Therapeutically in Forensic Settings
May 31, 2025
Media on Mental Health
May 31, 2025
Mad House
Part1
The term ‘mental health’ was not commonly used until the 1900s; until then, ‘mad’, ‘lunacy’ and ‘insanity’ were the accepted terms. Throughout this chapter the term ‘mental illness’ will also be used, since it was common in the past; however, the preferred modern term, ‘mental health issues’ or ‘mental health problems’, will be employed throughout the rest of the book.
These terms reduce the stigma previously associated with the old ‘mental illness’ label, which suggested that sufferers should be segregated from the rest of the population.
One of the first hospitals to open its doors to the mentally unwell was St Marys of Bethlehem Priory in London. It was originally founded in 1247 to heal sick paupers, but over the years it began to take in more people with mental illness.
In 1403 the hospital was taken over by the Crown and turned into a ‘madhouse’ or shelter for the insane; from 1547 the City of London ran it as a hospital for the mentally ill until 1948 (Kent, 2003). The hospital’s name changed from Bethlehem to Bethlem and then in turn to Bedlam, a term that is still used to refer to disorder, chaos and mayhem.
During the eighteenth-century Bedlam was open to the public and visitors could pay a fee to come and gawk at the patients. In the early 1790s William Tuke, a devout Quaker, led an investigation into the English ‘madhouses’ and was horrified by what he found.
Many of the patients were kept in awful conditions, chained to walls or beds in cramped conditions, sleeping on straw. The treatments given to the patients were often harsh, such as being starved, beaten and drenched in cold water, but Tuke believed that ‘mad’ people should be treated with kindness rather than cruelty.
Part2
In 1796 he opened the York Retreat as an asylum to protect those with mental health problems from society, rather than to protect society from the ‘mad’ as had been the ethos of previous institutions.
This heralded a new era in the treatment of mental health patients across Europe and the USA and initiated the age of the asylum (Kent, 2003).
In 1810 London physician William Blake created a table of the causes of insanity of those admitted to Bethlem, including grief, love, jealousy, pride, religion, study, drink and intoxication, childbed (giving birth or nursing), fevers, family and heredity, contusions and fractures of the skull, and venereal disease (Papionines, 2008).
How does this list differ from the way we currently think about mental health problems?
Would mental health professionals today recognise these as symptoms or causes of mental illness?
Blake’s list is very different from that used in current diagnosis and descriptions of mental illness and illustrates the contemporary lack of medical knowledge about mental health problems.
Another difference is that the list focuses more on causes whereas mental health professionals today tend to concentrate on diagnosis and treatment.
However, it could be argued that many of the issues in the list, such as jealousy (Kingham & Gordon, 2004), alcohol (Shivani, Goldsmith & Anthelia, 2002) and grief (Ott, 2003), can have a profound effect upon mental health.
The York Retreat was set up as a charitable non-profit sanctuary, where treatment was not based upon medical knowledge but on Christian morals and common sense.
Pat3
Patients were not punished for their behaviour, but treated with kindness and very seldom restrained, though they were occasionally placed in straightjackets if it seemed they might harm themselves.
While the York Retreat followed a Quaker philosophy of moral, rather than medical therapy, in the early nineteenth century several other medical institutions were established, such as St Luke’s hospital and Manchester Lunatic Asylum, with the aim of treating those with mental health problems (Jones, 1993). By 1914 there were over 100,000 patients in over 100 mental hospitals in the UK (The Time chamber, 2007).
The development of treatment
In the early mental health hospitals such as St Luke’s, treatment still focused on cold water plunges, drugs to induce vomiting, bloodletting and rotation therapy (sitting in a suspended rotating chair). It wasn’t until the early twentieth century and the publication of Sigmund Freud’s psychoanalysis theory that the ‘talking cure’ was seen as a form of treatment.
Freud believed that mental health problems came from suppressing unconscious desires, fears and childhood memories that could be uncovered by using techniques such as free association, where the patient is asked to relax and say the first thing that comes into their mind, and dream analysis.
Once unconscious memories and fears were brought into consciousness the patient’s symptoms would be alleviated (Parker, 2010). Psychoanalysis started the revolutionary Psychodynamic movement, which influenced not only psychiatry and the way patients were treated in mental health institutions but has also had lasting influences on the field of psychology and counselling (Porter, 2003; see also Chapter 13).
