The Devil You Know

by Gwen Adshead

  I didn’t take my eyes off Sam, but I heard one of the other patients let out a sort of half-gasp, releasing a little bubble of the tension I expect we were all feeling. Sam bent over in his chair, elbows on his knees, rubbing at his face with his hands as if to scrub away his features. I thought he might be working up the courage to keep going, and I was filled with a sense of sadness and dread that was almost theatrical, like that feeling of watching Medea or Macbeth, when you know what’s coming and whisper to yourself, ‘Oh no, don’t do it …’

  After a bit, Kaz leaned over and said, ‘You okay, mate? Need some water?’ Sam nodded, and one of my co-therapists got up, went to the water cooler and passed him a cup. He downed it in a gulp. Then he looked up at the ceiling, then over at the clock on the wall, which never told the correct time – anywhere but at one of us. ‘I don’t think I can say any more right now,’ he said hoarsely. Tim spoke up: ‘You only have to say what you can – we’ve all been there.’ And then Benny, another patient, added his two cents: ‘It took me years, man. Don’t worry, we know how it gets too real.’ I was touched by their support, and maybe Sam was too, because he was able to continue. I noticed he moved into the past tense at that point, as if he needed a little distance in order to get to the end. I made a particular effort to commit his language to memory, but there was little danger I’d forget its devastating and simple eloquence.

  ‘So that was it. That’s when I killed my dad. I don’t remember it all, but I know I started hitting him, grabbed something and started bashing him. And then Mum was there screaming at me, and I pushed her away and she hit the wall with sort of a cracking sound … and then there was nothing but me hitting my dad. And then no sound. It was like the world fell away. I was frozen there, standing over him, and he was lying there in this puddle of blood. I remember I looked around and thought, “This is it, this is the end of everything.”’ Sam dropped his head into his hands then, and I let a pause linger to see if he had anything more to say, but he was silent. Then I looked around the group and asked if anyone had anything they wanted to say to Sam. Nobody spoke. ‘Perhaps the rest is silence,’ I said. Not all revelation needs a response, and maybe no words matter when someone describes how they have shattered their world.

  Later, after the session was over, I suggested to my colleagues that the fact this had all played out in his childhood home made things worse for Sam, as if the past were his only safe place and now even that was closed to him. We talked about the ‘bicycle lock’ combination that had clicked into place that night, all those risk factors lining up, and if the final ‘number’ was the look of fear in his father’s eye – or just an intolerable feeling of not being the person he wanted to be.

  I’ve often thought about Sam and Judith since then, and whether his final fatal violence could have been averted. I still share my colleagues’ and the courts’ concerns about the protection of patient privacy, but I think we need to approach the question of confidentiality in a new way. Mental illness is a family affair; can we make risk management more of a co-operative effort between all those affected by it? This case forcefully brought home to me that for all the lip service paid to care in the community for the mentally ill, it still seems to be nobody’s job to look after their carers and family. In an era when privacy and personal information have been monetised to such an extent by social media and marketeers, perhaps we could create a counterweight in the realm of health and safety. It isn’t always necessary to treat privacy like Gollum’s ‘Precious’, and certainly not in cases like this.9 There need not be a competition between people like Sam and his parents about who owns or has access to his medical information.

  In the absence of such co-operation, Sam’s parents were landed with a new identity that they never chose, as victims of his violence. And now Sam himself is defined as a member of an extremely small group of people who have both a mental illness diagnosis and a homicide conviction, a complex identity that resonates with pain. How is he meant to go forward? I was heartened recently when one of our Homicide Group members diverted from the usual banter about escapist television programmes and announced that he’d been reading a good book, given to him by a fellow patient. He smiled at me and said, ‘It’s right up your street, Dr Gwen. It’s by a man called Victor Frankl who was in a concentration camp, and it’s all about finding meaning in places like that … or places like this.’10 He gestured widely with his arm, taking in the drab meeting room and the little circle of men and staff, as well as the whole institution.

  I had never mentioned Frankl to the group by name, but that patient was spot on: the premise that all suffering has meaning was right up my street, wherever that is. I always stand in awe when someone takes ownership of a life-and-death story and there arises a shared sense of hope that radiates outwards, allowing meaning and purpose to come from catastrophe. In this way, as one of my patients in the Homicide Group pointed out, people who have killed can make something of themselves, even if they face many years in prison, ‘otherwise two lives are lost rather than one’.

  I thought of Judith, faithfully visiting her son for years after the loss of her husband, and how the difficult work Sam had undertaken in our group might lighten her load because it had eased his pain more than any medication. I have spoken about how a new thought can provide hope, opening a new door in the mind. This is not a special insight of mine; hope is well known to be vital to well-being, and to all kinds of recovery. It is considered the main curative factor in group therapy, because once you step through that door, you realise you are not alone. Hope relies on this kind of connection. Grasping this is not only necessary for our patients, or for those who work with them – it is profoundly important for everyone.

  NOTES

  1 Hillbrand, M. and Young, J. L. (2008) ‘Instilling Hope into Forensic Treatment: The Antidote to Despair and Desperation’, Journal of the American Academy of Psychiatry and the Law, 36:1, 90–4.

  2 Adshead, G. (2016) ‘Stories of Transgression’, in Cook, C. H., Powell, A. and Sims, A. (Eds), Spirituality and Narrative in Psychiatric Practice: Stories of Mind and Soul (London: Royal College of Psychiatrists). Also Ferrito, M., Vetere, A., Adshead, G. and Moore, E. (2012) ‘Life After Homicide: Accounts of Recovery and Redemption of Offender Patients in a High Security Hospital – A Qualitative Study’, Journal of Forensic Psychiatry and Psychology, 23:3, 1–18.

