by Gwen Adshead
I was asked to join the latest case review for Kezia. The team wanted some feedback, or maybe some answers. Did I have any yet? Before agreeing, I felt I needed to talk to Kezia about what had happened with Mark. At our next session, I reminded her that we both knew Jean-Paul had instigated the debate that had brought us together, and that he had suggested a new explanation for her offence. I reminded her of our first meeting, and asked if we could return to the link between her mental illness and the crime. ‘I think it was hard for you to talk about it then, wasn’t it? Would it be okay to do that now?’ She agreed, but then asked, ‘Where do I start?’ I suggested she could begin at the point where she first met Mark. As she started to talk, her account merged with the reports and witness statements I’d absorbed, and the events began to live in my mind’s eye.
After she assaulted her mother and wasn’t allowed to return home from the local hospital, Kezia had spent a miserable year ‘stuck in there’ while an alternative placement was sought. Eventually, when a hostel bed became available, Mark visited her in hospital, coming by a few weeks before her transfer to introduce himself and explaining that he would be her key worker (or case manager). He was also of Afro-Caribbean heritage – his father was Jamaican. He answered her questions and talked to her about life in the hostel, making her feel welcome. On the day of her release, he helped gather up her things and drove her to her new home. They had a good relationship from the start. He was a man of strong faith and he talked to her about a forgiving God, a concept alien to her experience, but one that was comforting to hear. ‘He made me feel home,’ she told me, and I thought her slip of the tongue might be important. In therapy, words matter, regardless of how mundane they may seem. We can all relate to an experience of saying something we don’t intend – or, as the old joke goes, ‘A Freudian slip is when you say one thing and mean your mother.’ I thought Kezia may have said exactly what she meant. In that slip might lie the meaning of home for her, whether it signified that Mark represented Jamaica, a fantasy of a father or some more abstract concept of safety and love.
It was difficult to ascertain what happened next between Kezia and Mark, or if something changed in the weeks after she moved in. She did not add much to what I already knew. She had been well when she left the hospital with Mark, even if she still felt guilty and hurt about her mother’s rejection. She joined in with activities and settled into her new room. She told me she took her medication every day, even though in the wake of her arrest some people claimed that this might not have been the case. I sighed a little, as I always do when I hear this familiar cliché about people being ‘off their meds’, as if that handily explains everything. In one of my private-eye forays to the hospital records office in search of more insight, I had also come across some photocopies of police reports, which featured among them Mark’s handwritten notes confirming that she was compliant with her meds. I found it moving to see this kind man’s large, round handwriting on the page, commenting that Kezia was ‘stable but a little low’ as the weekend approached and he went off duty.
At the end of a previous session, Kezia and I had been talking about how people tend not to use the word ‘goodbye’ when they part company – ‘including you, Dr Gwen’, she said. ‘People will say, “See you,” or “Until next time,” or sometimes just “Later” or “Bye”, when they ought to say the whole word. “Goodbye.” Did you know it means “God be with you?”’ I had made a mental note of this because it seemed so important to her, and now I reminded her about it as we got closer to talking about her crime. She said she had seen Mark on the Friday afternoon before the homicide, which took place the following Monday. ‘That was the last time you spoke before you killed him?’ Kezia winced at that, but I trusted that she knew by now that I didn’t mean for my words to hurt her. Using such direct language at the right moment can help people to speak openly about their offence, because it shows that I am ready to hear about it. I was thinking of the bicycle lock model of risk factors for violence, curious as to what the final ‘number’ was that clicked into place for Kezia on the day she killed Mark. Was it something in their last goodbye? It might have been a tiny lever that dislodged a fatal cascade.
