by Gwen Adshead
Each chapter covers different ground, but an important theme here and in all forensic work is the common risk factors for violence. A colleague of mine helpfully describes the enacting of violence as a bicycle lock. A combination of stressors aligns: the first two ‘numbers’ are likely to be sociopolitical, reflecting attitudes to masculinity, vulnerability or poverty; bluntly, most violence in the world is committed by young, poor males. The next two may be specific to the perpetrator, such as substance misuse or varying kinds of childhood adversity. The final ‘number’, the one that causes the lock to spring open and release an act of harmful cruelty, is the most intriguing. It tends to be idiosyncratic, something in the action of the victim which has meaning only to the perpetrator: this might be a simple gesture, a familiar phrase, even a smile. At the centre of my work with offenders is always a search for that meaning, and how it may fit with the whole history of their lives, their self-narrative. Finding it can be like tracking an elusive quarry, a darting, tiny fish in a twisting maze of coral. It requires time and an opening of the mind, a willingness to look and a little light.
One of my most influential teachers and mentors was Dr Murray Cox, another medical psychotherapist at Broadmoor. He always spoke about the importance of listening out for the unconscious poetry that may be heard even from those who seem dangerously alien. A favourite example he would give came from a patient who once said, ‘I’m blind because I see too much, so I study by a dark lamp.’5 This remarkable metaphor sums up my purpose in writing this book. We can all be blinded sometimes, whether by fear, intolerance or denial. The person sitting next to me on the aeroplane who regards my patients as monsters may also ‘see too much’ when they watch the news and read the daily headlines on Facebook or in their Twitter feed. I am inviting readers to venture well below that surface level, in deep dives down to where dark stories hold much enlightenment. Together we will encounter individual people, not data points or mythical creatures, and I will show how their lives have informed mine and what they might teach us.
This won’t be easy. It takes a radical kind of empathy to sit with a man who has decapitated another person, or a woman who stabbed a friend dozens of times, or someone who abused their own child, for example. As they go through the therapeutic process, you may well ask, ‘What right do they have to emotions like love or sorrow or regret?’ (I think of Shylock crying, ‘If you prick us, do we not bleed?’) To comprehend them will require imagination, going where they walk to see what they see; it was the great oceanographer Jacques Cousteau who said, ‘The best way to observe a fish is to become a fish.’ Some things I will ask you to look at will be hard to unsee, but I know from my own experience that gaining insight into experiences that are alien to us is transformative, and I will be by your side, working to turn suffering into meaning. Chapter by chapter, as the light grows stronger, I hope the reader will be able to visualise new possibilities for acceptance and change.
Dr Gwen Adshead
NOTES
1 Some more reflections on the idea of evil can be found here: Adshead, G. (2006) ‘Capacities and Dispositions. What Psychiatry and Psychology Have to Say about Evil’, in Mason, T. (Ed.), Forensic Psychiatry: Influences of Evil (New Jersey: Humana Press), pp. 259–71.
2 From ‘Maggie and Milly and Molly and Mae’ by e. e. cummings. In Firmage, G. J. (Ed.) (1972), The Complete Poems 1904–1962. Copyright © 1956, 1984, 1991 by the Trustees for the E. E. Cummings Trust (New York: Harcourt Brace Jovanovich).
3 See Prison Reform Trust (2018) Bromley Briefings Prison Factfile: Autumn 2018 (London: PRT). Ministry of Justice (2018) Prison Receptions 2018 (London: Ministry of Justice).
4 It was nearly 5 per cent in the PRT’s 2018 studies, but the figures are rising annually. See the PRT fact sheet from April 2019 titled ‘Why Women/England and Wales’ for more granular detail.
5 Cox, M. A. (1995) ‘Dark Lamp: Special Hospitals as Agents of Change: Psychotherapy at Broadmoor’, Criminal Justice Matters, 21:1, 10–11.
AUTHORS’ NOTE
These stories are set in the context of mental health care as it is delivered by the UK’s National Health Service. As many readers will be aware, the NHS was founded after the Second World War on the principle that health care should be provided by the state and funded from the public purse, because all citizens benefit from a healthy population. But the costs of the NHS have risen as people live longer, and the techniques and medicines doctors use have become ever more expensive, so successive governments have tried to move the NHS towards a more market-based model in order to cope. Health care in the UK is becoming a commodity that people buy and sell, closer to the US model of care; more and more of those who can afford it choose to buttress their diminishing NHS access with private health insurance policies. Continued restructuring has focused on driving down costs, mainly by cutting services, so that today’s NHS delivers much less value than it used to, especially in relation to the provision of mental health care, as many of our stories indicate. References to NHS ‘trusts’ in the stories that follow signify the individual business units (similar to the US model of HMOs) that were set up in every region of the UK following a massive restructuring in 2001.
