by Gwen Adshead
NOTES
1 Haggerty, K. and Ellerbrok, A. (2011) ‘The Social Study of Serial Killers’, Criminal Justice Matters, 86:1, 6–7.
2 Radford study: Aamodt, M. G. (2016) ‘Serial Killer Statistics’, 4 September. Retrieved from http://maamodt.asp.radford.edu/serial killer information center/project description.htm.
3 Grover, C. and Soothill, K. (1999) ‘British Serial Killing: Towards a Structural Explanation’, British Criminology Conferences: Selected Proceedings, Vol. 2, p. 2.
4 Cleckley, H. (1941) The Mask of Sanity (St Louis: C. V. Mosby Company).
5 Hare’s website: www.hare.org.
6 Yochelson, S. and Samenow, S. (1994) The Criminal Personality: The Change Process (Lanham, MD: Rowman & Littlefield).
7 Lilienfeld, S. O., Watts, A. L. and Smith, S. F. (2015) ‘Successful Psychopathy: A Scientific Status Report’, Current Directions in Psychological Science, 24:4, 298–303.
8 Bowlby, J. (1988) A Secure Base (London: Psychology Press).
9 Lifton, R. J. (1986) The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books).
10 Morton, R. J. et al. (Eds) (2008) Serial Murder Symposium 2008. National Center for the Analysis of Violent Crime, Quantico.
GABRIEL
‘A man was arrested today after a stabbing in a north London café, in an apparently unprovoked assault. His victim is in a critical condition, fighting for his life. Our reporter spoke with Mrs X, who witnessed the attack on her way to work. “I was terrified … honestly, he came out of nowhere with this huge knife … It’s dreadful the way they let these deranged immigrants into our country to run around hurting innocent people …”’ Many people would have switched off the radio there and then, whether repelled by the offence itself or by the knee-jerk racism of the woman’s reaction. But I immediately wondered about the man who did the stabbing, and whether he would eventually be admitted to the hospital where I worked, since we tended to see cases from London.
Sure enough, a few years later, I would have the opportunity to learn more about the story behind the news report of this ‘deranged’ person, a man named Gabriel, when he did indeed wind up in Broadmoor. After I took on the referral, and before I went to meet him, I turned to the records department to get a better sense of his story. Unfortunately, they had been sent very little when he was transferred – at least, there was no background information, no family history to give me a clue about his life. I found his admission photo and held it up to the light, peering at the long, thin face and fine features, the hunched shoulders and slight frame. He was frowning, his eyes wary and intense. I thought I read fear there.
The records did at least contain some copies of the medical evidence from the trial, and I was able to review several expert psychiatric reports confirming that Gabriel had been seriously mentally ill at the time of his offence. At his trial, experts for both the defence and the prosecution found evidence of an entrenched paranoid delusional system and distorted reality testing indicative of a psychotic illness. Although most people with this kind of mental illness never harm anyone, in Gabriel’s case his symptoms had tragically escalated the risk of him inflicting violence on others.1 Thankfully, his victim survived the attack and the original charge Gabriel faced was attempted murder, but the Crown Prosecution Service indicated that it was open to a lesser plea. After first insisting he was acting in self-defence, eventually he was persuaded to plead guilty to grievous bodily harm (GBH), and upon conviction the court directed that he should be admitted to a secure hospital for treatment, based on medical advice from psychiatric experts. In an ironic win in the mental health lottery, Gabriel would gain access to the kind of specialised treatment that was unlikely to be available to his victim or the bystanders affected by his offence. This would probably never have been available to him before (or unless) he had committed the crime.
As with many patients detained under mental health legislation, Gabriel’s stay in the hospital was deemed ‘indefinite’. It would depend on the progress of his recovery and professional views about whether his risk to others was reduced, with the Home Office overseeing any decision regarding his release (a responsibility that is now in the hands of the Ministry of Justice). Today, the average stay in a secure psychiatric hospital is about five years, but when I met Gabriel, it could be much longer – he might be there for ten years or more. I had just completed my training and had qualified as a consultant forensic psychotherapist, but I was continuing to work as a forensic psychiatrist, mostly evaluating people for court reports and doing research. I was also working in an NHS trauma clinic, so I split my time between there and Broadmoor. It was a valuable juxtaposition in many ways. At the clinic I found it especially useful to be able to treat refugees from different parts of the globe, which would serve me in my work with Gabriel.
In that period of moving back and forth between hospital and clinic, I also gained new insight into the prevalence of post-traumatic stress disorder (PTSD) in both patient populations. It’s part of the myth of violence that the victims are always fearful and ashamed, whereas the perpetrators are angry and callous. My experience is that there are many perpetrators who are ashamed and traumatised by their offence, and many victims who really struggle to manage their understandable feelings of rage and vengefulness. Both victims and perpetrators need help for their psychological pain; as beautifully articulated by the American philosopher/priest Richard Rohr, ‘If we do not transform our pain, we will most assuredly transmit it.’2
Among the trial documents was a statement from Gabriel’s victim, which provided a point of view I rarely get to see. The bald type on the page seemed to shimmer with the man’s anger and confusion. ‘There I am, minding my own business, waiting for my coffee, when this little black bloke starts shouting a bunch of gibberish at me … waving a bloody great knife and then he comes at me for no reason …’ His statement ended with the assertion that his assailant ‘must be a fucking nutter’. I felt the man’s distress weighting every word, the present tense revealing how ‘live’ his terror was to him. It recalled the language of some of my patients at the trauma clinic, whose experiences ran the gamut from survivors of accidents and natural disasters to refugees who were victims of human rights abuses or even torture. I hoped that alongside the medical treatment he would have for his physical wounds, he would also get help for his psychological injuries.
