The Devil You Know

by Gwen Adshead

  On the day of my first session with Tony, I arrived early to check in with the ward staff and make sure that the room I’d booked to work in hadn’t been snaffled by someone else; as in every hospital I’d ever worked in, there were not enough therapy rooms at Broadmoor and there was always competition for space. I also wanted to set it up to my liking, with the chairs placed well apart, the patient’s by the window and mine nearest the door. ‘Never let the patient block your exit’ was a bit of lore I picked up as a trainee, and I stick to it even now. There’s also something important about allowing a respectful space for reflection between the participants; that notion of social etiquette we refer to as ‘not getting into someone else’s space’ is just as important in therapy, if not more so. I fussed about with the angle of the chairs, as if exactly the right placement might help me make a connection with this stranger.

  I felt nervous and knew I was flying by the seat of my pants. For one thing, I didn’t have a lot of information about him, beyond what I’d been able to glean from the referral letter. There was still a records department at the hospital in those days, and a clinician had the authority to walk in and request to pull files on their patient, but then, as now, there wasn’t a complete record. We could assemble a collage of their family background, education, medical history, police files, trial proceedings or prison documentation, but always with gaps. Ultimately, we knew we could only really get to know a person by speaking with them and hoping they would open up to us.

  Today, such background documentation is held on computers, not piled into dusty box files, but that doesn’t mean there’s a button to press or a code to type in that will unlock a trove of valuable material. If anything, it is harder to get useful details now, in this era of increased information governance and new legal privacy protections, than when I started out. We jump through hoops and have to rely on a range of people in different functions who may or may not be disposed to assist us. Sometimes I feel a little like one of those hapless private eyes in fiction who must manage to charm a friendly cop or otherwise shuffle around begging for reliable information in order to uncover clues. Maybe this is one reason why I enjoy reading detective novels so much in my leisure time: it is pure pleasure to sit back and let someone else do the problem-solving.

  I was not even clear about what I was hoping to achieve with Tony that first day, nor what the work would entail. How would we ever know if he was ‘better’? And what would that mean for a man who had three life sentences and was unlikely to be released until he was an old man, if ever? I was also having some qualms about ‘practising’ on another human being’s mind as part of my education. If what I was offering was pointless for him but helpful for me, wasn’t I mirroring some of his own cruelty and exploitative behaviour? I reminded myself that he must have had some need or purpose in requesting therapy, and I would have to find out what that was, even if it might not be straightforward. Deceit is a hallmark of psychopathy, which is a severe disorder of the personality that I knew was associated with serial killers. I realised it was possible Tony wanted therapy merely to help fill the chasm of time that he faced in custody. ‘If that is the case,’ I thought selfishly, ‘I won’t learn much.’ Maybe I’d been foolish to take this work on – but it was too late to back out now. Out of the corner of my eye, I could see through the reinforced glass in the door that a man was approaching, escorted by a nurse, and it was time to begin.

  ‘Mr X? Good morning, I’m Dr Adshead, thank you for coming to—’ He interrupted me, his voice gravelly and a little brusque. ‘Tony.’ It sounded like he might be anxious too. He allowed me to usher him in and direct him to the chair by the window, composing himself in a comfortable position without meeting my eyes. Gaze aversion is useful for all of us as a way to regulate intimacy, and I wouldn’t expect someone to make full eye contact at first. On the other hand, I knew Tony had worked as a waiter before his conviction, a role that required him to engage and to look strangers in the eye. I wondered in passing if he had made good tips. Was he charming to his customers? To his victims? I was conscious he might try to charm me.

  I began by running through some important guidelines for therapy in secure settings. Chief among these was the principle that while he could expect some degree of doctor–patient confidentiality, if he told me anything that suggested a risk to himself or others, I would need to share it with the team looking after him. Our work together would be part of the care that his team was providing, and I explained that I’d be liaising with those team members on a regular basis, including the nursing staff, the team psychologist and the consultant psychiatrist overseeing his care. All of this was part of an effort to keep him safe and ensure continuity. Our meeting would last for fifty minutes, I told him, and we would need to adhere to that each time we got together.

  I tend to keep to this boundary even though forensic hospitals are very different from Sigmund Freud’s comfortable consulting rooms. He initiated the fifty-minute session, or ‘therapeutic hour’, perhaps so that he could meet patients on the hour without them crossing over in the waiting room, or maybe he just wanted a break. Unlike Freud or most psychotherapists working in private practice, I don’t see people back to back in the course of my work, so I don’t need that buffer. Every day is different, but it would be unusual for me to see more than two or three patients in a day, partly because each session has to be written up in detail afterwards, and also because I have to make time to liaise with the other colleagues who work with the patients I see. I had learned by this time that the first five or ten minutes after a session are invaluable for jotting down memorable phrases or ideas that emerged in the session, while they are fresh in the mind. I don’t take notes while people are talking, not least because it can make the interaction seem more like an interrogation than a conversation; it’s also not a good idea if the patient is paranoid, for obvious reasons. Most forensic therapists train themselves to memorise their sessions. When I was working with Tony, I was still honing this skill, and I was anxious to work hard at recalling some of the exact words people used in order to retain key images, metaphors and their language of self. I found it helped me to divide the session into three chunks, to try to keep things from getting jumbled in my memory. That wasn’t always straightforward, and it would remind me of Larkin’s observation (paraphrasing Aristotle) that the novel, like a tragedy, has ‘a beginning, a muddle and an end’.