Part4
However, Freud did not envisage psychoanalysis as a treatment for those with severe mental illness, who filled asylums in large numbers (Kent, 2003).
In the 1920s and 1930s new techniques were developed to treat the mentally ill. One experimental technique thought to be effective for schizophrenia was insulin shock, or insulin coma therapy (ICT).
The patient was given a series of insulin injections until their blood sugar dropped and they went into a coma. Once comatose the patient was given a glucose injection to revive them, a process repeated over a series of days or weeks.
This therapy carried serious risks, including brain damage from the comas; one in every hundred patients died and many others were left feeling terrified or disorientated (Kent, 2003). ICT was used throughout the 1940s and 1950s in many psychiatric hospitals but was replaced by the advent of new drugs.
Another new technique was the use of electro-shock or electroconvulsive therapy (ECT), whereby seizures were induced by passing an electrical current through the brain. This was repeated until the patient stopped showing symptoms.
ECT was seen as a breakthrough and was used to treat a number of illnesses, including schizophrenia, depression and bipolar disorder. It is a treatment that is still used today, as a last resort for those with major depression when other treatments have failed, although it can have adverse effects, such as loss of memory and confusion (Dunne & McLoughlin, 2012).
The 1930s saw the advent of an operation called the prefrontal lobotomy, in which a series of nerves at the front of the brain were severed. Although lobotomy did appear to reduce the anxiety or violent outbursts of some patients, many others lost their ability to speak or think clearly due to brain damage, and some needed more care after the surgery than they had before (Kent, 2003).
Part5
However, lobotomy was seen as being at the cutting edge of medicine and was a popular treatment for patients with severe disturbances.
By 1951, 12,000 patients in the UK had undergone lobotomy until growing doubts about its effectiveness, and the psychopharmacological revolution, reduced the number of operations so that by the 1970s only just over 100 were performed every year in the UK (Barraclough & Mitchell-Heggs, 1978).
In the 1950s and 1960s of number of new drugs, including Largactil, Thorazine and lithium, were developed to help treat conditions such as depression, schizophrenia and bipolar disorder.
These anti-depressant and anti-psychotic drugs made it possible for many patients to leave psychiatric hospitals, although they often caused adverse physiological effects (e.g. uncontrollable facial twitches, tremors, dizziness and fatigue).
Furthermore, Freudians argued that anti-psychotic drugs simply masked the symptoms of sufferers, making it more difficult to get at the root of the problem (Kent, 2003).
Medication still remains a key treatment for mental health problems and an individual’s diagnosis will determine the types of drug they are prescribed. In 1952 the American Psychiatric Society developed the Diagnostic and Statistical Manual (DSM) of Mental Disorders.
The DSM contained several short descriptions of mental illnesses and was designed as a handbook to help doctors and other professionals make diagnoses. The DSM is still used today, although it has been criticised as pathologizing everyday life and putting diagnostic labels on emotional reactions that fall within the normal range (Kent, 2003).
Other critics claim that mental health problems cannot be measured or categorised objectively (Szasz, 1961) – an issue explored further in Chapter 3, which takes a critical perspective on diagnosis and categorisation.
Part6
But the DSM has been a source of controversy with some political implications: in 1974 gay and lesbian groups lobbied to have homosexuality removed from its list of mental illnesses; conversely, Vietnam veterans fought to have PSTD included, so anyone suffering from the condition could claim medical health insurance (Kent, 2003).
There has also been a rise in the prescription of psychiatric drugs, and it has been argued that this is associated with the increased influence of the pharmaceutical industry (Moncrieff, 2003
Today people suffering from mental health problems may be offered drugs, group therapy, family therapy, behaviour modification, and cognitive behavioural therapy (CBT), as well as admission to psychiatric wards.
Psychiatric drugs can help to alleviate symptoms, while talking therapies are employed to help people deal with the symptoms and underlying causes of their mental health issues.
However, at the time of writing the mental health services in the UK are overstretched and waiting times for talking therapies can be up to a year (Mind, 2013).
The chapters in Part III on ‘Treatment’ will look in more detail at different types of therapy and the approaches they use. The next section examines the history of the prison and probation services.
This, coupled with the advent of government policy to support ‘care in the community’, eventually led to the closure of many British and American asylums. In the UK the asylum population dropped from 150,000 in the 1950s to 30,000 in the 1980s (Porter, 2003) however, not everyone thought care in the community worked.