*
By the time I was asked to see him, Gabriel had spent many months in our intensive care unit for patients who are aggressive to others, meaning the focus is primarily on risk reduction and security. For some of that time he had to be in seclusion, the secure hospital’s version of ‘seg’ (the segregation unit in prisons), also known as solitary confinement. Social isolation is not recommended for someone who is acutely mentally ill; one judge in a recent US civil rights action described the segregation of prisoners in poor mental health as equivalent to ‘depriving an asthmatic of air’.3 I’ve studied this and given legal testimony on it, and I know there are no easy answers; its use in secure contexts is one of many ‘rock and a hard place’ ethical challenges for medical professionals working within the justice system. There is formal oversight of the use (and misuse) of segregation in the UK, from independent groups like the Howard League and the Independent Inspectorate of Prisons, and in Europe, from the European Committee for the Prevention of Torture. The American Civil Liberties Union and similar organisations are active in the US, where the application of extreme isolation in so-called ‘supermax’ prisons is controversial and the effects of total confinement are much studied.4
Eventually, Gabriel was able to move on to a rehabilitation ward, once medication had reduced his general level of paranoia and hostility. But I understood he could still be aggressive and disturbed, interspersed with periods of being depressed and tearful. He held on to a persistent belief that nursing staff were coming into his cell at night and raping him; this had also been a feature of his mental state when he was
on remand in prison awaiting his trial, and it had not abated over time, despite medication. This residual paranoia was the reason I was asked to see him.
Even before the sea changes in the NHS, and the subsequent years of austerity and increasing cuts to mental health care services in the UK, there were only two or three consultant psychotherapists on the Broadmoor staff at any one time, alongside a small group of (non-medical) psychologist colleagues. When I met Gabriel, we were serving a population of about six hundred. The grim concept of triage is a familiar one in medicine: if supplies are short, you treat the people who have the most chance of getting better. Back then, two decades ago, it was still relatively unusual for patients with psychotic illnesses to ‘make the cut’ and be offered any psychological therapy. They had long been thought to have too much reality distortion to be able to benefit from it; just as there are people who are too physically unwell to have surgery, a certain amount of psychological well-being is required for the self-reflective process of psychotherapy. Suffering delusional beliefs could also make people like Gabriel too agitated to sit in a room with someone like me for any length of time, much less an hour. Stalled in a kind of permanent fight or flight mode, he might be, as Gertrude says of Ophelia in Hamlet, ‘incapable of [his] own distress’.
Despite all this, the lead psychiatrist on the team looking after Gabriel wanted to test a theory he had. He knew about my work in the trauma clinic and outlined to me his idea that Gabriel’s continuing aggression and suspicion of the nurses at night could be PTSD. Some diagnoses enter everyday discourse because, unlike so many other medical acronyms, they are self-explanatory. We can all understand that living through certain kinds of scary experiences might destabilise your mind. The symptoms of PTSD are well known, from hyperarousal to flashbacks, nightmares and insomnia; they are a staple of many twentieth-century novels, movies and TV series. But descriptions of PTSD can be found as far back as Herodotus’ account of the Battle of Marathon and Shakespeare’s Henry IV, when Hotspur’s wife speaks of her worry for her husband, when ‘in thy faint slumbers, I by thee have watch’d and heard thee murmur tales of iron wars’. Once known as ‘shell shock’ or ‘battle fatigue’ (and the poetic American Civil War era’s ‘soldier’s heart’), the label of PTSD formally entered the medical canon about forty years ago, in response to the chronic symptoms American researchers observed in Vietnam veterans.
With so little of his history available, we had no idea if Gabriel had direct experience of war, but expanding research had shown us that PTSD affected people caught up in many other scenarios, including transport accidents, domestic violence and terrorism – virtually anything involving fear of loss, death or injury. Today’s statistics indicate that seven out of ten people in the UK are likely to experience PTSD in their lives, but thankfully most will make a full recovery within several months. The bad news is that for the few who do not, treatment of their chronic PTSD is difficult, in part because they face what I think of as a ‘survivor’s dilemma’: confronting their feelings can be too terrifying and overwhelming to bear, and yet continued avoidance makes them worse.
