by Gwen Adshead
In the weeks that followed, the acuteness of his grief receded, and Gabriel became open with me again. He could talk to me about how disturbing the call with his mother had been and why. As his ideas about the staff and their poison and witchcraft diminished, something new emerged. Gabriel wanted to ask me if I thought his mother might have the same fear that he did. Recalling the images we had looked at together, and the way we’d visualised fear in the body, he thought she may have felt her fear in her throat. He asked me if that could be what made her voice sound different. I said I didn’t know, but I suggested that perhaps we could try to arrange for him to talk to someone else from the Eritrean community – I was thinking about contacting non-profits or his original church group, since I knew we didn’t have that resource available in the NHS. Perhaps there was someone who could help explain what his mother might have experienced since he had left. If we could find the right interlocutor, they might even assist him with the dialect issue on the phone ‘next time’ … I trailed off, knowing my colleagues wouldn’t want me to suggest he have another call with his mother anytime soon. I thought that it might be something Gabriel would be able to revisit someday, when he felt ready. The period of mourning had been painful for him, but it had grounded him in emotional reality: his grief, unlike his fear, was real and justified.
I started to consider whether he could begin EMDR therapy, but others on the team looked dubious when I suggested it because the process involved holding frightening images in mind and going over and over the events he’d described to me. Although he’d proved that he could speak about these things, EMDR still might not be right for him; it could be too stressful. People were feeling bruised by the disappointment of that contact with his mother and were upset that an intervention we had all supported had caused him such distress. I explained how my experience of Gabriel during our ‘lamentation sessions’ suggested to me that his mind had changed at a deep level. Instead of fleeing from past trauma by reliving his memories in the present and locating his terror in strangers, he had allowed himself to grieve for his lost father, his lost home and his lost life as an ordinary human. I thought that a slow, gentle course of EMDR, with the right support, might give him more belief in his capacity to be sane, which would be a valuable outcome. The contact with his mother had been disturbing to Gabriel, it was true, but in more recent months he had not lashed out at anyone verbally or physically. Trevor and Dave, who experienced daily how Gabriel had benefited from therapy, also had some positive feedback, saying that the two night nurses, Michael and Joseph, had reported a much better interaction too.
When we next met, I explained EMDR to Gabriel in the plainest terms I could muster. I told him everyone on the team was aware that he had shown colossal courage and that we had all noticed a positive change in him. What did he think? I thought about the melon splitting, the fire in the sky and his lost father, standing by his mother in the sunshine with his musical instrument. Could Gabriel bear to look inside his own mind and work with those images? He reached under his beanie and scratched his head, and then, to my utter astonishment, pulled his hat off – the beanie that I had not been allowed to ask about at first and which I had effectively forgotten about all this time because it was out of bounds. Across his brown scalp and through his black hair ran a big white scar, looped like a rope across his ear, the tip of which was missing. By then I may well have seen or heard some reference to this from a member of staff, but I’d always respected Gabriel’s wish not to speak about it with me and to wear his hat. I’m sure I was always curious about it, but I was gradually becoming able to let things happen in their own time – and even if I had known that the scar existed, it wasn’t for me to ask him about it. I was far more interested in why and when he might choose to show it to me.
When he did, in that moment I understood that he was filling in an important gap in his self-narrative for me, indicating a new level of trust: his neighbours and his father were not the only ones who had suffered at the soldiers’ hands. But he had survived. Here was a manifest reminder that fear and trauma have to be transformed, or they will stay in the mind like an unsheathed knife, a real and deadly blade moving in unreal time, transmitting pain to others. For once, I was the one without words. I kept my eyes on Gabriel, waiting to hear what he was going to say next. He twisted his hat in his hands, then told me that he felt strong, like his name. He thought he could do what I’d suggested. ‘I think so too, Gabriel,’ I said with a smile. And I meant it. It was time. But I had to ask him one more thing: ‘I wonder what it was like for you to take your hat off for me just now? It’s the first time you’ve done that.’ He shrugged. ‘I was cold before.’
He had a long road ahead, but I had faith that EMDR might ease his symptoms and could even make it possible for him to progress to a medium-secure unit, where people who do not pose a ‘grave and immediate danger’ to the public are treated. As it turned out, he stayed on in the hospital for years and became a kind of elder, seeking to support new admissions, especially younger black men. While the EMDR may well have worked to release him from the pain of his past trauma, he seemed to be stuck at Broadmoor because there were no spaces in the medium-secure units, which were – and still are – always oversubscribed. I used to see him around now and then, long after our therapy ended. He would always greet me with a wave, and I noticed he’d given up wearing his beanie, most days.
NOTES
1 Taylor, P. and Kalebic, N. (2018) ‘Psychosis and Homicide’, Current Opinion in Psychiatry, 31:3, 223–30.
2 Rohr, R. (2008) Things Hidden: Scripture as Spirituality (Cincinnati, OH: Franciscan Media), pp. 24–5.
3 Federal judge T. Henderson in Madrid v. Gomez, 889 F. Supp. 1146, 1265 (N.D. Cal. 1995)
4 See valuable work by Lorna Rhodes (Total Confinement, University of California Press, 2004) and Craig Haney (‘Restricting the Use of Solitary Confinement’, Annual Review of Criminology, 2018, 1, 285–310).
