The Devil You Know

by Gwen Adshead

  I used the remainder of our session to explain our team’s set-up to Marcus. The goal was to work together to treat him for depression, aiming to reduce his suicide risk and get him back to prison to continue serving his sentence. He scoffed at the idea that he’d ever leave the hospital alive and asserted that any efforts to stop him from taking his life were bound to fail. Before he left, he did ask me how many people were on ‘Team Marcus’, and I sensed his satisfaction that a whole group of highly trained professionals – not just me, a lone woman – would be focused on his needs. I knew that just because I couldn’t immediately see signs of his depression, that didn’t mean he was faking it. By law, he must have been seen by two psychiatrists to qualify for his transfer, and I had no reason to think they’d been misled. It is much harder to deceive mental health professionals than people think.

  After that initial session, I put Marcus on a course of antidepressants and regular therapy sessions, which would explore his personality and relationships and might help us understand what his plans for suicide meant to him. I told the team that we needed to keep him under constant watch, whether awake or asleep. I can still remember the details and faces of two men I assessed as a young trainee who were successful at killing themselves, and I worry to this day that I failed them somehow. At the time, my colleagues had rallied around me and been supportive. My supervisor had assured me that in one case there was no way anyone would have had an inkling – the man seemed fine to everyone who met with him; and in the other the patient’s anger had masked a deep despair. Everyone in my job fears this eventuality, and I didn’t want it to happen again; we could not risk a human error that allowed Marcus to achieve his aim.

  *

  ‘Doesn’t look all that suicidal to me,’ grumped one of the seasoned health care assistants on the ward a few weeks later. There’s often a disconnect between body and brain, of course, but if someone does not respond to antidepressants, or any other kind of medical intervention for that matter, it can mean they aren’t in need of them. Marcus had only complained bitterly about the side effects. He’d also been utterly uncooperative with everyone, from his therapist to the nurses, just as he’d been in prison. The team were dubious about whether he was really depressed, or even distressed. ‘He just wants to make us anxious all the time,’ said one perceptive junior nurse. I thought she was right. Marcus was apparently not interested in understanding his suicidality, but still keen to threaten and show off about it, just in case we weren’t getting the message. There was one memorable occasion when, during the communal lunchtime, he tried ramming food and paper napkins down his throat in full view of other patients, who were highly disturbed by this display. Another time he tried to strangle himself with a twisted strand of loo roll in front of a staff nurse, in a disturbing parody of the way he killed Julia.

  His antics were gradually alienating everyone on the ward, although the staff would do their best to manage their responses. Our training, peer support and supervision help when we’re faced with someone as trying as Marcus, but the people on the front lines are only human, and it is especially challenging for the more junior staff. There were many tetchy exchanges and difficult moments. Having someone on constant suicide watch for days on end can disrupt the smooth functioning of a ward, as multiple staff are taken up with their full-time care. It makes them less available for other patients and treatment activities, and it is not unusual for the person on suicide watch to attract resentment from other patients. This was exacerbated by Marcus’s constant negativity; he complained about the nurses, the food, other patients and how we were failing to help him. I was told by a colleague that he had appeared one morning at the ward office in a terrible temper and demanded to see ‘the manager’. He wanted to report that the night nurse assigned to watch him the night before had dozed off for a moment. The nurse had to be disciplined, he said, for his total incompetence. ‘I might have died while he slept!’

  I myself witnessed how he would march around the unit with his put-upon nursing escort, proclaiming to anyone within earshot that he wasn’t used to being stuck with such uneducated and uncultured people. He complained that he had nothing in common with any of the other patients, clearly missing the irony that the only reason he was there was because he had, like them, been seriously violent to others. He was provocative in other ways, butting into private conversations to demand attention; more than once, this led to threats and attempts at assault from angry fellow patients.

  It felt as though we were all looking after a large malign baby with no awareness of others’ needs or feelings. Within the clinical team, we began to wonder if Marcus was more narcissistic than we had realised. The concept of narcissism in psychiatry is a complex one, referring not to an illness as such, but to a kind of personality style in which people present as entitled, exploitative and grandiose. It draws on the myth of Narcissus, a beautiful young man who rejected his admirers and fell in love with his own image when he saw it mirrored in the surface of a lake. The tragedy of Narcissus is that as he tried to get closer to the person he desired, he failed to recognise himself and so fell in the water and drowned. In real life, people with narcissistic personalities struggle with relationships and tend to die early. Occasionally they will seek treatment, but it is rarely successful because therapy requires trust and vulnerability, and a narcissistic person uses grandiosity and entitlement to suppress feelings of need. Controlling and belittling others brings them superficial relief, even if it means alienating people who might be able to help. That sounded a lot like Marcus.