She sat completely still, her lips pressed tight, head bent, perhaps mustering her courage. I noticed that her appearance had changed quite a bit since we began working together. She was dressed in a clean tracksuit and her hair was now arranged in neat cornrows. I told her I knew it was difficult to think about Mark’s death, but putting it into words might make it easier to understand. ‘I don’t think I want to understand more.’ She spoke so softly I had to lean in to hear her. ‘I know it happened because I’m a bad person.’ She had never voiced this sentiment before, and I echoed it, thinking it was significant: ‘A bad person?’ All along, she had appeared to accept the official judgement that she had done what she did because of her illness. This idea of fault or agency seemed like a new thought.
When she didn’t expand on her comment, I returned to my original question and asked her if Mark had said goodbye to her. Had he used that specific word? ‘No! “So long,” he said. “So long.” He repeated it twice.’ She told me that those two words and the way his voice sounded when he said them had made her feel desperately afraid. She suddenly realised that there was a hidden meaning in his goodbye: it was a reference to how long she might have left to live. Mark was giving her a coded message that he was possessed by a demon who was going to kill her, very soon. As she talked about the terror of this moment, her face flushed. ‘I stayed in my room all that weekend and said his words over and over. So long. So. Long. So long. I was pacing the floor, almost wearing a path in the carpet, and I couldn’t sleep. My heart felt like it was going to jump right out of my chest. The minute Mark walked back into the building, I was “not long” for this world. I knew I was going to die.’
She agonised over what she should do about it, and that’s when she had the idea to kill him. ‘I thought it was the right thing,’ she told me. ‘It felt like I had no choice.’ I waited for her to say more, then prompted her gently, ‘And you couldn’t tell anyone?’ My question sounded lame to my ears. She shook her head and started to cry, but collected herself soon enough, wiping furiously at her eyes. She was ready. She began to describe the day of the homicide.
‘Monday morning came, finally. I heard the door slam, and I heard Mark’s voice down below, calling out as he came in from outside. So I peeked out from my room on the landing. He was going through to the kitchen, and I knew he was getting a knife. He would stab me to death as soon as I went in there. I had to get away. I took off my shoes so I didn’t make noise on the stairs. I could see the front door, just a few feet from me. The sun was coming through the glass panes, in pink and green and yellow squares. I thought I could get out, run down the front steps and into the street, away from the danger. He wouldn’t dare kill me out there. Then Mark called out my name, asking me if I wanted a cup of tea. I had to face him. But I could never outrun a demon man. I figured the only way to do it was to surprise him, so I went into the kitchen and ran towards him, grabbing a knife from the counter, then another. I went for the demon’s eyes and throat, and then I stabbed its evil heart.’ She stopped there, winded as if she’d just run a mile quickly, and slumped in her chair, putting her hands over her face. I let her sit like that for as long as she needed to.
The shocking tragedy here, for me, was the juxtaposition of those bizarre delusions and coded messages with such familiar human responses as fear and exaggerated thinking. I’m sure most of us can recall instances when anxiety and insecurity based on fear made us invent stories about someone we cared for – the partner who gets a text from a strange number and therefore must be having a clandestine affair, or the child who is late home and must have been abducted or mugged. Those instincts combined with Kezia’s psychosis to terrible effect. It was a catastrophe, in both senses of the word: a sudden turn (or overturning) and an awful denouement.
I knew what fo
llowed from the witness statements at trial, including police testimony that was vivid in its detail. At around nine o’clock on a wintry Monday morning, the police and ambulance services were called to the hostel. The petrified staff and residents were huddled in a little gaggle outside in the cold, preferring to brave the elements rather than witness whatever lay within. The police entered the house with caution, stepping around the bloodstained prints of those who had run from the crime scene beyond. A young woman poked her head out of one of the bedrooms that lined the corridor, her name badge identifying her as a staff member. She pointed towards the kitchen. ‘In there.’ Behind her, a couple of other pale faces peeked out: two elderly women and a middle-aged man, residents she was trying to protect and comfort. ‘Blood everywhere!’ the man croaked.
