evident manner, even although its
results blot fine landscapes with the shame of uninspired
craftsmanship.
Thirty-four years have passed since the late E. M. Barry, r.a., in a
thoughtful book, asked the public to understand that modern
engineering was not architecture at all, but mere building; and he
chose as an example of horrible work the Britannia Bridge over the
Menai Straits. “Here we have the adoption of the trabeated principle
of large iron beams laid upon supports of masonry, which rise from
the valley beneath, and tower up above the beams to a height far
exceeding that which is necessary for their support. I well remember
the animated discussions in scientific circles as to the form and
design of these beams, which were ultimately decided upon as
rectangular tubes. In the many discussions of the merits and defects
of circular, elliptical and square sections, I do not recollect that a
word was said about architectural effect [or about military
convenience and strategy]. Had anyone ventured to suggest that
this, too, was an important matter, and that an unsightly structure
would be an eyesore for all time, he would have been promptly told
that the forms to be employed were an affair of science alone, and
that utility pure and simple would dictate their arrangement. In the
result a lovely valley was defaced....”
The same convention in mean tradecraft is shown in the tale
about Tennyson and the jerry-builder. “Why do you cut down these
trees?” the poet asked reprovingly. “Trees are beautiful things.” “Ah!”
answered the jerry-builder, “trees are luxuries; what we need is
utility.” And what this utility has done for us may be seen in a
thousand railway bridges as bad as those that disgrace even the
Harrow Road, near by Paddington Station.
It is not my argument that every railway bridge in England is
underbred and crapulous; here and there an engineer has made an
effort to be architectural, but the usual level of taste is exceedingly
vulgar, and not in railway bridges only. Even the Tower Bridge,
London, a vast feat in engineering, is so conventional with a
meretricious mediævalism that it needs the screening dust and mist
that veil the Thames. This is among the modern bridges that
Brangwyn has drawn and painted, raising them into art as a record
of current history. Nothing moves him more than the huge
mechanisms that seize upon to-day’s life and turn it into their
obedient slave. Men dwindle ever more and more in scale as
machines become fatal in their enormous bulk, like Super-
Dreadnoughts and the “Titanic”; not to forget such vulnerable
monsters as the bridges of New York, which airships sent forth by
Mr. H. G. Wells have already attacked with prophetic success. Is man
really doomed to be the tool of machines? Is this to be his final
convention?
 In one great picture by Brangwyn the High Level Bridge at
Newcastle represents our time. Historically the High Level Bridge has
much interest; it displaced the Britannia Bridge as an object of
scientific veneration, and from the first it has ranked high in the
conventional ugliness that the British public has accepted from
engineers. When the Britannia Bridge was proved to be a bad
railway line (trains were the decisive critics), and when men of
science after weighing their after-thoughts began to find fault with
the distribution of metal in the section of its tubes, then engineers
said, “And now—now we must have a good railway bridge,
completely scientific in all respects.” It was to be built with two
roadways, the one for common traffic passing under a railway, so
that business folk might be comforted by the noise overhead, which
would be as music to any believer in a pushful industrialism. Six
arches of metal would be united to five piers and the abutments;
their spans would have precisely the same width, i.e. 138 ft. 10 in.,
for minds long used to office hours and ledgers would enjoy a dead
uniformity. Indeed, everybody was pleased with these plans; and in
1849, when Queen Victoria opened the High Level Bridge, artists
alone were unexcited with joy. All the rest of the English world
imagined that science, at the cost of only £243,000, had achieved a
metal masterpiece. New London Bridge had cost six times as much
(i.e. £1,458,311), and her materials were stones, not metals, so
once more the north of England had scored heavily over the south.
“Besides,” remarked the engineers, “we have put into the
superstructure 321 tons of wrought-iron, and into the arched ribs
4,728 tons of cast-iron. Economy.... Scientific economy.... And we
have now in use a perfect example of the true bowstring arch in
which no cross-bracing is needed.” All this, when discussed at
dinners, enriched the flavour of champagne; and opinion became so
“heady” that even the “Encyclopædia Britannica” in its eighth edition
received the High Level Bridge as an inspired work, and gave to its
engineering as much space as the thrifty Romans would have given
to all their Spanish bridges and aqueducts.
 At last, and all of a sudden, a reaction came; enthusiasm not only
caught a chill, it passed in a hurry from its tropical summer into a
bad winter of discontent. Scientists went so far as to declare that the
High Level Bridge was a youthful indiscretion, advertised publicly in a
material which might endure for centuries; and this change of
opinion had a great effect on the “Encyclopædia Britannica,” whose
ninth edition gave only eighteen lines to its former favourite. Even
the bowstring arch was praised no longer, “being essentially more
expensive and heavier than a true girder.”

