by Gwen Adshead
The next half-dozen sessions did not give me much optimism that Gabriel would ever be able to receive therapy of any kind, let alone EMDR. At the most basic level, he lacked the verbal range. His English vocabulary seemed to extend to perhaps one or two hundred words, repeated with dreary monotony, with the ubiquitous ‘you know’ punctuating short sentences, and shrugs or grimaces doing a lot of the conversational heavy lifting.
Our sessions continued much like the first one: an awkwardness and some minimal exchanges, mainly about daily life, which tends to be a staple of early therapy. He avoided talking about feelings at all costs, blocking any attempts to try and draw him on things that he liked or disliked about the hospital. The most emotional observation I got out of him was that he didn’t like the food. At the time, I probably attributed this to the language barrier, or even to anxiety on his part; later, I read about a personality construct with the clinical name ‘alexithymia’ (literally, a lack of words for emotions), often associated with autism and other disorders, which might have been relevant. I’d also discover that there are many patients who just need a lot of time to be able to get to the point where their feelings can be explored, and regrettably, we can’t always offer that.
I heard little about his past. We established that he was thirty-seven years old and had mostly lived in London since he came to the UK. North London? Yeah. Had he worked? Yeah. What type of work? This and that. Sometimes odd jobs in restaurants; sometimes helping some guys in the street markets. His English comprehension appeared to be much better than his ability to articulate ideas, which I’m sure is common in second-language speakers.
Often he used curse words, mainly ‘fuck’ and ‘shit’, but not directly ‘at’ anything, and certainly not aggressively aimed at me. It was like dealing with someone who has picked up a few words of a new language, including some fruity slang, and then uses them indiscriminately as adjectives: ‘the fucking table’, ‘the bastard chair’. Sometimes I felt he was edgy, even hostile in response to my questions, but he did show up to meet me each week, and generally on time. He always wore that same brown beanie hat, tugged low over his ears, no matter the temperature on the ward or the time of day.
I began to think it might not be a safe assumption to base our course of treatment on presumed trauma. His past was ‘another country’, one that he might never want to revisit. I thought about his criminal history, as listed at his trial: all the cautions, arrests and convictions he had for repeated petty crimes and minor acts of violence prior to his final, near-fatal assault on the man in the café. There might be something in there, but it was really just a catalogue, terse and unrevealing. After many weeks, a social worker colleague told me that some further records she’d applied for had finally arrived, which gave us a few more morsels of information dating back to his arrival in Britain two decades earlier. It appeared that he had originally come to the UK as a young asylum-seeker, as had many of the people from war zones whom I was seeing in the trauma clinic. Trauma might be seen as inherent to their experience; after all, they had to have a well-founded fear of persecution in order to get asylum. But the trauma clinic experience taught me not to assume anything about the meaning of this in terms of a refugee’s identity, and I saw many times how some people were made more resilient and were fortified by their ability to survive. They were the first to remind me that it was paramount not to generalise about what it was to be either a trauma survivor or a refugee. At one point, I even had various individuals in group therapy at the clinic come to me to request one-on-one treatment because they felt they had nothing in common with the other people, aside from their immigration status.
Gabriel’s notes revealed nothing specific about what had prompted him to flee his homeland, nor what he felt about it. Nothing was recorded about his family either; all we knew about his asylum application was that he’d arrived on his own, with the support of a missionary group. I saw that he had been given leave to remain in the UK, probably because he was just seventeen at the time. Sadly, if the same young boy from a war-torn country tried to claim asylum here today, I imagine he would be refused; our current government’s ‘hostile environment’ policy is pretty pitiless.