The double doors to the kitchen were ajar, and when the police pushed through, they were greeted by a grim tableau. A big man aged around thirty, black, dressed in jeans and a T-shirt, lay on his back in front of the cooker in a spreading stain of blood, his sightless eyes raised to the ceiling. Kneeling beside him was Kezia, streaked in blood but evidently unhurt. She was rocking back and forth and chanting, ‘I’ve done the wrong thing, I’ve done the wrong thing.’ A kitchen knife, its long blade red to the hilt, lay beside her, and when a female officer persuaded Kezia to rise, a smaller knife was found half hidden under the body. Mark had sustained more than a dozen knife wounds and was dead before the paramedics arrived. I could feel Kezia’s anguish and imagined her crouched there, surrounded by uniforms, lost somewhere beyond reason. Truly a nightmarish scene.
Hostel staff and residents reported that Kezia was shouting as she struck at Mark again and again. She was locked in a bitter argument with an invisible opponent, using phrases like ‘Come out, come out’ and ‘In the name of Jesus’. Mark had tried to back away, and others attempted to intervene, but she was ‘like someone possessed’, as one resident had it, ‘unstoppable’. A description of her in custody in the immediate aftermath read: ‘Suspect made no sense – raving about demons, God punishing her, going to hell etc. etc.’ Ironically, this suggested to me that within her own reality, she had become the thing she most feared: a terrifying monster who kills.
There were plenty of psychiatric assessments to read: one made when she arrived at the hospital, as well as those prepared for her trial and sentencing. Colleagues who first saw her on her arrival in Broadmoor commented on how acutely ill she was, how she had talked of visual hallucinations, of shining demon eyes in Mark’s face and her belief that she was in terrible danger unless she could ‘get it out of him’. I was doubtful she would remember any of this, but I asked, ‘Do you recall what you said, what you felt about yourself, when you first came here?’ She met my gaze. ‘I was bad. A bad person. I ought to be punished. I ought to have died.’ I did not try to reassure her, but I did gently point out that the court’s verdict was that her illness was the cause. I reminded her again that she had told me as much when we first met.
‘I know,’ she said. ‘But I can’t – I just – I have to put it behind me and move on …’ She had her arms crossed, hugging herself as she rocked back and forth, repeating ‘put it behind me and move on …’ like a mantra. It was then that I felt the sleepiness return, really overwhelming me now, as though my consciousness had been blanketed by a heavy, suffocating force. I fought and lost, and I feel sure I was asleep for at least a minute. ‘Are you all right, Dr Gwen?’ Kezia tapped on my shoulder. She was peering at me with some concern. Was it my imagination or was her expression critical? Honesty is always the best policy at such awkward moments because it demonstrates a commitment to look at everything that happens in the room. I told her that I didn’t know what had come over me then, but it felt as if my mind had switched off for a minute.
‘I wish I could switch mine off too,’ she said. ‘I don’t like having thoughts about what I did to Mark.’ ‘You’re afraid to think of it?’ I asked, my mind going to Macbeth and his haunted line, ‘I am afraid to think what I have done.’ ‘Yes,’ she said. ‘If I think about it, I’ll know the truth. I’m a bad person. It was not my sickness, it was me doing evil.’ What did she mean by evil? I had to ask. She looked a little confused. ‘Well, Jean-Paul … he thought maybe I killed Mark because I had feelings for him. I mean … boyfriend kind of feelings. And if I did, then that’s evil, that’s the devil in me for sure. Isn’t it?’ So much was interesting in that thought, but I wanted to explore the notion of ‘boyfriend feelings’ first. I asked if she thought Jean-Paul had been correct. She frowned. ‘I don’t think so. I’ve never had a boyfriend, though, so I really don’t know.’
That comment stunned me with its simple sadness, though I think I was able to keep my face neutral. I was acutely awake now, aware that a new thought was forming in Kezia’s mind, something I needed to pay attention to and unpack with her. She went on, a little haltingly but determined. ‘I thought if Mark … I mean, Mum would never tell me about my dad, so I was thinking maybe … he might have looked like Mark. Or what if Mark maybe even had the same father, back in Jamaica, and we were related?’ A familial attachment, rather than a romantic one. I pressed the point. ‘Do you think you were jealous of Mark?’ She thought about that and then said simply, ‘I was sad when he went away.’ ‘Went away?’ I echoed, thinking she was referring to his death. ‘At the weekends … He went off home at the weekends and there was nobody to talk to.’