By the end of the twentieth century there was an increase in mental health problems recognised by the DSM, such as post-traumatic stress disorder (PTSD), and new forms of therapy to accompany them.
The growth of drug therapy to help people with mental health problems manage their symptoms reduced the need for long stays in mental health institutions.
History of the prison service
Part7
The aim of the criminal justice system is to detect and prevent crime, to rehabilitate and punish offenders and to support victims and witnesses. It comprises several different agencies, such as the police,
the Crown Prosecution Service (courts), and the National Offender Management Service (prisons and probation services), that all work together and are overseen by the Ministry of Justice, the Home Office and the Attorney General’s Office (McMurran, Khalifa & Gibbon, 2009).
This section looks at the development of the prison service and how sentencing developed from a form of punishment to involve rehabilitation.
For centuries prisons were used simply as a place to hold people until they faced trial or punishment, which often consisted of the death sentence or transportation, for example to the American colonies or Australia.
It wasn’t until the middle of the eighteenth century that a prison sentence, with hard labour, was seen as a suitable sentence for minor offences such as theft (The Howard League, 2016).
From the late eighteenth to the middle of the nineteenth century prisons changed dramatically, from chaotic places that housed a mixture of prisoners to regulated institutions that were quiet, orderly and populated only by prisoners and prison staff.
In 1777 John Howard’s The state of the prisons in England and Wales captured the public’s attention about the awful conditions inside local prisons, where illness, gambling and drinking were rife, and many prisoners who were acquitted were unable to leave as they could not afford to pay the jailers to release them (McGowen, 1995).
In 1779 the Penitentiary Act made it possible to sentence offenders to one of two planned state-run prisons in England. During their imprisonment offenders would be subjected to solitary confinement, religious instruction, a harsh diet, and would be required to work without payment and wear a uniform.
Officials working in prisons would be paid a salary, with the costs being recovered from prison labour (Wilson, 2014).
Although a change of government shelved plans for the penitentiaries, the Act paved the way for local prison reconstruction and reform, derived from an ethos that if prisoners were kept in clean, secure conditions and subject to hard labour, solitude and religion they could be rehabilitated into law-abiding citizens (Jewkes, 2011a).
Part8
By the nineteenth century many British prisons still operated with different local regimes and qualities. In 1877 the Prison Act was passed to bring local prisons under the control of the state in England and Wales, and then in Scotland in 1878.
This Act paved the way for the current prison service and saw the transfer of prison administration to the Home Secretary (Wilson, 2014). In 1895 a report to the government suggested that the aim of prisons should not only be to punish but also to reform, so that men and women left prison as better people, while younger prisoners should not be incarcerated in the same place as older offenders.
This report led to a new Prison Act in 1898 which placed more emphasis on reducing recidivism (Parliament, 2016, www.parliment.uk).
Prison populations remained relatively stable until after the Second World War when numbers began to rise dramatically, from 15,000 in 1945 to 42,000 in 1978. Many prisons became overcrowded and the conditions inside were very poor due to lack of funding and the ageing Victorian prison infrastructure (McGowen, 1995).
In January 2016 there were 85,461 prisoners in England and Wales and 7,887 prisoners in Scotland (www.offendersfamilieshelpline.org/index.php/prisoner-category). Today the UK prison population is the largest in Western Europe.
Neither crime rates, the creation of new offences nor population have risen at comparable rates, suggesting that the twenty-first century increase in the prison population is largely the result of longer custodial sentencing and release policies (Jewkes, 2011a).
A report by the Prison Reform Trust (2015) showed that prisons have been overcrowded every year since 1994, with fewer staff employed and ever higher death and assault rates.
The report also stated that prisons have a very poor rate for reducing reoffending and that 45% of adults are reconvicted within a year of release.
This was especially the case for those serving short prison sentences of less than 12 months, who were more likely to reoffend in comparison to those serving 12-month community sentences for similar offences.
Prisons are not the only places in which offenders can be penalised; the information box looks at the issue of community sentences and the history of the probation service.
National Probation Service
Part9
The National Probation Service, established in 1907, is responsible for supervising offenders in the community. Its origins can be traced back to 1876 when Frederick Rainer made a five-shilling donation to the Church of England Temperance Society to help break the cycle of those who became repeat offenders through drunkenness.