  Tony nodded along as I talked him through the preliminaries, seeming neither concerned nor particularly interested. I thought he had the look of an actor – not a leading man, more the nondescript fellow hovering behind the powerful boss’s shoulder. His hairline was receding, but his bare forearms and hands were furred with black curls, with more sprouting from the neck of his T-shirt. He was short and stocky, verging on overweight; it is difficult for our patients to avoid putting on extra pounds, as exercise is somewhat limited, the food is starchy and certain medications cause weight gain. He wasn’t showing any hostility or resistance, but after I’d finished my explanations he stayed silent. He just sat there with me for a long, long time, probably several minutes, and I wasn’t sure what to do.

  Today, I’m not sure I’d let such a silence run for so long, especially in a first session with a patient who could be anxious or paranoid and might experience it as threatening. But at that stage in my training, I’d learned that a psychotherapist shouldn’t speak first, instead letting the patient start the session as they chose. I waited, and after a bit, I found I didn’t mind the silence. Nor apparently did Tony, who sat idly picking a hangnail on his thumb, not looking at me. And yet I had a sense he was taking the time to size me up, considering whether he could trust me. Eventually, I thought of a way out. ‘What kind of silence is this for you?’ I asked. He jerked his head up, startled. Then he broke into a friendly, open smile. I could see how attractive he might be, how he would easily convince you to order the daily special or another glass of wine. ‘Nobody’s ever asked me a question like that be
fore.’

  I told him therapy could sometimes involve odd questions, trying to hold eye contact with him as I said it. His eyes were so dark they appeared almost black, as if the pupil were a broken yolk that had spread into the iris. He let his gaze drift off to one side, over my shoulder, towards the glass panel in the door just behind me, which looked out on the corridor. There were sounds of life out there, underscored by the hum of the ward TV, which was always on – usually tuned to MTV in those days. I heard people talking, a low and indistinct murmur some way off. Closer to hand, someone’s voice rose in complaint to a staff member outside, and we both listened until they moved off. Then he answered me: ‘I was thinking that it was kind of peaceful in here.’ I thought I detected the careful diction that I associate with those for whom English is their second language. ‘This ward is so noisy,’ he said. ‘Is it?’ I asked. I had the sense he wasn’t just talking about that moment, that he had a larger point to make.

  ‘There’s a man in the room next to mine who keeps shouting in the night and—’ He stopped himself, as if he needed to monitor what he said, perhaps wanting to make a good impression and not appear to be a moaner. ‘I mean, I don’t want to complain, it’s better here than in prison, but I don’t sleep well … so it’s nice to sit quietly for a bit. And Jamie, that’s my primary nurse, he said this was a good thing for me to do, and he’s a good guy. I trust him.’ I thought, but didn’t say to Tony, ‘But there’s no reason for you to trust me at this point,’ and made a mental note to talk to Jamie as soon as possible. Tony’s comment reflected how important the role of the primary nurse can be; they offer individual support sessions to their patients and usually have the best understanding of their state of mind. My work has to be integrated with the work of the nurses, who spend so much more time with the patient than I do, and I have come to rely on their observations and greatly respect their insights.

  Over time, as this case and others will illustrate, I’ve seen just how essential it is for the nurses and the therapist to work in tandem so nothing is missed – much like teachers and parents must liaise to help children develop and grow. This is not to say our patients are childish (although some seem stuck in their memories of childhood), but the demands of a secure environment inevitably limit patients’ autonomy and liberty, which can leave them feeling like children and dependent on professionals to help them get what they want.

  At no time in this initial interview did I form the impression that Tony was in the secure hospital by design, as some happy alternative to prison. The media seem eager to perpetuate the idea that criminals try to blag their way into secure psychiatric hospitals as a cushy alternative to prison, but the reality is very different. Life in these hospitals is psychologically demanding. In prison it is possible to withdraw and to some extent fade into the anonymity and monotony of routines, but in secure units choice and privacy are severely limited, and professionals like me come around all the time, asking difficult questions about mood and feelings. In fact, most offenders don’t want to be sent to psychiatric services (there’s an unpleasant phrase for this: being ‘nutted off’) because it’s stigmatising and, unlike most prison sentences, it can be indefinite.

  I asked Tony if he could tell me more about his problems with sleeping. He’d been depressed, and insomnia is a curse of anxiety and mood disorders, but I was intrigued that he’d mentioned it to me so quickly. ‘I have nightmares.’ This was an opening. Most of us don’t tend to introduce the idea of a dream or nightmare to another person without wanting to unburden ourselves. There are some entrenched stereotypes of therapists interpreting dreams to explain people’s minds to them, but the best therapists follow where the patients lead and assume that the patient is the expert on their own mind. But back then, I was like a learner driver in psychotherapy, keen to do everything by the book, and for a brief moment I thought, rather wildly, that maybe I ought to delve into Tony’s dream like a ‘proper’ analyst. Was that what he wanted? But when I asked if he could tell me more about his nightmares, Tony shook his head emphatically. Silence resumed. I sat back in my chair, trying to look relaxed and to convey with my body language that I was fine with his reticence. It is never easy for two people who don’t know each other to talk about dreadful things.