5 van Schie, K., van Veen, S. C., Engelhard, I. M., Klugkist, I. and van den Hout, M. A. (2016) ‘Blurring Emotional Memories Using Eye Movements: Individual Differences and Speed of Eye Movements’, European Journal of Psychotraumatology, 7, 29,476.
KEZIA
I loathe being late at any time but especially when I have a big day ahead. A new case was preoccupying me as I drove fruitlessly around the hospital lot searching for a parking space. I was full-time at Broadmoor now, having qualified as a forensic psychotherapist a few years earlier. My role in the rehabilitation ward involved working with between fifteen and twenty male patients with varying mental health needs, but I’d just been asked to see someone on the female ward, a young woman called Kezia. There were far more men than women in Broadmoor, reflecting the fact that our prison population is overwhelmingly male and many more men than women are violent. I did not often get called upon to work with women there.
During my days in the trauma clinic, I’d become interested in whether exposure to trauma might be a risk factor for violence in female perpetrators. I’d published one or two papers on this theme, and Kezia’s case sounded like it might resonate with some of the ideas I’d been exploring. But from what I could gather, her situation was complicated, for the staff as well as the patient. Officially, supervision is mandatory only during training, but I’d made a point of speaking to a colleague in advance, putting in place some support from them if I was to see Kezia regularly.
I slid my car into a spot at least ten minutes’ walk from the staff entrance, just as the heavens opened for a heavy downpour. I realised I didn’t have an umbrella and would have to make a run for it. As I went through security, the image I presented was not an elegant or a dry one, and I was grateful when one of the staff took the time to get me a bunch of paper towels. He did his level best to keep a straight face as he checked my ID, and let me through with a cheery, ‘Lovely day for it, Doctor!’
I made my way to the admin building, swabbing at my wet hair while juggling keys and bags to wrestle wit
h the series of gates and doors leading to my office. After checking my diary and messages, I caught the last part of the morning staff review, which alerts us to any significant events from the night before and gives the current state of play in different areas of the hospital. I was just in time to catch the tail end of a discussion about ‘a spoon lost on the admission ward’, which might sound amusing, unless you know that a spoon in the wrong hands and the wrong state of mind can become a weapon. Grabbing a notebook and pen, I headed off to the women’s wards to see my new patient.
Today, Broadmoor is an all-male facility, but at that time there were still a hundred or so female patients. A move had begun to decommission some high-secure services and create more medium- and low-secure psychiatric units for both males and females around the country, which would be provided by both the NHS and the private sector. I’d worked in one of the first of these, in south London, before I came to Broadmoor. Due to greater need, the initial wave of new facilities had been for men. Now medium-secure female units were being phased in as well, and the plan was that all the women held in Broadmoor, many of whom had been there long-term, would gradually be transferred out, so that within a few years our women’s service would close. Kezia was meant to be part of the first group to move on, but just at the point when she was considered ready, a concern had arisen about her original motives for offending, and how that might affect her future risk. Her clinical team thought someone from our psychotherapy service should assess her to see whether some therapy sessions might help.
I arrived on the women’s ward with a few minutes to spare, and as usual I went to check in with the nurse in charge of the shift. I was glad to see it was Mary on duty; we knew each other, and she gave me a friendly wave as I signed in on the wall chart. She was ‘old Broadmoor’, a psychiatric nurse whose father, mother and extended family had all worked there and who knew the place like a groundskeeper knows his garden. She had a phone jammed between her shoulder and ear, finishing a call as she pushed a folder towards me – Kezia’s medical notes, where everyone on the team would write something about their contact with her. The entries didn’t tell me much about her state of mind, mainly providing brief glimpses of the mundanity of life on the ward: ‘Kezia ate a good dinner’; ‘Kezia went to education this afternoon’; ‘Kezia was compliant with her medication’.
I waited for Mary to come off the phone, wanting to ask her for her view of my new patient; we who helicopter in and out of life on the ward depend on and greatly appreciate the insights of our colleagues ‘at the coalface’. But Mary didn’t have much for me, shrugging as she admitted, ‘She’s a bit hard to read … A model patient, you know.’ I made a face, and we both laughed at the hospital shorthand: the model patient is the one you watch out for most. I thought she might also be reminding me not to take this at face value. ‘I wouldn’t have thought she needs therapy myself,’ Mary was saying, her tone deliberately bland. ‘But then she’s not my patient. Jean-Paul would know more.’ She flicked her eyes over to a colleague standing in the doorway, a tall, slim young man I’d not met before who was busy chatting with two older patients. I planned to catch up with him later. Now it was time to meet Kezia.