We touch on a wide range of issues relating to offending, mental health, forensic psychiatry and the treatment of mental disorders, all vast research topics in their own right. This is not a textbook or a comprehensive review, nor is it meant to be a claim to expertise in all the subjects that arise. Given the complexity of the extensive literature and debates about the human mind, it seemed best to us to offer just a few notes for each chapter with suggested reading, as well as some references for data sources or direct quotes. These appear at the end of the book and are intended as signs on a path for those who want to know more.
When the word ‘offender’ appears in the text, it is not pejorative or used to dehumanise; this is a term of law denoting people who have been convicted of a criminal offence. The word ‘normal’ also arises often, usually in quotes because it is a loaded adjective which defies easy definition in a world of billions. The authors make no assumptions about what is ‘normal’ in any categorical sense for any group of people or institution; one of the first things that psychiatrists discover in training is that ‘normal’ is rather like tofu in a spicy soup, gaining flavour from its context. Apparent normalcy may well be a veil that hides risk, as more than one of these patients I describe will demonstrate.
Another key word we have held in mind throughout the writing is ‘privilege’, in two senses. First, it is a true privilege to bear witness to people taking risks in order to share what Shakespeare called ‘our naked frailties’, and we are respectful of that. Second, privilege is a vital medico-legal concept, meaning that patient information and conversations with them should be kept for private knowledge. The duty to protect privacy in forensic work extends beyond the offenders with whom we work to their victims and both sets of families, and these stories have been constructed with honour and respect for all. It is obviously not legally or ethically possible to describe individual medical cases, but by drawing from many encounters and case studies over the years we have created composites; the eleven mosaic portraits presented here are clinically and psychologically accurate but won’t be found on Google.
Dr Gwen Adshead and Eileen Horne
December 2020
THE DEVIL YOU KNOW
TONY
‘Who wants to see a serial killer?’ We were in the weekly psychotherapy department meeting at the hospital, where referrals are discussed and allocated. Most people had taken on a new case, and we were onto the last few. There was some brief laughter in response to the chair of the meeting’s ironic query, but nobody volunteered. ‘Really? No takers?’ I was itching to raise my hand, but as the most junior person in the room, I worried that I might be seen as professionally naive or that I had a prurient interest. I could sense the invisible collective shrug of my colleagues around the table. The public, stoked by popular entertainm
ent and the media, are endlessly fascinated by those rare people who commit multiple homicides. But within my profession they generate much less interest. Rehabilitation into the community is never going to be an option for them. As one of my colleagues remarked to me, ‘What have they got to talk about except death?’
I had a lot to learn. It was the mid-1990s, and I had recently started at Broadmoor Hospital, an NHS facility set amidst rolling hills and woodland in a picturesque area of south-east England, not far from Eton College and Windsor Castle. After qualifying as a forensic psychiatrist a few years earlier, I had welcomed an opportunity to come and work part-time as a locum (or ‘temp’ doctor, filling in as necessary) at Broadmoor while I was completing my additional training as a psychotherapist. To build up my skills, I needed to spend as many hours as I could giving one-to-one therapy to patients while I was under supervision. It seemed to me that a man going nowhere would have a lot of time – and if he wanted to talk about death, well, that was on my curriculum.
It may be surprising that we were having this discussion at all. Attitudes to, and the resourcing of, mental health care for offenders, whether they are in hospital or in prison, vary considerably around the world. My European and Antipodean colleagues work in systems similar to the UK’s, where some individual therapy is offered, but many other countries have none. I’ve found my American colleagues in particular always remark on the differences. Having visited a number of different countries to observe first hand how things work, I’ve been struck by the fact that it is those that have known military occupation within the last century, like Norway and Holland, which have among the most humane, progressive attitudes to the mental health treatment of violent offenders. Some studies suggest that experience makes it easier for them to understand these fellow human beings as rule-breakers who are ill rather than ‘bad people’.
‘I’ll take the referral,’ I said. ‘What’s his name?’ I looked to my supervisor as I spoke, hoping he’d support me. He smiled his agreement. ‘Knock yourself out, Gwen.’ One of the senior doctors chipped in. ‘I saw one of these guys in prison for years. All he did was drone on and on about his art classes and how good he was at painting still lifes …’ That comment actually struck me as intriguing, but before I could ask about it, the chair was handing me the referral letter, saying, ‘He’s all yours. Tony X … killed three men, decapitation, I think. Oh – and by the way, he asked for therapy.’ The older colleague gave me a knowing look: ‘Mind how you go.’
It was only later that my supervisor, a man of huge experience, told me had only ever seen one serial killer himself, and that was for a psychiatric assessment, not long-term therapy. I was glad I would be able to access his knowledge and support as I went forward. To this day I greatly value that sense of being held by my colleagues and miss it when I’m working outside of institutional environments. I confessed to him that as a trainee, I thought I was lucky to get such an opportunity. Now I was beginning to feel a bit daunted. I went away to prepare as best I could, but soon realised that while there were a lot of lurid reports out there about serial killers, there was little available on how to talk to one, and nothing about how to offer him therapy.
