The Devil You Know

by Gwen Adshead

  As the eleventh anniversary of her offence came around, Kezia and I reflected on the emotional importance of the event together. She was tearful in these sessions, and I felt tearful too, but I didn’t think this was a projection on my part, only a natural human resonance with the tragedy of what had happened in her life. The work I do often makes me sad. I doubt I’ve worked with many patients with whom I’ve not experienced some kind of sorrow, especially when we’ve got to know each other over time, in long-term therapy. There aren’t any rules for therapists about how to handle this, other than to make a judgement specific to the patient and to bear in mind that trust must be established before certain kinds of communication are possible. I had enough experience by the time I worked with Kezia to know that sharing grief in treatment can occasionally be helpful, but knowing quite when to do so is part of the art of the work, which is new every day.

  Ultimately, all I do in therapy is in service of the patient and the work; it’s not mutual or about me. This means that sometimes, letting my sorrow be seen is important to the patient; more than empathy, it is a form of witnessing and respecting their lament, what they’ve been through. I might also say, as I did that day to Kezia, that I am conscious of how sad I feel listening to them. With her, I added, ‘I can see why this is distressing for you,’ which led us into a deeper discussion about the meaning of feelings. I asked her about the demon she imagined had taken possession of Mark and threatened her life, and how she felt about it now. She told me she thought it was maybe located inside her, not Mark, like a ‘normal demon’. ‘A normal demon?’ I asked. ‘Yes, like … grief or anger or sadness …’ she sighed. ‘You know … the kind we all have.’

  I felt I was ready to report back to the clinical team. Our work together had convinced me that the original understanding of Kezia’s offence was sound: that she had been mentally unwell when she killed Mark and that her actions were motivated by her delusions rather than jealousy. I stressed that it was also important to realise that Kezia’s violence was influenced by her unresolved feelings of loss. In future, it would be important for those working with her to think in a careful and nuanced way about her need for close relationships and how they related to her survival. She was so sensitive to loss that any sense of rejection or feeling of abandonment might cause her suicidal feelings to return, even if she managed to mask them under her placid, ‘model patient’ exterior. This could make her risky to herself and others.

  I thought all this made perfect sense, but I could see that some of the people in the review session looked bemused. I had the impression they felt I was over-thinking things, even if they were being nice about it. Someone asked if I thought we could still move her on to the medium-secure unit. Yes, I said, but it was important that professionals working with her there were encouraged to look beyond the labels of ‘schizophrenia’ or ‘psychosis’ or ‘homicide’ to see her grief, which she might still need help to think about and work through. I was surprised not to see Jean-Paul at this meeting, as Kezia’s primary nurse, but Mary told me he had gone. He’d decided ‘Broadmoor wasn’t his kind of place’, she said. ‘Too stressful.’ She gave a disdainful sniff at her colleague’s lack of persistence, as if he’d failed a test of loyalty. I wasn’t all that surprised; by now I knew this kind of turnover wasn’t unusual for mental health workers, who have long had higher rates of burnout than any other medical staff in the NHS, which in turn are significantly higher than in any other white-collar profession. This was once reflected in their compensation, but austerity cuts have put an end to that.

  That wasn’t quite the end. Kezia’s transfer process would take nearly another year, so I offered to keep seeing her, not least because I was concerned that leaving Broadmoor might be another big loss for her, after so many years there. In a sense it had been her most secure home, or her ‘stone mother’, which is a twentieth-century idea about long-term residential care. We continued to talk about the long-term effects of loss and grief on a person’s mind, and how sometimes we have to lament for what we have done and what is lost in order to start afresh. At our last session, Kezia gave me a card she had made for me and cried when we said goodbye. This time I made an effort not to do the same but to share with her my respect for her hard work and my hope for her future.

  *

  It was nearly a year later before I had reason to return to the female ward to see another patient. The plans for closure of the women’s service were advancing by then, and I asked Mary, still a permanent fixture in the ward office, if she knew how some of the women who had already moved on were doing in their new home, including Kezia. ‘I went up to one of her case reviews in the new unit. She’s doing fine. Just fine. In fact, she asked after you. Told me you used to fall asleep in her sessions sometimes … is that true?’ I ruefully confessed. ‘Not quite the model therapist, are you?’ she teased. ‘You’re right,’ I told her, but maybe it was for the best. To be a model anything is a little too lifeless.