  Narcissistic personality disorder is a popular diagnosis these days, especially for men in powerful roles. I’d suggest this is partly because accounts of pathological narcissism seem awfully like our current cultural concept of healthy masculinity. There are debates in my field about whether all narcissism is bad, and if it isn’t, where we might draw the line between normal and abnormal, or possibly malignant, forms. It’s clear that all adolescents go through a narcissistic phase, for example; I remember that period in my own life, manifesting itself in truly terrible poetry about the bleakness and beauty of the world which no one but me could fathom. Thankfully, most of us come out the other side of this process unscathed (with bad poetry unpublished). Those people left with an enduring dash of narcissism in adulthood can be dynamic and charismatic, and it may help them in motivating and inspiring teams. I noticed that quality in Marcus during patient community meetings on the ward, where he began to lead discussions about demands for better conditions; it was another forum for performance. To my surprise, a few professionals who visited from other wards and were unaware of the details of his case told us that they found him to be charming and thought we were a bit hard on him. I did notice that none of these people were male, a fact that had more relevance later, when I found out more about his true history.

  Marcus continued to resist attempts to help him and to complain and interfere on the admissions ward, to the point where staff grew worried about the risk of him being assaulted by fellow patients. We decided to move him to a rehabilitation ward, where the other patients had less acute mental health problems and were making progress in their recovery. This meant they would be off the ward for much of the time, taking part in occupational therapy and other activities. They might still find Marcus infuriating when they had to be around him, but at least they would be less likely to hit him. His therapist kept patiently trying to engage him in some reflection on his feelings, and I spent time chasing down colleagues at the prison who had sent him to us, as well as contacting his lawyers, hoping to find out if they knew anything more about his past that might help us to gain a better understanding.

  It became clear that he was an unreliable narrator of his own life. He’d been to university but didn’t graduate, dropping out after a year. He’d run businesses, yes, but none of them was successful, and he was mired in debt and litigation. He didn’t have convictions for violence, but he had previously served two short sentences for f
raud. I also learned that he had an old conviction for criminal harassment (which included behaviour the law would now define as stalking) relating to a girl he had dated in his twenties.

  His deceits extended to his family life. In addition to his wife and Julia, Marcus had simultaneously been involved in at least two other long-term romantic relationships. The first that his wife of ten years knew about all this was when the police arrived at her door to inform her that her husband was under arrest for murder. She met the women when they came to the trial to give evidence about Marcus, and they were equally shocked and distressed. Both of these ‘other women’ testified in court that they never knew he was married, nor were they aware of the reality of either his financial or his professional situation. Each one had believed Marcus when he explained that his frequent absences were due to important business abroad – quite a tribute to his skills of denial and control.

  And yet I knew from talking to my prison colleagues that his wife had continued to make regular phone calls and visits to him in prison after his conviction, sticking by him when the others did not. He told our therapy team that he construed her loyalty as evidence of him being an excellent husband, in spite of his collection of other women – let alone the affair with and murder of Julia. I was powerfully reminded of the narrator of the Browning poem ‘My Last Duchess’.5 The narrator, the duke, is about to acquire a new bride, whom he describes as ‘my object’. He also describes calmly how he had his late wife killed because she smiled and thanked other men in the same way that she smiled and thanked him; she did not treat him as ‘special’. I could easily imagine Marcus using the same language.

  So far, he’d said little about the killing of Julia. I read more about the circumstances of her death in the court documents, bearing in mind that the only living witness was Marcus himself. Computer records did support his account that she had been online dating and had shown him her profile on the night of the murder, when he said she taunted him about her ‘other men’. I tried to imagine what her reasons would be for doing this, if what he said was true. Was it to wound him? To show off? Or to prove they were just friends? When I’m working with people who have hurt or killed others, I have to think about the victims and their view of things, almost as much as I do with the perpetrator. It’s important for me to consider how they saw or heard the person I am now working with, and I try to stay mindful that they too had a story to tell, though their voice has been silenced.

  Thinking about the victim also reminds me of the risk the person posed to them then, and might still pose now. I never thought that Marcus would be violent towards me while he was a patient; the risk seemed linked to his attachments to women he attracted. This did not include me, but I realised that it could in theory apply to others around him, thinking of those women colleagues who had visited the ward and commented about how likeable he was. It is important to grasp that most murders depend on the perpetrator’s particular relationship with the victim, and outside of that relationship the danger is minimal. Contrary to irresponsible media reports, people who have killed are not generally dangerous to everyone. But in this case, a risk remained that Marcus might try and con any women he encountered into liking him, if he saw them as a potential addition to his collection of admirers.

  I thought of how he might have disarmed his victim, Julia, whom I imagined as slim and dark-haired, for some reason, though I’d never seen a photo of her. I wondered about her last evening with Marcus. There must have been a point when she realised that something was different. Did his expression change? His voice? When she first felt his necktie slip around her neck, did she think that he was joking? The police reports noted that the laptop was found on the floor, the screen cracked, as if it too had been assaulted. Did he hammer it with his fist or sweep it off the table?