The National Probation Service works closely with the courts, preparing pre-sentence reports on risk assessment, offence and proposed sentencing. Probation officers can also work within prisons, looking at sentencing, treatments and working with the local probation service where the prisoner will be released.
Over the years the Probation Service has obtained more powers to take the lead on community sentences, including drug testing, electronic tagging and providing probation hostels. It also works with police, mental health services and the prison service under the Multi-Agency Public Protection Arrangements (MAPPA) to manage violent and sexual offenders (McMurran, Khalifa & Gibbon, 2009).
Part10
Statutory provision for the medical care of prisoners began in the late eighteenth century, when the 1774 Health of Prisoners Act empowered county magistrates to appoint prison doctors paid from the local rates. This service remained localised until the 1877 Prison Act created a national prison service under central government control.
By then it had long been evident to Prison Medical Officers (PMOs) that the prison population included a higher than average proportion of the insane (Guy, 1869), a fact that is still true today (McRae, 2015); thus, a significant proportion of their duties was taken up by mental health assessments of remand and convict prisoners who, under the terms of the 1840 Insane Prisoners Act, could be removed to an asylum.
As a result of their experience, some PMOs became experts on forensic mental health (Eigen, 1995). Members of the new medical specialism of psychiatry also sought to establish themselves as experts on mental health and criminal responsibility.
Offenders could be acquitted on the grounds of insanity if the court was convinced that their free will had been undermined by disease. While such a decision was relatively straightforward in the case of the stereotypical ‘raving lunatic’, it was much more difficult in the absence of the classic symptoms of insanity, especially if the individual had apparently normal intelligence.
Part11
As psychiatrists identified more varieties of insanity, the distinctions between them gained forensic importance, particularly in the case of partial insanity, when a person was insane in relation to one issue but appeared otherwise rational.
Lawyers disputed the degree to which free will was lacking in such cases, and when Daniel McNaughten was acquitted of murder on the grounds of insanity in 1843 the issue came to a head: public outcry led the government to appoint a judicial committee to review the decision.
The resulting guidelines, known as the McNaughten Rules, stated that to establish a defence on the grounds of insanity it must be clearly proved that the individual was suffering from a ‘disease of the mind’ so that he did not know what he was doing; or, if he did, that he did not know it was wrong.
The McNaughten Rules remained the only test of criminal responsibility in England and Wales until the 1957 Homicide Act introduced the concept of diminished responsibility, a partial defence to murder which reduces a conviction to manslaughter (more on the McNaughten Rules in Chapter 3).
The incidence of both pleas has been in decline since the 1990s, and the 2009 Coroners and Justice Act amended the law of diminished responsibility to require that the defendant suffer ‘a recognised medical condition’, giving medical evidence a central role.
Part12
Although psychiatric evidence in insanity trials has been common since the nineteenth century, it was only mandated in all insanity trials by the 1991 Criminal Procedure (Insanity and Unfitness to Plead) Act (Loughnan & Ward, 2014).
There was no formal legal provision for mentally ill criminals, who were either acquitted and released or convicted and gaoled, until the 1800 Criminal Lunatics Act authorised the indefinite detention of individuals acquitted on the grounds of insanity.
A new category of offender, the criminal lunatic, was now the object of forensic interest and by mid-century their growing numbers necessitated a special institution for their secure confinement.
Broadmoor Criminal Lunatic Asylum, the nation’s first secure psychiatric hospital, opened in 1863 to provide a therapeutic regime for a patient population largely comprised of violent offenders who could be released only when medical staff were convinced, they would not reoffend.
Today Broadmoor is one of only three such facilities, the others being Rampton (1912) and Ashworth (1990), both opened as Broadmoor overspill facilities. All three hospitals were administered by central government departments, and were thus outside the National Health Service, until 2001.
Mentally ill criminals
Part13
In 1939 the East–Hubert Report recommended the creation of a special prison to provide psychological treatment designed to reduce the risk of reoffending. Special psychiatric wards were set up in prisons (Wormwood Scrubs 1946; Wakefield Prison 1947), and prison psychologists were introduced in 1950.
In 1962 Grendon Prison opened for prisoners with mental disorders considered responsive to treatment; a significant proportion of its population is made up of prisoners with personality disorders. HMP Grendon will be discussed in more detail in Chapter 19.
The concepts of psychopathy and personality disorder are linked to two longstanding areas of debate: (1) where the boundary between the bad and the mad is difficult to identify, who determines criminal responsibility? (2) since the nature of the psychopathy makes patients dangerous, should they be confined to safeguard the public? If so, where – in a prison or a hospital?