  NOTES

  1 Adshead, G. (1994) ‘Damage: Trauma and Violence in a Sample of Women Referred to a Forensic Service’, Behavioral Sciences & the Law, 12:3, 235–49.

  2 See Halvorsrud, K., Nazroo, J., Otis, M. et al. (2018) ‘Ethnic Inequalities and Pathways to Care in Psychosis in England: A Systematic Review and Meta-Analysis’, BMC Medicine, 16, 223.

  3 Read, J., Bentall, R. and Fosse, R. (2009) ‘Time to Abandon the Bio-Bio-Bio Model of Psychosis: Exploring the Epigenetic and Psychological Mechanisms by Which Adverse Life Events Lead to Psychotic Symptoms’, Epidemiologia e Psichiatria Sociale, 18, 299–310.

  4 Enoch, M. D. and Trethowan, W. H. (1979) ‘The Othello Syndrome’, in Enoch, M. D. and Trethowan, W. H. (Eds), Uncommon Psychiatric Syndromes (Bristol: John Wright & Sons Ltd).

  5 See United Nations, Global Study on Homicide 2013 – Trends, Context, Data. https://www.unodc.org/documents/gsh/pdfs/2014_GLOBAL_HOMICIDE_BOOK_web.pdf.

  6 Bhugra, D. and Becker, M. A. (2005) ‘Migration, Cultural Bereavement and Cultural Identity’, World Psychiatry, 4:1, 18–24.

  MARCUS

  The man sitting opposite me leaned forward and stabbed the air between us with his index finger. ‘The first chance I get, I’m going to kill myself. Got it?’ I wondered what response he wanted – that I would beg him not to do it or urge him to reconsider? ‘I mean it. First chance I get, that’s it!’ Again, I couldn’t tell what he thought I should say or do with this information, and I wasn’t sure myself. So I went for this: ‘Can you say why?’ His eyes widened and he snorted in disbelief, as if he had never heard a dumber question. ‘Why? Seriously, woman. I’ll be pushing sixty when I come out. If I live that long. I’ll be an old man. Ugh.’ He shuddered theatrically at the very idea.

  This was my first meeting with Marcus, and though new patients will generally address me as ‘Doctor’, I noted that he had called me ‘woman’. It was almost an epithet, which might say something about his idea of me or about what all women meant to him. I was even more curious as to why the idea of old age was so terrible to him. He made it sound as if it were a fate worse than the years he faced in prison, or even death. I let the horror of his older self settle a bit. I wasn’t surprised that the silence stretched on for a while – many people in therapy are muted after something disturbing or fearful is raised. He had a new thought. ‘And I do feel bad about what I did, you know. About Julia.’

  We were sitting in one of the nicer meeting rooms in the admissions ward, facing the well-tended gardens. Through the window behind him, I could see the high perimeter fence, jutting out beyond the trees. It was mid-morning, when most patients were off the ward doing occupational therapy or taking exercise. I’d picked a time when we could get a quiet room where we would not be disturbed or distracted, although there was always the background noise of the television in the common area nearby. Marcus had recently been transferred from prison to our care at Broadmoor Hospital because of concerns about his suicide risk. I was not meeting him as his therapist. By thi
s time, in the mid-2000s, I was looking after a ward as one of the senior psychiatrists on the hospital’s staff, overseeing a team of people, including mental health nurses and therapists. I continued to see a few of my one-on-one therapy patients, but the majority of my time was now spent supporting staff in their work, acting as their supervisor and sounding board, an important function and something I continue to do to this day. My role in Marcus’s case was as his ‘RC’, or responsible clinician; in legal terms, this meant I would be acting as co-ordinator of his treatment while he was detained in hospital. I would have some dedicated individual time with him, but other team members would be doing the day-to-day work and providing feedback in regular case conferences.