By definition, serial killers kill repeatedly, but there is no official agreement about the number of victims required for membership of this macabre club. Historically, there had been quite a debate about this, with some consensus reached around three or more, although public attention has always inevitably been given to the smaller subset of preternatural individuals who kill dozens of people in separate events. It was a little disconcerting to read about the medical professionals within their number, who had easy access and the means to carry out their crimes, often going unchecked and unsuspected for years. A cooling-off period or gap between killings is also an accepted criterion, and their victims are not thought to be randomly chosen. Spree killers, who may take the lives of a great many people in one day, tend not to be included in this category, and for some reason I’ve never fully understood, neither do the politicians and leaders responsible for the deaths of thousands or even millions of their fellow men.1
From the vast volume of fiction, film and TV shows on the subject it would be easy to get the impression that killing multiple people is a common crime that’s happening all the time, everywhere. The data provide a different picture. There is evidence that serial killing can and does happen around the world, with reported instances on every continent, but even allowing for under-reporting, poor or deliberately opaque data and the ones that got away, we know that this kind of multiple-event homicide is vanishingly rare. I can’t give you definitive figures for this crime any more than I can for most other forms of violence; nothing is certain but uncertainty in this field, for a variety of reasons, from under-reporting to different standards of classification and methods of data collection over time and different geographies. A search engine query about global figures for serial killing offers more than six million articles and answers. The majority of these will agree that serial killers are overwhelmingly male and an endangered species, falling into decline in recent years; this is in line with global crime statistics of all kinds, which demonstrate a slow decrease in all violence over the last quarter-century.
One recent study which focused on the last hundred years, led by Professor Mike Aamodt at Radford University in Virginia in 2016, created a database which showed there were twenty-nine serial killers caught and identified in the US in 2015, versus a peak of one hundred and forty-five during the 1980s.2 Some FBI figures I’ve seen quoted put those numbers at a much higher level (over four thousand in 1982, for example3), which only emphasises the difficulty of data collection and a lack of universal criteria for comparison; but every source I’ve found supports the idea of a diminishing number. Some credit for this must go to improved detection and surveillance methods, and specialist units set up by different law enforcement groups to study and deter the perpetrators. Another major contributor is probably the widespread use of mobile phones and social media, which makes it much harder for people (whether victims or predators) to disappear without trace.
Law enforcement sources don’t publish country-by-country comparative lists of serial killers, but drawing from the same Radford study, the US is at the head of the pack by a considerable margin, claiming nearly 70 per cent of all known serial killers in the world, and this is borne out by other sources I’ve looked at, from Wikipedia to various journalistic pieces. By contrast, England, which comes in second place, is at 3.5 per cent, South Africa and Canada are next at about 2.5 per cent, and China, with its vastly larger population, has just over 1 per cent of the total. I don’t know why the US dominates in this way, but theories abound, from ideas about the lack of gun regulation there to their decentralised law enforcement to the dangers of American ultra-individualism. It may well be that the Americans are just better at detecting and telling us about them, thanks to a free press and a relatively open government. But the number of serial killers caught in the US per year is still tiny relative to the country’s total population of over three hundred million, and it is also dwarfed by their ‘regular’ homicide numbers. In one large American urban centre, such as Chicago or New York, four hundred murders in just a single year are considered unremarkable. By contrast, that figure represents two-thirds of the annual homicide rate across the whole of England and Wales.
At the time I met Tony, I knew that there had been a few serial killers admitted as patients to Broadmoor, people with tabloid-generated pseudonyms like Ripper or Strangler. Although the majority of homicide perpetrators admitted to the hospital had killed only a single victim when mentally ill, these few repeat killers contributed to Broadmoor’s public status as a kind of grim receptacle of unspeakable evil. I knew that reputation, and it was enhanced by the hospital’s appearance as a red-brick Victorian fortress, although when I first went to work there, in 1996, the process of modernisation had begun. I remember being struck at first by the seemingly endless doors
and airlocks and gates, which required a complex assortment of keys that had to be drawn each morning at security and attached to my person at all times by a big, heavy leather belt. Initially it was cumbersome, but I got used to it. I actually developed a sentimental attachment to the extra-large belt I was given when I was pregnant with my first child, and I have it still.
Once inside the gates, my early impression was of a university campus, with different buildings scattered about and walkways between them. There were carefully tended gardens and flowering trees. Best of all there was the terrace, which had a magnificent view over four counties. I’ve always thought it was a massive act of kindness to give those men and women a place to walk, with a perspective that invited broader thinking and hope. There were high red-brick walls that circled the perimeter of the grounds; I’ve always seen them as a valuable divider between my personal and professional life, enabling me to leave my work behind each night, to be held securely until my return.
