'This whole monsterisation of Broadmoor itself is a kind of crime fiction'

Psychiatrist Dr Gwen Adshead is a New Zealander who has spent decades treating Britain's violent offenders. She talks to Craig Sisterson about 'monsters', myths, and mental health

One thing Dr Gwen Adshead didn't expect when, decades ago, her interests during her medical studies began veering more towards mental rather than physical health, was that one day she'd be running a therapy group for people who'd killed a family member. In Broadmoor.

"I never, never anticipated that," says the Christchurch-born forensic psychiatrist and psychotherapist. "But 10 years of doing that was an amazing experience – actually sitting down with people and talking - and the work is to be human together in a slightly odd situation."

Broadmoor.

Each week Adshead walks the corridors of a high-security hospital bearing a name that's conjured fears and fascination across the globe for more than a century. Like Sunnyside or Seacliff in Aotearoa, Broadmoor was established during Victorian times as a "lunatic asylum" to house the criminally insane. Prison-like complexes that, for much of their lifespan, were viewed in popular culture as repositories of horror and depravity: the patients and treatments, both.

"In the 19th century a lot of countries built these asylums to put mentally ill people in," says Adshead. "They were sort of oubliettes [secret dungeons], there was this idea that we'd locate all our deviance within this group of people, then we'd physically pick them up and put them over there, and we'll know where the badness is, and we'll all feel safe."

Sitting on a rise in the Berkshire countryside about 60km outside of London, Broadmoor is one of the most (in)famous of many examples across the world. But the reality, as Adshead has experienced since the early 1990s, is quite different from the longstanding reputation.

"There's this creation of a mock Gothic narrative," explains Dr Adshead, who still sees patients, runs groups and supervises staff at Broadmoor one day a week – alongside other work at women's prisons, teaching, and court assessments – following her retirement from a full-time role with the NHS. "This whole monsterisation of Broadmoor itself is a kind of crime fiction."

Nowadays Broadmoor has 234 beds. In decades past there could be more than 700 men and women housed at any time. While many thousands of mentally ill people have been treated there, much of Broadmoor's notoriety sits with a few past patients, whose crimes are perennially recycled story after story, such as the "Yorkshire Ripper", Peter Sutcliffe, London gangster Reggie Kray, or Robert Maudsley – who some think was an inspiration for the character of Hannibal Lecter.

Broadmoor was home to some of Britain's most notorious mentally ill criminals, including London gangster Reggie Kray, pictured right with twin Ronnie. Photo / Getty Images

"There's this bizarre thing where even the local Berkshire Post published an article about Broadmoor recently, I think because there was TV programme about it, and the article was literally about an imaginary place," says Adshead, who has worked as a psychiatrist and psychotherapist at the hospital for much of the past three decades. "Nearly everybody they mentioned was dead, a couple of people had never been there at all, like Mr Brady and either of the Wests. And they always use a picture of a Victorian gate that nobody's used for 30 years."

After publishing several academic texts and more than 100 papers, Adshead has now co-written a myth-busting book for the general public that shines a light into the dark corners. The Devil You Know takes readers beyond (mis)perceptions into the realities of the treatment of violent, mentally ill offenders. It's a riveting, unflinching read that offers compelling insights.

British Member of Parliament David Lammy praised Adshead and co-author Eileen Horne for making "an invaluable and urgent case for improved mental healthcare", noting their book "could forever change the way we think about violence".

Subtitled "stories of human cruelty and compassion", The Devil You Know, says Adshead, is an invitation for readers to come and see what she sees, meet the people she meets, and see how the everyday interests and concerns of her patients may not be so terribly different from anyone else.

Broadmoor was home to some of Britain's most notorious mentally ill criminals, including the "Yorkshire Ripper", Peter Sutcliffe.

"And when they come to do terrible things, some of the risk factors that take them there are things familiar to many people," says Adshead. "Substance abuse being the obvious one."

Throughout the book, Adshead and Horne take us into the room as Adshead meets and treats a variety of mentally ill patients who've killed people or committed other grave violence. Adshead doesn't shirk from her own missteps and learnings, or the complexities of her chosen field.

The Devil You Know consists of 11 case studies of patients that some may see as "monsters".

Each is a mosaic, built from parts of real cases Adshead has been involved in or knows about. Apart from confidentiality and ethical issues, Adshead says the principle that her patients' lives are not for public entertainment, nor their victims, meant that her and Horne crafted mosaic portraits that are "clinically and psychologically accurate, but won't be found on Google.

"That's why writing it with Eileen was so important, because she's a dramatist and professional story writer and television producer," says Adshead. "So what we could do is we took tiny fragments from different people. The first one in the book is 'Tony', and he's based on cases I've been involved in, other cases I've read, real cases, but also what I've known in terms of other cases I've been involved in in terms of serial killers. We took little bits from this case, that case … I wanted to convey the journey of a man who kills repeatedly and who ends up in a psychiatric hospital. Because that's not unusual. People who are serving very long prison sentences often do develop mental illnesses while they are in prison, and if they need in-patient psychiatric care they often have to go to a high-secure hospital like Broadmoor."

The Devil You Know is a fascinating, at-times confronting read. It offers a fly-on-the-wall perspective that may challenge readers' perspectives on mental health and violence. As legendary crime fiction author Val McDermid has said, it's "a myth-buster of a book – crammed with compelling, constructive, candid and compassionate insights into the criminal mind".