  On admission to Broadmoor, Marcus had just turned forty and was one year into a life sentence for the murder of Julia, a young woman who had been the receptionist at his workplace. He was married, she was single; they’d had a brief affair that had ended amicably, and they had remained friendly. On her last night alive, Julia had invited Marcus to her flat for a drink after work. According to him, after sharing some wine and crisps and chatting for a while, she revealed that she’d begun online dating. In response, he’d strangled her to death with his necktie. Afterwards, he drove home to his unsuspecting wife, and then got up the next morning and went to the police station, where he confessed to his offence, telling them that Julia had ‘made me jealous’. As I’ve discussed in regard to Kezia, jealousy has long been accepted in our society as a motive for ‘crimes of passion’, and it’s notable how often it is volunteered as a rationale when people are arrested for violence. It is also well known that intimate partner homicide (IPH) is the most common type of relational murder, and numerous studies have shown that women are the main victims, although their abusers are not a homogenous group.1 IPH also has the highest risk of subsequent suicide, so Marcus was not atypical in that regard either.2 But I thought there was much more for our team to discover about why he felt Julia had to die and why he was now expressing a wish to kill himself.

  At this time in my career, I was getting deeply into reading and writing about early childhood attachments, and was working on a book about it with a German colleague.3 Attachment theory is a psychological model that built upon Freud’s ideas about the significance of early childhood, and it was developed by John Bowlby, a British psychiatrist working with emotionally disturbed children in the 1950s. He suggested that humans, like other primates, are motivated to attach to others across their lifespan, and developing a secure attachment bond in childhood is important for later mental health. Subsequent studies using this theory would show that insecurity in that early attachment is a risk factor for a range of psychological problems, including mood regulation, psychosomatic disorders and difficulties in forming close relationships with family, partners and even health care professionals.4

  It was not until the 1990s, when I was in training, that empirical research into this subject really took off. It had not been on the curriculum when I was a trainee, but now ideas based on attachment theory were being more widely discussed among my colleagues. I made it a focus of my research after I qualified, studying the links between childhood trauma, insecure attachment and poor mental health in later life. It also became more and more apparent to me that there was an explicit link between attachment experience and the linguistic ability to tell a true story of yourself. I’d seen examples of this before, but Marcus would provide new insight – all the more so because he did not immediately appear to have any difficulty in talking about himself.

  Around the time I met him, I had also become a mother, which gave my thinking about the attachment bond between parents and children a further ‘lived’ dimension for me. Like the arts, working in my field requires an involvement of heart and mind that means the personal and the professional are never separate, something that can be a difficulty and an advantage in equal measure. The Venn diagram of ‘Gwen’ (mother, wife, daughter, friend) and ‘Dr Adshead’ always has some overlap, although, like the mind, it is always transforming and re-forming.

  In our first case conference, my team of colleagues had talked of how Marcus’s situation was particularly puzzling because he had no previous history of violence before he took Julia’s life. Killing another person by strangulation has to happen at close quarters, whether it involves pulling tightly on a piece of cloth around their neck or squeezing hard with one’s hands, both of which require considerable strength and determination. The man sitting opposite me seemed to have both, and it occurred to me that this might also mean that he was able and likely to take his own life. I took in his stance: shoulders back, spine straight, palms on his knees, feet planted on the floor, seeming both grounded and ready to move. It was the posture of a man claiming his space and asserting his masculinity. With his thick dark hair, blue eyes and youthful appearance, I could see why women might find him attractive.

  As I usually do on a first encounter, I asked him where his story started and how we came to be meeting. Everyone’s approach to that seemingly bland opening question is different, and the choice they make about where to start their narrative is revealing. I noted that Marcus seemed pleased to be asked, and I thought perhaps it was a welcome distraction from talking about suicide. His body language changed. No longer staring at me, he gazed at the ceiling, clasping his hands behind his head and relaxing into his seat. ‘Where shall I start?’ he said. It was clearly a rhetorical question. ‘I’m in financial services,’ he began, ‘pensions, investment funds, bonds. Know what I mean?’ I nodded briefly, sensing that he wasn’t really interested in whether I did or not. It was clear he wasn’t going to start with his birth or early childhood. The narrative that followed contained many clichés of a self-made, special person: he was ‘first in the family to go to university’, ‘a bit of a rough diamond’, ‘the odd man out’. He claimed he had set up a thriving business by the time he was thirty.