  My mind wandered to memories of other first sessions, to my colleagues and mentors discussing how to talk and listen to people who’ve killed. Soon I was miles away, only to be pulled back into the room when he spoke again. His voice had challenge in it. ‘So how does this work? We just sit here? Aren’t you going to ask me more questions?’ It appeared that he wasn’t comfortable any more with the peace in the room and was using enquiry to disrupt it. I responded that it could take a while for us to get to know each other and become comfortable, and in the meantime it was possible that silences might come and go, and could feel different at different times. I reminded him that he’d said he liked it before and asked if that had changed. ‘Now I feel a bit tense for some reason,’ he answered. I mentally punched the air at this seemingly innocuous reply, because it revealed that Tony had the capacity to notice his mental experience and could describe how it altered over time. He had also answered a direct question without defensiveness. Every time I see anyone as a therapist, I want to know, are they curious? Are they willing? Are they interested in their own mind? These were good signs.

  I knew that it was sometimes easier for people to respond to questions at the start of therapy, so I asked another one. I wanted to know if he saw any connection between his tension and the nightmares he had spoken about. He folded his arms across his broad chest, and I had the thought that he wanted to block me – he was also covering his heart, as if protecting it from some perceived threat. ‘I don’t want to talk about the nightmares. It will be upsetting for me, and I don’t see how it will help.’ Well, that was clear enough. I didn’t try to reassure him. It’s a strange paradox in psychology that reassurance can convey to a patient that the therapist doesn’t really want to hear about whatever is worrying them; this might be just as applicable in other environments – at work, in school or in the home – whenever people are in close dialogue about emotive subjects. I knew I needed to show that I was there to listen to whatever he had to say, when he was ready, even if it was difficult. Changing the subject, I reminded him I was there at his request, asking him bluntly, ‘Can you tell me, why did you want to see a therapist?’ Again, I was still finding my way in this work, and with the benefit of many more years of experience, I doubt I would ask a ‘why’ question so early, because it can feel too intrusive. But once again, he answered me readily: ‘Because I think … I know I have to try and understand what I did, and I guess that this kind of talking might help. I told you – that’s what Jamie said.’

  I used this mention of his nurse to go on and explore what he thought about the team looking after him more generally, then asked for his account of how it was that he had been transferred to the hospital. He told me he had been ten years into his life sentence in a high-security prison when he’d been attacked on a landing by some other prisoners, who called him a nonce – pejorative prison slang for sex offender. Tony stammered a little as he described to me how three men had jumped him, holding him down and stabbing him with a home-made weapon, which he later found out was a sharpened toothbrush. He had needed emergency surgery and was fortunate to survive. When he recovered physically, he became depressed, particularly as he had considered one of the three attackers to be a friend. He made a serious suicide attempt, and this led to him being diagnosed with severe depression, and ultimately his transfer from prison to hospital for treatment.

  As our first session closed, I asked him if that tense feeling had gone. He said it had, and he would be willing to meet me again, adding, ‘It wasn’t as bad as I thought it would be.’ Music to the forensic psychotherapist’s ears. Later, I sought out Jamie to introduce myself and ask him more about those sleep issues. A quietly spoken, graceful man with a warm smile, he told me he had
come to mental health nursing after being a landscape gardener, and it seemed to me his observations had the precision of detail of a horticulturalist describing his flowers. He took time to think about my question about Tony’s nightmares, adding some insight about their impact on others. ‘It’s a problem for us, because the man in the next room complains about Tony shouting out in his sleep, waking him all the time. But there’s not much we can do. There aren’t any spare rooms to move him to.’ I was puzzled by his comments. As I made my laborious way back to the admin building, airlock by airlock, gate by gate, I was struck by a sudden thought: was the man who shouted and the man who complained about the shouting the same person? Were they both Tony?

  I came away from that first encounter not knowing what to make of Tony. The received idea about serial killers is that they are all psychopaths – but I wasn’t sure if that really applied to him. It didn’t feel like it, but perhaps I might not know. The concept of psychopathy is a complex one and first emerged in psychiatric discourse in the 1930s, really taking hold after the Great Depression and the Second World War. There was a rising social concern about isolated men, many of them emotional casualties of economic ruin and war who seemed disconnected from social norms, with callous states of mind that caused them to treat others as ‘things’, instead of as fellow humans. By the 1970s, this kind of antisocial behaviour would be defined in DSM-3, the third edition of the Diagnostic and Statistical Manual of Mental Disorders, which is published periodically by the American Psychiatric Association. This behaviour is similarly described in the ICD, the International Classification of Diseases handbook published by the World Health Organization. Both the DSM and the ICD include a version of what is called antisocial personality disorder (ASPD), and most people argue that psychopathy is a severe form of this.