by Gwen Adshead
I’ve said that the people I work with are like survivors of a disaster where they are the disaster, and much like other survivors they can struggle with the language needed to describe unspeakable memories. Unlike with trauma survivors, we do not ask them to process painful memories by rehearsing every last thing that happened in great detail. Rather, we invite them to deepen their understanding of what they did by articulating their story aloud to the group and being willing to hear others do the same. Sometimes they’ve never been asked to speak in this way, outside of a specific legal framework which focuses on motive, method and developing a defence. Being a member of a group like this can reduce their emotional isolation, and they can learn from each other how to live with their changed identities.2 No one is suggesting to them that the past doesn’t exist. British psychoanalyst Caroline Garland puts it bluntly: this recovery process is about ‘getting on with it, not getting over it’.3
After the group session is over, the therapists always sit down together over a welcome cup of coffee and make notes on the themes discussed, and share and reflect on what we’ve experienced. On the day that Sam first mentioned his parents, one of my colleagues asked if we knew whether he had spoken to anyone about his mother before or if she was still in contact with him since his conviction for the murder of his father. As it happened, I told them, I had met with Sam’s mother, Judith, in the past, as part of my medico-legal work. I knew she was still in touch with her son and visiting him regularly. It’s understandable that some family members will cut off contact in cases like this, unable to find a way to be with the perpetrator, but I’m always moved when people can continue to care for their relative and stay in their lives. It is usually the mothers who are the ones to stand by their troubled ‘child’, whatever their offspring’s age and no matter what has happened.
When Sam’s criminal trial was over, Judith had brought a negligence case in civil court against the mental health services trust that was looking after Sam at the time of the murder. I was asked by her lawyers to assess whether she had suffered mental health problems as a result of the trust’s failure to warn her of Sam’s release and the tragic consequences. This was well before I came back to Broadmoor and met Sam, who had served a few years of his prison sentence before his mental health deteriorated and he was transferred to the secure hospital for treatment. I remembered Judith’s case well, as it raised significant ethical issues about confidentiality and risk. It had been publicly reported, so I was able to give my colleagues some background about what had happened and how it might bear on what Sam had said in the group session that day.
Sam was one of a subset of chronically mentally ill young people, usually male, who are revolving-door patients in our mental health services. The cycle begins in early adolescence, when psychotic symptoms first emerge, typically hallucinations or delusions and other types of reality distortion. Sometimes medication is helpful, sometimes it’s not; it can stop hallucinations, but it cannot erase grief or fear, as the author and mental health nurse Nathan Filer has described so movingly.4 Teenagers in particular can be reluctant to take their ‘meds’ due to unpleasant side effects or because they are in denial that they have a problem. Some, including Sam, will turn to drugs and alcohol to ease psychotic symptoms and cope with painful feelings. Widely available substances like skunk or cocaine only worsen their mental state, causing a paranoia that may lead to acute mental crises and periods of involuntary detention in hospital. There they may be violent to professionals, with mental health nurses most at risk of assault. It’s ironic that the few times I have been assaulted in my long career were in general psychiatric wards, and not in prisons or high-secure units. In Sam’s case, he did try to assault his carers on a few occasions, but his target was his family, which is unsurprising; as we’ve seen, most violence is relational.5
When his sister and his peers were heading for university or finding jobs and having romantic relationships, Sam was left behind. If anyone had been studying his progress on a map, as meteorologists might track an extreme weather event, it would have been plain that he was gathering force out at sea and might wreak havoc when he made landfall, with his family as the almost inevitable target. ‘Almost’ is the operative word: just as hurricanes can change course or fluctuate in intensity, averting catastrophe, so can acute mental states, with some intervention. But Sam could not or would not get the help he needed, and his episodes of violence escalated until they ‘peaked’ with the murder of his father.
I explained to my colleagues how Judith and I had met some three years after the tragedy, since this type of civil litigation takes far longer to come to court than criminal cases. This was not a big coincidence, as they knew: I work in the only high-secure hospital in the region where Sam’s offence occurred and where his prison was located, and I also take on some legal work from time to time, as I have described in Sharon’s case. Some overlap is uncommon, but it can happen. I’d been asked to see Judith because of my experience working in trauma clinics and interest in the impact of murder on families. Her legal team were particularly focused on evidence of her long-term trauma; recent research by American colleagues had suggested that people bereaved by homicide could have intense and atypical grief reactions that persisted for years, resembling symptoms of PTSD.6 My job was to hear Judith’s story, examine her medical records, make a diagnosis and comment on treatment. I never saw Sam as part of this work, nor would there have been reason to do so. Unlike in a general psychiatric setting, where we have the usual hour (or fifty minutes), I could take all the time we needed. As I recalled, it was a thoughtful interview and I had the impression of a woman with real dignity and grace.