We had a new therapist in the hospital who had trained in a promising PTSD treatment called eye movement desensitisation and reprocessing (EMDR). I had no training in EMDR, but I knew a little about it. First introduced in the US back in the mid-1990s, it is a technique that charges our memory system with a dual task involving attentional eye movements. The therapist moves a finger back and forth in front of the patient’s face, asking them to follow the movement while remembering and describing traumatic images and the feelings they evoke. Today, it has become the treatment of choice for people with PTSD flashbacks, and numerous studies conclude that the results can be impressive.5
The EMDR therapist had the usual doubts about working with a psychotic patient, but said they were open to trying the technique with Gabriel, if I could prepare him through therapeutic conversation. I was willing to try. Times and ideas were changing, and I had seen some intriguing new research coming out of Holland that introduced the new idea of a psychosis spectrum. While individuals at the far end might be too unwell to benefit from therapy, others might respond if therapists adjusted the dialogue to keep in mental step with them and meet them where they were. Although it could happen, studies were showing that it was rare for the whole of a person’s mind to be psychotically irrational, and therefore it should be possible to reach out to a part of a patient’s mind that still had the capacity to reflect.
Before my first session, I tracked down Dave, Gabriel’s primary nurse, hoping to find out what he thought about the problems his patient had with the night staff. Dave professed himself as baffled as everyone else. ‘Gabriel’s from East Africa, and we thought he might feel some connection with Michael and Joseph because they’re from Kenya … but he shuts them out and gets hostile if they try to speak with him.’ I knew him to be a well-meaning and good nurse, but I winced internally at Dave’s assumption that his colleagues Michael and Joseph would have anything in common with Gabriel, apart from coming from the same vast continent. But it was an easy assumption to make, and I have to admit that I’ve made similarly simplistic observations myself over the years. I think any of us can use clunky language at times, even if (or perhaps because) we have completed our mandatory sensitivity training.
I was prompted by Dave’s comment to go away and better educate myself about Gabriel’s native Eritrea, about which I knew little. His country was incredibly diverse, with seven national languages and as many different religions, and it was full of internal conflicts, as well as intermittent wars with neighbouring Ethiopia. I was cautious about reading too much into Gabriel’s choice of Michael and Joseph as antagonists. He could be struggling with a mistrust of authority figures in general – which might include me. ‘How’s he doing today?’ I asked Dave, trying not to sound anxious. ‘You’re in luck,’ he said. ‘He’s in a good mood, seems willing to see you. Just don’t ask about the hat.’
So, of course, the first thing I noticed about Gabriel was the hat, a soft brown beanie pulled low over his ears, which he wore with the usual patient uniform of baggy T-shirt and tracksuit bottoms. Hats are not encouraged in the hospital as they can be a hiding place for weapons or contraband, and they can also be symbols of allegiance, sporting or political, which might provoke controversy. I was surprised that he was allowed to keep it on, but I did as I was told, trying to suppress a Fawlty Towers-style thought of ‘Don’t mention the hat!’ My curiosity about it could wait.
We met in the corridor outside the nursing station. I introduced myself, showing him my name badge, before unlocking the door to our meeting room and ushering him in ahead of me. I had been given one of the rooms nearest to the nursing station, and it had reinforced glass panels in the door. That can be a distraction for patients, but if Gabriel could see the nurses and they could look in on us, he might feel more comfortable – as would I. In addition to Dave being on duty, I was glad to see one of the health care assistants, Trevor, was keeping a watchful eye. He was a big round bear of a man, popular with staff and patients alike, and his presence was always reassuring.
Once we took our seats, I confirmed that Gabriel understood who I was and why I was there, and explained the usual ground rules. In response to simple questions, he muttered something which might have been ‘Yeah’. He had a surprisingly deep voice, I thought, in contrast with his slim build. I knew that his first language was Tigrinya, the most widely spoken language in his home country, and that although he’d been living in the UK for the whole of his adult life, his English was not fluent. This was another layer of difficulty to surmount: it’s always hard to offer reflective space to people whose first language is not the same as my own, and in my experience, therapy cannot be done through an interpreter. It’s a fact that few staff in prisons and secure hospitals are fluent in a second language – I include myself in this – and even if staffing has become somewhat more diverse over time, unfortunately there have n
ever been the resources to hire bilingual experts on an as-needed basis. In a flawed system, I try to do what is possible within the limitations and work to change the things that I can. I would speak as slowly and clearly as possible, and hoped we could find a way forward.
Gabriel readily agreed when I began by asking if I might call him by his first name, which is never something I take for granted. Next, I enquired if he had ever met a therapist before, and got only a blank look. I realised he might not recognise the word, and it occurred to me that he might not know what therapy was. I tried again. Did he have any experience of talking about his life with a doctor? ‘Yeah,’ came the throaty reply – which could mean anything or nothing. I hadn’t phrased that well. ‘Are you okay with us meeting today, Gabriel?’ He thought for a moment, wrinkling his brow as if it were a trick question. ‘S’noo,’ he offered. After a confused pause, I realised that he meant, ‘It’s new.’ Underneath that comment might have lain a little pleasure at the novelty of this encounter, which was something. We spent the rest of the time on banalities, with me asking how he was finding life at the hospital, phrasing questions in such a way that he could answer ‘no’ or ‘yeah’ as he wished. I didn’t see any point in forcing him to say more if he wasn’t ready. It was a long hour, and I left feeling doubtful – but I also knew that, as ever, I needed to sit with my uncertainty and keep an open mind, as I hoped Gabriel would too.