She was waiting for me in the corridor, and I smiled and held out my hand as I walked up to her. She smiled back, immediately making good eye contact. I introduced myself and led her to the interview room I’d booked. The chairs were not uncomfortable, and though the room was small, the window looked out over the trees to the hills beyond and the ceiling was high, giving a feeling of space. I’d seen her admission photograph, taken around the time of her trial ten years earlier, when she was in her early twenties. To me, it brought to mind a school photo of a squirming child forced briefly to sit still, with hair combed neatly and white blouse buttoned high at the collar. Now a wild tangle of tufts and curls formed an uneven black halo around Kezia’s head, and a jolly cartoon unicorn decorated her faded T-shirt. Her shapeless leggings were rucked and stained, and she wore bright-pink fluffy slippers on her feet. She had the dazed appearance of someone who had just rolled out of bed, but it was immediately interesting to me that she had been on time, ready and willing to attend our meeting. It might mean that she was agreeable to the idea of working with someone like me and understood why I had come.
Kezia had been admitted to the hospital ten years ago, shortly after her arrest on a potential murder charge involving the death of a male care worker, Mark, who was working in the rehabilitation facility for people with mental illness where she was living at the time. She had a history of paranoid schizophrenia, with vivid auditory and visual hallucinations. When the police arrived, she told them that Mark was a demon and was ‘trying to possess her brain’, so she’d had to kill him. As they took her into custody, Kezia insisted she could still hear the demon’s voice taunting her. She lashed out and kept shouting at some unseen figure, until the police hastily arranged for her to be assessed by a local psychiatrist, who referred her to Broadmoor. There she had remained as she awaited trial, and she never left.
At her trial, the psychiatrists who gave evidence had been unanimous that Kezia was acutely mentally ill at the time of the killing. Eyewitnesses spoke of her disturbed mental state, and evidence of recurring bouts of inpatient treatment and medication was presented. She pleaded guilty and was convicted of manslaughter, an offence which in English law is differentiated from murder in terms of the intention to kill. Kezia’s intention to kill was thought to be diminished by her mental illness at the time of the offence, and so she was convicted of a slightly less serious crime, similar to the idea of second- or third-degree murder in the US. In English law, such a defence can only be raised in murder cases, and judges have discretion over the sentence passed. Many people like Kezia do go to prison and serve long sentences there, but because there was good evidence that she was mentally ill at the time of the offence, the judge opted to send her to a secure hospital instead, following the recommendation of expert witnesses.
The psychiatric formulation (the medical explanation of her case) was quite straightforward. Kezia’s fatal violence was driven by the paranoid delusions that were a recognised symptom of her severe mental illness. She had not had a sane motive to kill Mark; it was her illness that was to blame for the killing, not Kezia. The psychiatrists who had looked after her over the years agreed on this narrative. They assured her she was not to blame, and if she kept taking her medication, her mental illness would not recur and she would not be dangerous to others. By all accounts, she was compliant and accepting of this explanation and had never been at all difficult or rude. When a place became available, the clinical team applied to the Home Office for permission to transfer Kezia out of the hospital to one of the new medium-secure units. In time, it was possible that she might make further steps in her rehabilitation and even return to community life.
Then Jean-Paul sounded a note of alarm. He had not been at the hospital for long, having come from working in general psychiatric services, but he had quickly formed a good rapport with Kezia and became her primary nurse. The primary nurse is an important supporter of and advocate for their patients, and Jean-Paul had initially been positive about her proposed transfer. However, at a team review of her case, he outlined a concern that Kezia was becoming too attached to him. He was getting the impression that she felt jealous if he spent time with the other female patients on the ward, and this had prompted him to ask Kezia for more information about her relationship with Mark, her victim, who had also been her care worker. Not all nurses would do this, but it’s certainly not forbidden or discouraged. I imagined Jean-Paul was curious and eager to help her.
He reported to the team that Kezia had indicated to him that she had been in love with Mark, and possibly jealous of him as well. It made him feel uneasy to think that jealous impulse could be activated again if she became as attached to him or any other male carer. What if she might actually be ‘bad, not mad’? Borrowed from a description of Lord Byron (‘mad, bad and
dangerous to know’), this is somewhat clichéd shorthand for a major academic debate in my field. It is the kind of dualistic thinking we find in relation to other complex philosophical questions: for example, the well-worn nature or nurture question in mental health or discussions about sex and gender. I think such binary arguments dodge complexity and seem to be an attempt to prevent us thinking about what it takes to live together in a group, in terms of our culture, our habitat, our norms. I am reminded of a wise observation, often credited to Carl Jung, that ‘thinking is hard, that’s why most people judge’. I knew the temptation. Like Jean-Paul, I had come into the profession with a lot of learned theory and youthful assurance, giving rise to a jagged kind of judgement that had to be gradually sanded down over time. Working with Kezia was an important marker on that journey.
The referral letter I had read had been frank about the problem Jean-Paul’s report had caused within the team: some people were inclined to dismiss the nurse’s anxiety, but others were concerned that Kezia might present a risk that couldn’t be managed with medication. It could be that they’d overlooked something important for the last decade, and that this might even lead to a challenge to her original conviction and another trial. The psychiatrist co-ordinating her care (the responsible clinician, or ‘RC’ in hospital jargon) told me he was sceptical, but the anxiety was enough to make him put the brakes on Kezia’s transfer and ask for a psychotherapy assessment.