I remembered her as a slight woman in her sixties, with pallid skin almost the same colour as her short hair. She was Englishly stoic at first, then tearful and in pain as our interview progressed. She told me she had worked in the HR department of an accounting firm for many years, before her husband was killed. Ever since then, she had been signed off work by her doctor, and the resulting loss of income formed part of her injury claim against the hospital that had been looking after Sam at the time of the homicide. She went on to tell me how she and her husband Ralph had met in their late teens and fallen in love. They had always wanted two children, and Sam was the youngest, born when his sister Caroline was three. Judith smiled fondly as she recalled what an easy baby he had been and how happy he was as a little boy.
But the smiles receded when she described Sam’s transformation during puberty. At first, she and Ralph had thought his ‘acting up’ was just typical adolescent boy stuff, but he became more and more unhappy and agitated as he moved through his teens and started to be aggressive towards them. All adolescents struggle with their parents to some extent, experiencing the internal tug of war between need and separation, but those feelings are much aggravated by mental illness, and Sam was beginning to exhibit signs which would eventually lead to a diagnosis of schizophrenia.
His parents were not quick to grasp that possibility, and when the school suspended Sam for smoking cannabis, for a while they decided that must be the problem. He was increasingly confused and frightened, and appeared to be talking and listening to ‘voices’.
Auditory verbal hallucinations (AVHs) are probably one of the most familiar symptoms associated with psychotic illnesses. It’s a fascinating phenomenon, and not well understood. It’s not the case that AVHs are always an indicator of enduring mental illness, and they can be positive and comforting in religious contexts or when people describe hearing the voice of a deceased loved one (there’s been some interesting work on this by a group called the Hearing Voices Network). One time, Judith had asked Sam what the voices sounded like. She admitted to me that she imagined they might have different accents or genders, an idea she’d picked up from seeing lurid films about people with ‘multiple personalities’, which is a common misconception. ‘They sound like me, Mum,’ her son had told her, staring at her as if that were obvious. Other patient
s of mine have described to me a series of inchoate mumbles or whispers that are hard to discern, which could explain why people experiencing AVHs may appear to be concentrating intensely as they struggle to hear. However, in severe mental illness, most patients say that the voices are nearly always negative and might include opaque commands like ‘You know what you have to do.’ It’s also common for the voice to speak in the third person, as in ‘Sam’s going to die soon’ or ‘Everyone hates Sam.’ Despite some famous cases of violent offenders claiming they heard the ‘devil’s voice’ (or God’s) telling them to act, it’s comparatively rare to hear a specific order like ‘Kill yourself’ or ‘Kill them,’ and of course, people don’t always do what these hallucinatory commands tell them.
Judith and Ralph took Sam to their GP and described what was happening, which eventually led to an appointment with the Child and Adolescent Mental Health Services (CAMHS), where Sam got some support from a specialist team for young people with psychosis. But he was reluctant to take prescribed medication, complaining that it made him feel nauseous and ‘numb’, including a loss of libido that felt both unfair and alien to a boy of his age. After he turned eighteen, he came under the aegis of the adult mental health services and his parents were no longer updated about the details of his care, which would be considered a breach of confidentiality since he was no longer a minor. But he was living in their home, and they were in a constant state of worry. He would get into highly paranoid states and sometimes accused them of plotting against him. On one occasion he had torn apart his sister Caroline’s room, looking for something he said she had stolen or hidden from him, smashing her things and terrifying her to the point where she decided to move out and live with friends, which her parents encouraged. When Sam ‘came to’, as Judith put it, he was acutely distressed by what he had done and unable to explain himself, which was immensely frustrating. This kind of episode is typical of a ‘psychotic break’, in which the sufferer is disconnected from reality by their paranoid beliefs.
Sam could also be tearful, hopeless and needy. Judith’s eyes welled up as she recalled how he would come to her and sob that he had nothing in his life and how much he wished he was ‘normal’ like his peers and had a girlfriend or plans for his future. With his parents’ encouragement, he would occasionally try to work with rehabilitation services in the community, but his symptoms always returned and he’d revert to being paranoid and surly, especially when he was smoking strong forms of cannabis, such as skunk. A pattern of relapsing psychotic episodes took hold which became increasingly difficult to tolerate. It sounded like Judith and Ralph’s love for their son was unflagging throughout this period, even when he became violent towards them. Judith called the police on one occasion, when Sam hit Ralph and nearly broke his arm, but they hadn’t wanted to press charges. Their hopes were raised when Sam got a specialist placement in a rehab hostel, where there was occupational therapy and other interventions available to help him. For a while, things improved, but he would turn up sporadically at the family home to ask for money or complain about life at the hostel, and after some tense and frightening stand-offs, Ralph and Judith were persuaded to take out a restraining order against him.
This brought them a little peace, Judith said, but less contact with Sam meant almost no news about his condition. He was going in and out of hospital, they knew, after losing his place in the hostel, and he had spent some time living on the street, which made his parents feel guilty and worried. Now and then, when he was an inpatient, they would be invited to participate in case reviews at the hospital, but if Sam refused to have them there, they had to leave. They let the medical team know that they would continue to support him as best they could, but they could not have him back in the family home because of the violence. I had the impression that they had been caught in a middle ground between acceptance of their powerlessness and an unwillingness to detach fully from a son they had already lost many years ago.