Another possible meaning for her attachment to Mark was starting to emerge. Her sense of rejection by him when he went home to his family at weekends had stimulated an older memory of being left behind as a child when her mother went to the UK, coupled with other painful ‘leavings’ – the loss of her homeland a few years later, the loss of her grandmother and the aching loss of a father figure she’d never known, whom she wanted to imagine as a kindly Jamaican man like Mark. The psychological pain of separation, migration and bereavement can be agonising, but these aspects of her life may have been overlooked or at least underweighted when Kezia first became mentally ill.6 The periodic loss of her mind (breaking with reality) due to her illness added an extra psychological load: for her, leaving and being left meant both love’s removal and mental chaos.
At some point, her internal fear of being left alone became an external one of being attacked. She had been struggling with terror for who knows how long. What an overpowering burden this must have been. For the last few minutes of that session we sat together without speaking, which can be as important as any dialogue. It was a companionable silence, as if we had endured and survived something together, which I suppose we had. When I left her that day, we both said, ‘Goodbye,’ being formal and careful with the word, as if we were exchanging a gift.
In my supervision I had a lot to discuss, starting with my baffling loss of consciousness. It wasn’t something my colleague had direct experience of either, and I can say that in the thirty years since, I think it has happened to me with only one other patient, a man whom I knew had a history of depression and suicidal ideation. It is unusual for therapists to become sleepy in sessions; generally, it’s not boring or soporific work. If it does happen, we are trained not to ignore it, like any other sensation that might arise. I was counselled to interrogate the feeling as I might any other emotion that came up in sessions.
In the weeks following Mark’s death, Kezia had on more than one occasion expressed a wish to die, and this led my supervisor and me to think about whether the suicidal thoughts in her mind might be too awful for the ‘model patient’ to allow into her consciousness. We began to formulate the idea that she had projected those feelings into me. When therapists mirror and identify with their patient’s experience like this, it is called ‘projective identification’, meaning the therapist’s mind is resonating with a patient’s displaced feelings. At a superficial level, this is similar to the idea of an infectious mood. When we are trying to empathically connect with our patients, some of the more atypical aspects of their mental experiences m
ay be transferred. In conversation with my supervisor, I found myself saying that I felt like I was ‘drowning’ as I struggled to make sense of Kezia’s mind. After some discussion, we both recognised that this could be a response to suicidality in my patient. Kezia’s conscious mind might be trying to drown out her liveliness, and with it her pain, like a ‘big sleep’, to use Raymond Chandler’s striking euphemism for death.
In our next session I tried to explain something of this to Kezia, but when I couldn’t get my point across, I came right out and asked if she had ever felt suicidal, which she promptly denied. I was mindful of her evangelical Christian background: she may have been raised to think of suicide as a terrible sin, which might make it doubly hard for her to talk about it. But now that I had aired the subject, I noticed that there was a change of atmosphere in the room, as if I had surfaced into fresher air. In future sessions, I would still fall asleep from time to time, and Kezia would wake me up. She would always ask me what I thought it was that she didn’t want to think about that day. It seemed she had not only grasped the idea of projective identification, but she quite liked it. Eventually, I would return to the theme of suicide, and we were able to talk more about it. My brief unconscious episodes faded away, and together we explored the metaphor of ‘dropping off’, as if from a cliff of consciousness, and discussed whether both she and I were in less danger of that now. We agreed that if the idea of suicide was out in the open as something we could both think about, then perhaps I could stay awake and she could stay alive. It was such a valuable lesson for me about the subtle and surprising ways human beings can project and share strong emotions, especially painful ones of grief or loss.