  All the while, he spoke spontaneously and easily, making eye contact and occasionally using hand gestures, most eloquently when describing the size of a deal or the scale of his various businesses’ rapid growth. He emphasised several times over the phenomenal success he’d had, telling me how he’d been profiled in the press and invited on the speaker circuit alongside captains of industry twice his age. If all this was true, it would make him an unusual offender, because to be that successful in business, you usually need pro-social aspects to your personality, traits like empathy and conscientiousness. I made a mental note to compare the details of his account with whatever documentation I could access about him. Even small discrepancies can be illuminating, and false self-narratives increase our risk to ourselves and others.

  As he went on and on, like a singer listing his greatest hits, I recall thinking that most really successful people don’t do this; they don’t need to. It was almost as if Marcus was trying to convince himself that all this was true. Suddenly, he changed the subject. He sat for a moment, looking at me through slightly narrowed eyes, as if gauging what I thought of him so far, then commented, ‘I hear you’re very good, by the way.’ I didn’t for a moment think that he’d heard such a thing, and I made no response to his flattery, but I was interested that he wanted to say it. In the context of his self-aggrandising professional narrative, he might feel he had to claim ‘the best’ for himself; there was something entitled there.

  He’d said quite a lot since our session began. I had hoped he might go back further in time, to his school years, if not his early childhood, but he shifted to the present day and wanted to complain about it. He listed for me all that he had lost and what he missed from his old life, especially his business empire, but also his wife, his freedom, his possessions … He mentioned several cars he’d owned, smiling fondly as he spoke of his favourite, a sports car of some kind which was ‘a real beauty’.

  By this time, I was starting to feel a bit nonplussed. In contrast to what I’d understood from the referral which had brought him to our care, Marcus did not
appear depressed or suicidal in the least. It was possible he was building a ‘wall of words’ around him, as people sometimes do to buttress themselves against deep distress so that they don’t become overwhelmed. After all, he was just a short way into a life sentence, and coming to terms with that is akin to getting a terminal cancer diagnosis. You lose the time you thought you had to live out your life and it takes real effort to find a new way forward, like feeling your way in a dark room, lost without a light.

  ‘How do you come to be here in hospital?’ I asked, when he finally paused. He rolled his eyes. ‘You know all that, they must have briefed you.’ I told him I’d like to hear it from him. There was something in his stubborn gaze, a flare of anger I sensed, as he rewound to his first statement of the day. ‘Because I tried to kill myself in prison, and I’m still going to do it, first chance I get.’ I nodded calmly. ‘And what has prevented you from doing that before now?’ I don’t think he was expecting that question, and he had to consider his reply for a minute. ‘The truth is’ – I wondered what was coming, thinking that Marcus’s truth might be different from other people’s – ‘the only reason that I haven’t done it so far is that the prison officers were watching me day and night.’ There was no hint of distress or paranoia in his voice; he seemed proud, like an actor who had commanded a loyal audience. ‘So I’ll do it here instead. First chance I get. I’ll do it.’ I gave an ‘I see’ sort of response, which definitely wasn’t what he wanted. He looked deflated, as if he needed more from me. There was something vulnerable about his manner, a fragility, I thought, despite his alpha male presentation.

  I’d spoken to my colleagues in the prison who had requested his move to hospital, and they admitted that although they had stymied Marcus’s attempts to kill himself, they thought he was serious about it. They described one incident when he managed to get hold of a broken CD and dared them to stop him from cutting his throat with the sharp edge. It was unsurprising that they had sent him to us; he must have taxed them to the limit, and I knew they had already had three suicides in that prison in the last twelve months. I could see exactly why they didn’t want him there. His suicide risk was now the responsibility of the hospital.