Adshead, who began her schooling at St Margaret's College in Christchurch after being born in the Garden City to British parents who worked at the University of Canterbury, is something of a rarity nowadays in that she's a forensic psychiatrist (which involves earning a medical degree, then seven years of specialist psychiatric training), who is also a trained psychotherapist.

"It used to be the case that all psychiatrists trained as therapists also, but nowadays that's not the case," says Adshead. "If you want to be a therapist you have to do extra training. So I went off and did extra training on the side, which meant that I crab-wise moved sideways in jobs."

Adshead had briefly flirted with orthopaedics while at medical school, even having a "bit of a hairy time" while being on her own in the orthopaedic ward at Christchurch Hospital at night while doing her elective back in New Zealand after going to secondary school in the UK.

But she was always quite interested in psychology, in the human mind. "When I went off to train in psychiatry it was just, 'Oh, this feels right,' you know, when you're doing something you like."

It was the law and ethics of psychiatry, in particular, which drew Adshead's interest early on.

"I was struck by the fact that mental health law becomes a way to deprive people of their liberties, and often for long periods of time," she says. "And the basis of those decisions is often astoundingly subjective. We were aware of this as trainees but it was kind of scary to think you had this power to detain people. Particularly the concerns about racism, about medicalising deviance, and issues about gender; all these very interesting issues."

Along with her medical degree, Adshead completed a Master in Medical Law and Ethics. She says given her interest in those areas, it seemed "terribly obvious" she'd specialise in the management of offenders. "Forensic psychiatry is the assessment, treatment, and management of people who've committed serious violence when they've been mentally ill."

While undergoing her practical psychiatry training, which takes several years, Adshead was mentored by a barrister-turned-psychiatrist and a psychoanalyst. "So I had these two really, really interesting bosses who encouraged me to think psychologically but also legally about cases - and also ethically," she recalls. "About halfway through the training, I thought I really like all this legal stuff but what I really, really like is sitting down and talking to these people."

That led to further training as a psychotherapist, ensuring Adshead would be the one in the room with the patients, rather than a consultant who oversaw things as a case manager.

While the additional training meant Adshead stayed in junior roles for longer, early on, her hands-on experience with violent offenders led to her becoming one of Britain's leading experts in the field. She was honoured with the President's Medal for services to psychiatry in 2013.

Looking back, Adshead says that in an odd way she thinks her interest in forensic psychiatry and working with mentally ill criminals came about not just because of her interest in law and ethics, but because she saw the field as less "ethically ambiguous" than general psychiatry.

"In a sense, if someone has done something horrible, then it felt more straightforward both legally and ethically to detain them. It didn't seem an oppression to say, 'Now, Mr Thing, you've killed three people in Swindon, would you stop doing that?' Whereas with general psychiatry, if Mr Thing is behaving oddly [but not harming anyone], then why shouldn't he behave oddly?"

A tricky thing about psychiatric hospitals, says Adshead, is that in theory you are taking away a patient's autonomy in order to help them, because they lack the capacity to make decisions for themselves. Where do you draw the line?

It's more clear-cut when working with violent offenders, and reassuring, she says, to work alongside justice, prison officers and others to "try to encourage a man or woman to give up being violent and pursue something more pro-social, something richer, a different kind of life".

Adshead is aware that plenty of people see those she works with as "monsters" or "evil", but over the years she's come to think of her patients instead as "survivors of a disaster, where they are the disaster and my colleagues and I are the first responders". Most of the mentally ill people she treats have a litany of childhood traumas, five times that of the general population.

Given the link between early trauma and later onset offending, we need to do more to prevent childhood trauma, and a lot more work on parental mental health, says Adshead.

While Adshead has spent her life trying to help mentally ill people who've been violent, she says it's important to remember that "the vast, vast, vast majority of people with mental disorders will never be violent to anyone". And while patients at places like Broadmoor are often "monsterised" because of notorious, high-profile rarities, for many "there but for the grace of God" would fit.

The violent mentally ill make up a small proportion of the violence in society, notes Adshead. While there are only 1000 high-secure beds in the UK, each year there are around one million weekend assaults between young men, and more than 1.2 million domestic violence incidents reported ("and there's probably another 1.5 million that never get reported").

Adshead says that her view for a while has been that there is no "us and them" between the mentally ill and the general population when it comes to violence or criminality, and that "evil" is a kind of state of mind "that probably any of us could get into, if all the factors line up".

A Broadmoor colleague of Adshead's devised a model of a "bicycle lock", she notes, where if numerous risk factors aligned, "then we might find ourselves doing something absolutely unimaginable". What's the solution then if there's dormant violence within us all?

As Adshead sees it, there are two things that she thinks can be important.

"One, I think in schools we need to be teaching people emotion management, that when people get into their teens, we start to teach how to manage painful emotions," says Adshead. "The other thing we really need to do is to discourage the denigration of the vulnerable. I think quite a lot of violence takes place because someone who is angry or miserable and feels very small or ashamed projects all their own vulnerability on to someone who is a bit vulnerable."

The Devil You Know, by Dr Gwen Adshead and Eileen Horne (Faber, $35), is out now.