One thing that was clear, even from the scant record, was that Gabriel didn’t settle into life in the UK easily or happily. A placement was found for him in a foster home, but he repeatedly ran away. Once he turned eighteen, he lived on the streets and began to abuse drugs and alcohol, supporting those habits with theft and burglary. He was reported to be in possession of knives more than once. That wasn’t out of the ordinary for a homeless person who might need to defend themselves, but I thought it could also be an early indicator of paranoia. I was interested to read that the police had taken him for psychiatric assessment on several occasions, concerned that he was mentally unwell. But each time his behaviour was put down to drug use, and once he was detoxed and had served a short sentence, he was sent back out on the streets. He had been involved in minor episodes of violence on and off, usually scuffles with other homeless people, until the day in the café, when he committed what is known in the jargon as his ‘index offence’ – i.e. the crime which led to his detention. It is not unusual for prisoners and patients to refer to this offence as ‘my index’.
When I arrived on the ward for our seventh session, Trevor was on duty, and he didn’t look happy. He said Gabriel had been up in the night, shouting at the staff again. But now he was a little more settled, and Trevor hoped we could go ahead with our meeting as planned. He went off to fetch him, while I set up the room. When Gabriel arrived a few minutes later, I was in my seat. I smiled up at him, gesturing to his usual chair. ‘How are you today?’ As I spoke, I heard my voice bouncing across the dead air between us, a little too chirpy and upbeat, colliding uncomfortably with his apparently dour mood. He didn’t reply but slumped down, crossing his arms and drawing his brows together in an exaggerated frown, the familiar hat pulled low over his forehead.
I wasn’t especially concerned – the sullen posture was familiar enough from him, and indeed from many of my patients. I watched his sneaker-shod foot kicking irritably at the floor tile – any minute now, I thought, he’ll call it a ‘fucking tile’. But instead he said nothing. I told him Trevor had mentioned that he’d had a lousy night. Gabriel nodded and glared out of the window, brooding. Then he mumbled something rapid under his breath. I managed to catch a few phrases: ‘Bastards won’t leave – how do I sleep – stop it, I said, leave me alone!’ Quite a lot of words for him to come out with in one go, and perhaps that’s why I then made an error. I wanted to encourage him to say more and thought it would help to focus on his lack of sleep, so I put to him the most banal question, requiring only a ‘no’ or a ‘yeah’: ‘Did you manage to get any sleep at all?’
At that, his body language transformed. He snapped up straight in his chair, hands balling into tight fists, his voice resonating in the small space. ‘How can I? Fuckers want to fuck me.’ I said nothing, despite the shock of his words, and he rolled on: ‘If I sleep, they DO IT like in prison. Rape me, RAPE me. They want to make me a WOman!’ I still tried not to react, keeping my face impassive and nodding, hoping to show only that I comprehended what he was saying. He’d really worked himself up. I was hit in the forehead with some flying spittle as he hissed, ‘You know it. You a woman! You can be raped any time, any minute. DANGER! We both in danger! These people! People treat me like dirt! Get in me – get inside … make me not a MAN …’ His fist pounded the table, and I think I flinched. Then he raised his right hand, and I sensed he was going to strike me, but no, he was pointing his index finger, furiously indicating something outside the door, and I followed his gaze to the nursing station. ‘Fuckers, fucking nurses …’ As he raged, his eyes bulged and his words became less intelligible, as if they were stuck in his throat, choking him.
I was aware of feeling frightened, but I could see that he was distressed and needed to express his emotions. I tried to bring the emotion
al temperature in the room down. ‘Gabriel,’ I said softly, ‘is there anything I can do to help?’ He leapt up out of his chair and began pacing to and fro, growing more and more frantic, with more shouting and spitting, a torrent of words spilling out. I thought I heard something about being ‘fucked up the ass’, and the words ‘night’ and ‘nurse’ repeated again and again, like a furious mantra. This was a reprise of familiar accusations, his delusions of men breaking into his room and raping him. ‘No more! No more! Enough of this shit!’ In the moment, I thought I should stand up too, meeting him on his level, but it was a bad move. Maybe he thought I was trying to stop him or block him from leaving – and he shoved me hard in the middle of my chest, causing me to topple backwards onto the floor. My yelp of surprise brought the staff running.
