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Book Review   |    
Managing High Security Psychiatric Care
Bruce Swartz, Psy.D.
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.3.396
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edited by Charles Kaye and Alan Franey; Philadelphia, Jessica Kingsley Publishers, 1998, 302 pages, $39.95 paperbound

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In Great Britain the notion that individuals who commit violent crimes and also suffer from mental illness are entitled to treatment in a psychiatric facility rather than imprisonment originated 200 years ago. In 1800 James Hadfield was found not guilty by reason of insanity following his attempt to kill King George III. The court ordered that Hadfield be held in strict custody under humane conditions until "His Majesty's pleasure was known."

Sixty-three years later saw the opening of Broadmoor Hospital, the first of Britain's three currently operating institutions for the criminally insane. Three additional facilities were eventually constructed to meet the growing need for secure psychiatric care. The 1959 Mental Health Act deemed these facilities "Special Hospitals" for individuals in need of "treatment under conditions of special security on account of their dangerous, violent, or criminal propensities." The patient population included those suffering from mental illness, mental retardation, or severe character disorder.

This book documents the brief but significant impact of the Special Hospitals Service Authority (SHSA) between 1989 and 1996 in its mandate to bring about vast organizational and cultural change that essentially elevated the Special Hospitals from custodial to treatment environments. The book's editors, Charles Kaye and Alan Franey, played significant roles in the change process, the former as chief executive of the SHSA and the latter as general manager at Broadmoor Hospital during this crucial period.

Contributors—mental health system and hospital administrators, psychiatrists, nurses, and a hospital chaplain—paint a grim picture of life inside the walls of the institution before the SHSA's emergence. Patients were locked in their rooms through the night with a chamber pot to be emptied the following morning in a ritual graphically termed "slopping out." Methods of physical control, including seclusion, mechanical restraints, and excessive medication, were commonly used. Staff were members of the influential and security-minded Prison Officers' Association. Military-style uniforms highlighted by peaked caps reinforced an atmosphere of authority and control to the exclusion of concepts such as individualized treatment planning and rehabilitative therapy.

The book painstakingly documents the SHSA's evolution over the course of its seven-year existence. The capital improvements, policy initiatives, multidisciplinary treatment concepts, and educational opportunities detailed within embody Mr. Kaye's firmly held belief that "dangerousness is reduced as progress is made towards stabilisation and recovery, and treatment is thus part of security." I came away from this book with a profound respect and appreciation for the contributors' accomplishments in the face of a deeply entrenched culture from within and a fiercely unsympathetic view of the patients.

The organization of the book makes it difficult to obtain a clear sense of the chronology of how the change process unfolded over time. Also, more careful editing might have diminished the reader's experience of traversing the same territory over again. Yet Managing High Security Psychiatric Care is an informative book that accomplishes its objective of chronicling how enormously complex systems of care can evolve to better address the needs of patients when the political will and financial resources are present.

Dr. Swartz is a staff psychologist at Boston University Medical Center.

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