The maladaptive behaviour pattern now known as ‘personality disorder’ has a long history. Early nineteenth-century psychiatrists believed that mental illness resulted from a derangement of one of three essential faculties: reason (intellectual understanding), emotion (feeling or empathy), and will (the ability to control thoughts and feelings) (Colaizzi, 1989).
Largely because of observed cases of violence, by the late 1820s there was a growing medical acceptance that a person might have normal intelligence but a warped personality which made it difficult or impossible to resist impulses.
In 1835 the term ‘moral insanity’ was coined to describe an affective form of this disorder, in which an individual’s emotions, but not their reason, were abnormal (Prichard, 1842).
By the twentieth century the emerging discipline of criminology had embedded the concept of moral insanity in the ‘psychopathic personality’, an illness identified by Victorian psychiatrists. Its symptoms of criminality, aggression, impulsivity and lack of remorse, compounded by intelligence, made patients dangerous.
Interwar psychiatrists considered them responsible for their actions and psychopaths who committed crimes were imprisoned.
Preventive detention became an option under the 1959 Mental Health Act, which gave psychopaths both medical and legal status: ‘a persistent disorder or disability of mind … which results in abnormally aggressive or seriously irresponsible conduct … and requires or is susceptible to medical treatment’ (Mental Health Act 1959, s.4).
The Mental Health Act 1983 retained ‘psychopathic disorder’ but stipulated that treatment must be ‘likely to alleviate or prevent deterioration’. This permitted detention of remand prisoners and those with untreatable mental disorders, heralding the 1990s shift towards public protection.
The numbers detained under the legal category ‘psychopathic disorder’ were small, only 655 out of a total of 14,681 mental health detainees in England in 2006 (Forrester et al., 2008).
Part14
Policy debates about the care and disposition of mentally ill offenders were resolved in favour of preventive custody in the Mental Health Act 2007, which abolished the term ‘psychopathic disorder’ and excluded ‘personality disorder’, replacing them with a deliberately wide definition of mental disorder.
Moreover, the Act permitted detention if ‘appropriate medical treatment is available’, with no stipulation that the patient must benefit from it. Thus, patients may now be detained for public safety even in the absence of effective treatment (Glover-Thomas, 2011; McRae, 2015).
It remains to be seen whether the positive inferences of this change – improved access to assessment and appropriate treatment for personality disorder – will occur.
Given the prevalence of personality disorders in prisons, approximately 63% of the population in 2007, the development of personality disorder-specific services would significantly improve prison mental health services (Bradley Report, 2009).
This chapter has explored how mental health services have developed from ‘madhouses’ to care in the community and psychiatric wards, treating those with mental health problems in a more humane way.
Mental health treatments have developed from cold water plunges and lobotomies to psychotropic drugs and talking therapies.
However, it should also be noted that there is still controversy over the diagnosis of mental health problems (Szasz, 1961) and the increase in prescription of psychiatric drugs (Moncrieff, 2003).
Furthermore, those who suffer from mental health issues can still find it difficult to receive treatment and may still feel stigmatised due to being labelled as having a ‘mental illness’ (Corrigan, 2004).
Many who have been prescribed medication can experience adverse effects that impair their quality of life (Haddad & Sharma, 2007).
Prisons have developed from places to hold prisoners to a means of punishment and have become regulated over the last couple of centuries to the present day.
Although it appears on the whole conditions have improved for prisoners, the prison system is currently experiencing significant problems of overcrowding, stretched resources and a high rate of repeat offending.
This seems to suggest that prisons are not always effective for rehabilitating offenders and reducing recidivism. In some cases, it appears that community sentencing under the gaze of the Probation Service can be more effective than short prison sentences.
The final part of the chapter examined the legislative and medical approaches to the risks posed by mental health issues in offenders. While some degree of risk assessment has always existed in forensic mental health decision-making, late 1990s proposals linked mental health provision and preventive detention for the first time, as part of a state-led response to the notion of dangerousness which culminated in the 2007 Mental Health Act.
Personality disorders are now recognised as among the most immediate challenges facing prison mental health services.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.
Havard, C. and Watson, D.K. (2007) , Historical Overview, Mad or Bad? A Critical Approach to Counselling and Forensic Psychology. Milton Keynes: The Open University.