The throbbing, shrill tones of the alarm bell echoed down the ward, just as Gabriel burst out of the interview room, casting about for something to wield as a weapon. He went to pick up a chair, but they are special heavy ones that don’t readily move, for just this contingency. In frustration, he grabbed some magazines and papers from a nearby counter and hurled them into the air, raining them down on the crowd of staff who had arrived in response to the bell. He was wrestled to the floor by five or six people; they are highly trained for such eventualities, and it took only seconds.
I dusted myself off and held back so that I was away from the restraint zone and out of Gabriel’s line of sight. I could see Trevor kneeling at his head, speaking softly to him. The alarm bell had stopped, and all was hushed now, so quiet I could make out some of the comforting words Trevor was using, the repeated ‘Okay, it’s okay, you’re safe, you’re okay, Gabriel.’ The other members of staff held his legs and arms until he stopped raging and thrashing, and when he settled enough, they took him away ‘in holds’, his arms pinned to his sides. I saw that the few other patients who were on the ward at the time quickly melted back into their rooms or were ushered away by one of the nurses. Although rare in a rehabilitation ward, these things happen, but such incidents can still be unsettling for everyone. For patients, depending on their own experience, reactions may vary from anxiety to anger to lack of interest; for staff, it will be of paramount concern not to let the episode cause an escalation in tension that might spread and complicate life on the ward.
‘Gwen, you okay?’ The nurses were anxious, fluttering around me, bringing me water and checking I wasn’t bruised or bleeding. I told them I was fine – and I really was. Mostly I felt angry with myself for not being able to help Gabriel, and I was also worried about what this incident might mean for our work together. It could be taken as evidence that Gabriel was, as some had predicted, just ‘too mentally disturbed for psychotherapy’. In addition, he might now be seen as higher risk because he had attacked a doctor, which is pretty unusual anywhere in the health service, but especially rare in Broadmoor. The most at-risk staff are probably the ward nurses, because they are a constant presence, but the majority of our patients never attempt to harm anyone who is caring for them.
The incident was nobody’s fault, but fears of accusation and blame were heavy in the air when the staff met to discuss the incident before they went off duty. Notes had to be taken and forms filled out; a formal follow-up was required. Gabriel had come into the room already upset by something, I said. My sense was that he had been sleep-deprived, agitated and fearful, and that he didn’t assault me as such; I was simply an obstacle when he wanted to leave the room. Trevor was rueful and apologetic, saying he should have anticipated a problem that day and we should have cancelled therapy – he knew his patient wasn’t at his best. I couldn’t let him take on that responsibility. I had wanted to go ahead with our session, as had Gabriel, and to my mind there had been no obvious risk.
I asked the team if anything in particular had happened with Gabriel the night before, something out of the ordinary. They didn’t think so; nothing had been reported or logged. I didn’t for a moment believe that anyone had actually tried to hurt him, but I wanted to know if there was some word or action that had triggered a memory of another night, or another time. Again, I felt frustrated at how little we still knew about Gabriel’s mind or history, but I was determined not to give up. Later, I would wish I had clarified which nurses had been on duty the night before, and would feel as though I had missed a clue.
Debate continued the next day about whether the therapy was too much for Gabriel to handle. The team psychologist suggested that Gabriel was not ready for psychodynamic psychotherapy, with its emphasis on reflection and relationships. It might be that he needed a different type of treatment. There are several types of talk therapies, each with a particular emphasis and application; all have them have value and efficacy. I practise psychodynamic therapy, an approach with its roots in psychoanalysis; as the work I have described thus far suggests, it is mostly focused on increasing self-knowledge. This comes through helping people recognise the meaning of their language or actions using the relationship with their therapist. I argued that I wanted to continue this work with Gabriel, adding that it might be harmful to him if our work was terminated abruptly. If we went ahead, we would signal that his anger was understood and might have meaning. Why take an outburst of anger as evidence that therapy wasn’t right for him, when outbursts of anger were part of the problem we were addressing?