  The nearest Marcus had come to that moment in therapy was to express his outrage that Julia had showed him the dating site at all. ‘She didn’t think of me for a minute!’ he had told a colleague in one of his therapy sessions. ‘How was I supposed to feel when she did that?’ He looked genuinely puzzled when they pointed out that given his marriage and other girlfriends at the time, it appeared he had one rule for Julia and another for himself. ‘She invited me to her flat! She made me feel small!’ he blustered. When asked if he thought that excused his response, he was, for once, unable to muster a glib reply. He was not so out of touch with reality that he could reply in the affirmative, even if he wasn’t able to articulate a ‘no’. Instead, he reverted to a familiar complaint. ‘Our discussion of this is totally pointless,’ he said. ‘You people are doing nothing to help me, and I might as well kill myself.’ But when asked what kind of help he wanted, he could not answer.

  The next time I met with him, I tried to ask him a little more about that night with Julia. We had been talking about all the plans he’d made for his life, from a young age, during one of his usual litanies about how much he’d lost and sacrificed, and how all that planning was wasted. I commented that it felt like planning was important to him, and he agreed, saying it was essential in his line of work. He liked to plan, but what was the point now, when life stretched out so emptily ahead of him? He really needed to just end it all … Before he could slip back into that groove, I interrupted him, asking if he had made a plan to kill Julia when he arranged to go to her flat that night. I wondered if the question might anger him or if it was too much to ask, but he looked amazed, almost shocked by the idea. He insisted that his crime was unpremeditated, that it never would have happened if she hadn’t provoked him like that. This is a cruelly familiar line of reasoning in domestic violence cases. The blame is put squarely on the victim, who is generally female. If only she hadn’t done this or that, everything would have been rosy. Marcus admitted to me he had actually been hoping that Julia would sleep with him that night, for old times’ sake, and had told his wife not to expect him back home till late.

  How was he feeling when she opened her laptop to show him her dating profile? He said he was angry and saw it as her boasting about meeting other men, ‘rubbing it in’. The way he framed it made me wonder if she had been the one to end their brief romance and was therefore – in Marcus’s perception – rubbing salt in that wound. He recalled her sitting at the table scrolling through the internet dating site, asking him what he thought of this or that prospective suitor, and he got the feeling that she was laughing at him somehow, shaming him. That was interesting, but I didn’t want to interrupt because now he was into the story, his words coming fast. ‘I had to make her stop,’ he told me. ‘I had to stop her talking.’ The mode of death made sense to me then: by strangling her, he had literally stopped her voice and her laughter. I was reminded, too, of how many of his own failed attempts at suicide had involved his throat, his mouth or choking. If we were tired of hearing his endless complaints, perhaps some part of him was as well; suicide might be the only way he could silence his own voice.

  Marcus moved in his chair, so that he was half turned away from me and looking out of the window. I followed his gaze but there was nothing to see, only a row of bare trees beyond the fence, stark and black against a pale winter sky. Slowly, he told me how he’d ‘watched the light go out in her eyes’ as he twisted the necktie around Julia’s neck. In a neutral tone, he said it reminded him of a time when he was a boy and his dog had caught a pheasant, bringing it to him in its death throes. He was quite surprised, he commented, at the similarity between the two experiences, that extinguishing of life and light.

  I believed that Julia had never seen this coming, and now I wondered if Marcus hadn’t either; if he was being honest when he said how he had not planned to kill her but had been ambushed by his anger. I have heard many times over how that derailment of reality, that crash into fatal violence, can begin with what might sound like such a trivial action, the final number in that mental ‘bicycle lock’ combination clicking into place. Here it seemed as if it was something as random as a wave of Julia’s hand, a little laug
h heard as teasing or dismissive. I have seen again and again in my work how what seems like nothing is in fact huge, how a tiny moment has a terrible butterfly effect that triggers disaster.

  This kind of dissociation from reality may help to explain why progress in therapy with people who have committed violent crimes takes so much longer than with those who have not. To get to that one revealing moment with Marcus, my team and I had to endure many long months of complaints, tantrums and those endless repeated threats of suicide, which we could not ignore. And soon after he told me about the homicide, he made another attempt on his own life, this time by using clothing to try and fashion a noose with which to hang himself in his room. It was time for a new approach. When we next met, I invited him to think about whether it made sense for him to continue in hospital any longer. I wasn’t bluffing; if he wouldn’t engage, returning to prison had to be a genuine option for him. After all, he had not responded to medical treatment, and as he had said to us so many times, we weren’t helping to ease his suicidality.

  I added that I was worried he was alienating everyone around him, which made it hard for us to sustain a therapeutic relationship. Only that morning, one of the younger female health assistants on the ward, Amanda, had come to speak with me about him, shaken and distressed by his behaviour. It was part of my role as the RC to be there for staff who needed help in staying compassionate, which they can only do if they speak out about and own their critical thoughts. I knew Amanda to be a kind and not easily ruffled young woman, and listened carefully as she explained that she had not allowed ‘that asshole’ to leave the dining room for his occupational therapy appointment because he had not cleared his breakfast plate, as was usual practice for all patients. Marcus had been incredibly rude in his response, calling her names and telling her she was unqualified and uneducated, and he would make sure she was disciplined, if not fired, for her behaviour. He didn’t quite say, ‘Do you know who I am?’ but he might as well have.