the tower bridge, london

Such are the comedies invented by our new playwright, the

genius of civil engineers. Still, the High Level Bridge at Newcastle
looks well on a misty day; by moonlight it is more impressive than a
Whistler nocturne; and in Brangwyn’s art it represents our industrial
age with a vigour that is manly and impressive.
For the rest, from the pictures in this book you will be able to
choose for yourself many a convention in the craft of bridge-
building. Study, for example, the arches and their shapes, noting
those which have a character of their own. These mark a new
departure, and are famous. Thus the bridge at Avignon is admired
by technicians because its architect, the great Saint Bénézet, gave to
the arches what Professor Fleeming Jenkin has described as “an
elliptical outline with the radius of curvature smaller at the crown
than at the haunch, a form which accords more truly with the linear
equilibrated arch than the modern flat ellipse with the largest radius
at the crown.” Good Bénézet! Seven hundred and thirty years have
gone by since he turned from the Roman tradition of semicircular
arches, and designed an excellent arch of his own, a beautiful thing,
with a look of triumph in its quiet dignity. Many writers think that
L’arc de Saint Bénézet is original also in construction, its vault being
composed of four separate bands put side by side in stones of about
equal bulk. Sometimes this method of building is condemned as
weak, though four of Bénézet’s arches have outlived seven centuries
of war; and what engineer would feel disgraced if he were baffled by
the terrific floods to which the Rhône is subject?
Moreover, Bénézet was not an originator in this matter; he
borrowed from the Romans. In his time there was a bridge that
carried the Via Domitiana over the Vidourle at Pont Ambroise; the
vaults of its five arches were built in precisely the same manner, in
four parallel arcs or bands that touched each other; and the bridge
was notable for other reasons, and thus attractive to all bridge-
builders. In the first place, a Bull of Pope Adrian IV, dated 1156, now
treasured at Nîmes in the Church of Nôtre Dame, has proved that in
the twelfth century a chapel was built either on or from the middle
of the bridge; it was dedicated to St. Mary, and it belonged to the
chapter of Nîmes Cathedral. A Roman bridge sanctified by a
Christian chapel recalls to one’s mind the devotion of the Flavian
family that placed the monogram of Christ among the ensigns of
ancient Rome. Unless the chapel stood out on corbels from the side
of the bridge, it must have been a tiny place of prayer, for the bridge
was only three metres wide, while the Via Domitiana had an average
width of six metres. Further, the roadway across the bridge was
peculiar; it followed in gentle curves the contour of the arches,
instead of being either flat (as in most Roman bridges) or with a
slight incline at the abutment ends (as in the bridge of Augustus at
Rimini).[22] We cannot suppose that this bridge, so noteworthy in
several ways, was unknown to Bénézet, head of the Pontist Friars.
Anyhow, the immense Pont du Gard, near Nîmes, a Roman
masterpiece, must have been known to him; and the arches of its
second tier have in the belly of each vault three parallel bands of
equal-sized stones. If this method of construction be unsound, how
are we to explain the heroic stability of the Pont du Gard, the finest
of all the Roman aqueducts?
Myself, I do not believe that Bénézet was inexpert as a borrower.
We shall meet him again (p. 236), but let us note here that his work
is rhythmical and charming; so it does not belong to the underbred
heaviness that bridge-builders often copied from the art of mediæval
fortification. This art was an unthrifty engineer; it employed far and
away too much blind masonry. Castle walls were ten feet thick, and
brave soldiers at home feared the light of day, merely to show
respect for arrows and machine-worked catapults. They were not
discreet; they made caution too timid and too uncomfortable. Did
gallant married knights forget to sleep in their suits of mail? Was a
honeymoon in armour a trifle more tiresome than were twelfth-
century castles with their arrow slits for windows? For many a year
home life was an ill-smelling twilight, particularly to persons of rank;
and from this we may infer that the custom of war during the Middle
Ages went hand-in-hand with a superstitious dread of death.
Bénézet needed courage as well as genius when he slighted in a
graceful manner the ponderous conventions of safety that ruled in
his day over castles (1177-1185). It was his arch that saved the
vigour of his design from being dull and clumsy.
 Some other arches in French bridges have provoked paper wars.
This is true of those in the bridges at Albi and Espalion, chosen by
Brangwyn partly because of their controversial interest, and partly
because they illustrate a mood of handicraft which may be called the
uncouth picturesque.
 an old town bridge in perugia, italy, to illustrate a pointed arch which has in its
curve a sort of lingering sentiment for the round arch of the romans

IV
CONTROVERSIES
Students are tested and judged by their attitude to controversies.
Common sense should keep them from partisanship; and when they
feel tempted to look on as mere spectators, they should remember
that crowds at boxing matches are very apt to form wrong opinions.
It is better by far to laugh at both sides by caricaturing the weak
points of a discussion. In a few days a student will learn which side
is the more difficult to caricature, and this knowledge will help him
to sift all rubbish from a controversy and to form a judgment of his
own on facts and on inferences. As Sir Thomas Browne said, a man
should be something that all men are not, and individual in
somewhat beside his person and his name.
The bridges at Albi and Espalion have caused some men to break
old friendships over a simple question, namely: “When were pointed
arches used for the first time in French bridges? At what date were
they brought from the East?” As the pointed arch was copied by
Europeans, not invented by them, the precise date of the mimicry
ought not to excite a pontist; it is a thing for antiquaries to be
flurried about. If the question ran in another form: “Was the pointed
arch in French bridges an independent discovery?” then a battle and
some exploded reputations would be worth while. But no such
hypothesis has been put forward by either side in a warm dispute.
One party declares that as early as the time of Charlemagne,
towards the end of the eighth century, or the beginning of the ninth
(768-814), a French builder seems to have played the part of the
sedulous ape to Eastern architecture, cribbing the pointed arch, and
using it without much skill in the bridge of Espalion, whose
construction (as documents prove incontestably) was ordered by
Charlemagne himself. In this bald statement there is no challenge,
no provocation; it is nothing more than a conjecture supported by a
documented fact.
If Charlemagne had been a weak ruler, like Louis the Indolent, it
would be fair to suppose that his commands were neglected more
often than obeyed; then we could not accept his character as a fact
of greater value in a controversy than a command of his mentioned
in authentic documents. Let us say that the Black Prince or his father
ordered a bridge to be built at a given place; we have documents to
prove this, and at the place named in the documents a very old
bridge is extant. Should we not read these documents by the light of
the reputation won by the Black Prince or by his father? Myself, I
should say at once, “His orders were obeyed.” And so, too, in the
case of Charlemagne. I accept his character as a guarantee that he