I knew by now that ‘upsets’ like this (and they come up again in other cases I will describe) can also be turning points, leading to a discovery of new feelings and ideas that are essential to progress. I still had hopes we might eventually fulfil the original idea of readying Gabriel for EMDR. I could sense the pessimism about this, palpable in the room, but I looked to the consultant psychiatrist for support, and to my relief he said, ‘Let’s stick to the plan.’ We resolved that I would continue with the therapy for the time being, with increased supervision from, and liaison with, the ward staff. Gabriel’s medication would be increased at night to help him sleep, and I would only have a session with him if he was feeling settled on the day of our appointment.
I returned to see him the next week, and the next and the next. The sessions were slow and frustrating, and there were days when I thought maybe others were right and this man was just not ready. Gabriel could only tell me that he felt ashamed that he had pushed me and kept apologising for it in a way that was frankly distracting because it kept us focused on the event without actually reflecting on why it had happened. I tried to get him to think about what could have got him into such an angry and fearful state of mind. Did he have any idea what I may have said or done that had made him erupt? ‘Nah,’ he said, looking stricken.
After some weeks, the increased medication and possibly some good nights’ sleep appeared to have settled him. He was able to convey that his distress when he lashed out that day was not with me but instead had come from his ‘night fear’. His accusations of rape by the night staff were, I noticed, morphing into complaints about being spied on. He mentioned Michael and Joseph, the two African colleagues that Dave had talked about with me early on, and mimed how they would press their faces to the glass in the door of his room to check him on their rounds, at all hours of the night. He thought this was ‘fucking with him’ in some way, although the staff explained to him that such visual checks were required for safety. He told me that he knew their interest in him was ‘evil’, but when I asked him to elaborate, helping him by using the simplest ‘yes’ or ‘no’ questions I could formulate, he couldn’t. There was something there that was too hard for him to communicate or for me to understand.
As Christmas approached, our conversation took an unusual turn. It was mid-December, the last session before the holiday break; I would not see him again until January. We had taken our seats and were settling in when I heard the sound of singing. Some of the ward staff were practising for a carolling session that they were doing later to raise money for a mental health charity. I’d been saying something bland about the darkness drawing in early lately, when Gabriel
put his finger to his lips. ‘Sssh …’ I shut up and listened. Faintly, through the wall, came the sweet sound of voices combined in a carol. ‘All hail said he,’ they sang, ‘thou lowly maiden Mary, most highly favoured lady …’ before stopping short for someone to recover from a sudden coughing fit.
‘Right, again, once more from the top,’ called a male voice, rising above the others – that was Trevor. The choir began anew. ‘The angel Gabriel from heaven came, his wings as drifted snow …’ At that, Gabriel broke into a smile that actually merited the adjective ‘beatific’. ‘S’me!’ he said, triumphant. ‘S’me!’ ‘Oh, of course,’ I said. ‘Your name … a name with meaning.’ That touched him, I could see. ‘Yeah. Strong,’ he responded quickly, placing his hand over his heart. ‘God is strong in me.’ Next door the choir were singing another verse; they were on to Bethlehem and Mary now. A clear female voice rang out with the line ‘most highly favoured lady’. Encouraged by Gabriel’s good mood, I ventured an obvious observation. ‘A song about mother and son, isn’t it?’ ‘Yeah,’ he said. ‘Mother Mary.’
And then, to my amazement, he added, ‘I miss my mother.’ This sentiment was so fluent and so appropriately sad; any one of us might miss our far-off mother in the holiday season. This was his first-ever mention of his family to me or anyone on the staff, as far as I knew. We didn’t even know if his mother was still living, let alone his father. The minimal information I had been able to gather thus far suggested that young Gabriel might have been orphaned by war when he left Eritrea to make a new life, but was that actually the case? I would not ask him straight out, because I wanted him to enlighten me, but he lapsed into silence, head bent so that I was looking straight at the top of his worn beanie hat. A few threads of wool stood on end at the crown, like filaments from a burnt-out bulb.