Not long before the murder, they had written to his consultant detailing the history of Sam’s abusive behaviour towards them and asking if he needed long-term care in a psychiatric hospital, although they knew they had no role in that decision. There was little to no chance that would happen. It is not widely understood that the old system of asylums or long-term care for the mentally ill is long gone in the UK (and also around the world); in the NHS, the average length of stay in a psychiatric unit bed is three weeks. Following the anti-psychiatry movement of the 1970s, and as part of the general anti-government zeitgeist of the era and the austerity that followed, Britain and most social democracies adopted the idea of social integration of mentally ill and learning-disabled people, transitioning to a system of ‘care in the community’. This meant that the burden of care fell on the family, since community services were (and remain) drastically underfunded. This is yet another manifestation of the disproportionate and misguided emphasis our society places on physical health over mental health, and possibly the gravest example.
A dear friend of mine who experienced the tragic conjunction of her husband’s serious cancer diagnosis and her teenage son developing symptoms of schizophrenia similar to Sam’s described to me the stark difference in their experiences as patients, and the hollow meaning of ‘care in the community’ in practice. Health service providers rallied around her husband, with fulsome provisions for treatment and assurances that these would be available for as long as he lived, for which the family were grateful. Meanwhile, her son, whose mental state was disintegrating fast, had almost no options for treatment, and those that arose were limited and ineffective.
Judith’s experience was not dissimilar, and it was exacerbated by the fact that she felt unmoored from her son’s care in his adult life, when she was no longer privy to most of the details of his diagnosis or treatment. Her language had begun to falter as she recalled for me the last few occasions when she had seen Sam, perhaps two or three times in that final year before the murder. He had turned thirty, she said, though he always looked young for his age. She worried about him being so shaky and sweaty, which she was told was due to his meds, and it was heart-rending that he always seemed so sad. Her composure returned when she began to describe the homicide itself, I noticed, probably because this was a narrative she would have had to revisit many times over for various professionals.
She described how Sam had arrived at the house one night when they thought he was still in hospital and let himself in through the back door, which they had left unlocked. Ralph had been washing dishes after dinner; she was in the utility room just off the kitchen, doing some laundry, when she heard shouting – Ralph’s raised voice and Sam swearing at him, demanding money. She ran in and saw the two men struggling together, locked in a fight. She went to dial 999, when, to her horror, she saw Sam grab a rolling pin from the jar of utensils by the cooker and aim it at Ralph’s head. She dropped the phone and tried to intervene, but Sam swatted her away with great force and she hit the wall and fell to the ground; she heard her arm break with an audible crack. She also banged her head hard and blood was dribbling into her eyes. But she did see and hear Sam kicking Ralph viciously, over and over, as he lay unconscious on the floor. ‘I think I passed out then,’ she said tonelessly.
Sam ran away from the scene, but he was picked up by the police almost immediately and confessed to the crime. He was soon charged and remanded to prison. He went on to be convicted of murder, receiving a mandatory life sentence in prison. This was a little surprising to me, given his psychiatric history, which might have suggested the lesser verdict of manslaughter, but the two psychiatrists who assessed Sam for the trial did not agree about whether he was unwell at the time of the killing. The jury had clearly preferred the evidence of the psychiatrist for the prosecution and found Sam guilty of murder, which meant that there was only one sentence the judge could pass.
Judith’s testimony was also relevant; she had heard Sam demand money from his father, and the prosecution emphasised Sam’s history of be
ing abusive and violent to his parents when he needed money for drugs. The mental health history in this case was not wholly ignored by the jury, but it is complex to distinguish between sane and insane motives in a case like this, and you never know how a jury will decide. If Sam did become mentally unwell in prison, he could get some kind of treatment, and if his condition was bad enough, he would be transferred to a secure hospital. Ten years after the murder of his father, this is what happened. As part of his treatment, and with his agreement, he started work in our Homicide Group.
Judith’s negligence case looked simple on paper: the hospital trust had a duty of care to Sam and breached it by failing to assess his risk properly. They had compounded this by allowing him community leave from the ward when they knew his behaviour could be dangerous. They did not warn his family that he was allowed out, nor that he had absconded. That breach had caused harm to both Sam and his family, and therefore they ought to be able to claim damages in respect of that harm. The hospital’s position was that they had no legal duty to Sam’s family, only to their patient. They pointed to the fact that the criminal court had concluded he was not mentally ill at the time of the homicide. It was not their legal duty to prevent him from harming others, and under the Mental Health Act they had an obligation to care for him using ‘least restrictive practice’. At the time of the homicide, Sam had been assessed as being of minimal risk and was on an open ward, where community leave was both normal and inevitable as part of the treatment protocol. It was true that he had gone AWOL, but that had happened with him during other hospital stays without him seeking out his parents or doing anything harmful to anyone. The medical team had no way of knowing he would go home or try to hurt his parents, and there was no legal requirement to contact them when he was found to be absent. In fact, to do so would have been a breach of Sam’s right to control the disclosure of his private information, a familiar concept we all know as ‘doctor-patient confidentiality’.