  3 Garland, C. (2002) Understanding Trauma (London: Routledge).

  4 Filer, N. (2019) This Book Will Change Your Mind about Mental Health (London: Faber & Faber).

  5 Estroff, S. E. et al. (1998) ‘Risk Reconsidered: Targets of Violence in the Social Networks of People with Serious Psychiatric Disorders’, Social Psychiatry and Psychiatric Epidemiology, 33, S95–S101. Also ‘Raising Cain: The Role of Serious Mental Illness in Family Homicides’, June 2016 report from the Office of Research and Public Affairs.

  6 Heeke, C., Kampisiou, C., Niemeyer, H. and Knaevelsrud, C. (2017) ‘A Systematic Review and Meta-Analysis of Correlates of Prolonged Grief Disorder in Adults Exposed to Violent Loss’, European Journal of Psychotraumatology, 8 (sup. 6), 1,583,524.

  7 Adshead, G. and Sarkar, S. (2005) ‘Justice and Welfare: Two Ethical Paradigms in Forensic Psychiatry’, Australian and New Zealand Journal of Psychiatry, 39, 1011–17.

  8 Vitaly Tarasoff et al. v. Regents of the University of California et al. (S.F. No. 23042. Supreme Court of California. July 1, 1976).

  9 There is an excellent discussion of the questions about and meanings of privacy in medicine in Allen, A. (2016) ‘Privacy and Medicine’, in Zalta, E. N. (Ed.), The Stanford Encyclopedia of Philosophy (winter 2016 edition); https://plato.stanford.edu/archives/win2016/entries/privacy-medicine/.

  10 His reference is to Victor Frankl’s classic book Man’s Search for Meaning (Boston: Beacon Press, 1962; first English edition translated by Ilse Lasch).

  DAVID

  I share my private consulting room on rotation with other therapists. It is a pleasant spot, w
arm and light, and I like it because it is such a different environment from the prison and the hospital. There are soft furnishings, the walls are not painted a uniform dirty white, and above all there are no locks and no alarms, no constant anticipation of danger. I’ve reduced my workload these days, but I continue to work as a therapist in secure settings within the NHS a few days a week, alongside some writing, teaching and medico-legal work. Very occasionally, I will see a private patient. Like most NHS doctors, I do not have a private practice as such, which I’m aware is a contrast to the situation in the US, where most psychiatrists and psychotherapists are sole proprietors of a private therapy business who may also be affiliated with a hospital or other institution. In the NHS, we aren’t prohibited from having private patients, but there are only so many hours in a day, and it is my preference to work within the state-funded system with those who do not have the resources to pay for private help.

  My new patient was a family doctor in the nearby town who had been referred to me by a colleague. I had agreed to meet him because if I do offer private therapy to anyone, it will usually be to fellow medical professionals, as it can be so hard for them to access help, for a whole range of reasons which I will describe. I’m not offering long-term therapy, and I make that very clear to them up front. I will give an assessment and do a limited number of sessions, then guide them to someone else, if necessary. I’ve chosen to work in this way because I’m accustomed to having firm boundaries between my forensic work and my off time. As I’ve described, I am always grateful for the high walls of secure institutions, which create such an unambiguous line between my job and my private life, helping me to leave work behind at the end of each day. If someone is agreeable to the idea of short-term therapy, I find a few sessions are often enough; as one surgeon who came to me put it, he had felt ‘mentally messy’, and a handful of hours together were sufficient for him to clear his head.

  I heard David before I saw him that morning. The window of my room overlooks the parking area and I had been sitting quietly, expecting his arrival, when the sudden slam of a car door outside made me jump a little. As hurried footsteps crunched across the gravel, I gathered he was finishing a phone call – not a pleasant one, by the sound of it. After a moment there came a muffled rumble of the same voice at reception, one of those baritones I associate with singers or soldiers. Closer now, I heard a snapped ‘No need, she’s expecting me,’ immediately followed by three quick raps on my door. He came in before I could rise from my chair.

  ‘David X,’ he announced, thrusting his hand out to shake mine. He wasn’t a big man, but his presence filled the small space. He had a strong handshake and a professional smile that didn’t make it to his eyes. His clothes suggested he had paid attention to his look: he wore a crisp white shirt and a patterned silk handkerchief peeked from the pocket of a smart blue blazer. A high forehead was crowned with a mass of curly salt-and-pepper hair and his head seemed too big for his body. The double meaning of ‘big head’ occurred to me later, and I wondered if this initial association was a response to something ‘bullish’ in David’s presentation of himself to me at this first meeting.

  ‘What brings you here today?’ I asked him, as I picked up my notepad and pen, adding, ‘I’m going to make a few notes just so I don’t forget the important things. Is that okay?’ He waved his hand to signify not just assent but the irrelevance of the question. He was a doctor too; he knew the drill. ‘What exactly did Giles put in the referral?’ I sensed an antipathy in his tone which might have reflected a difficulty in swapping over to the patient’s chair – or perhaps it was just anxiety about what his GP might have said. These first minutes with a new patient are always full of cues, and it can be frustrating that there’s no time to process them in the moment. His GP had mentioned depression, I told him. David shook his head: ‘No, I wouldn’t call it that, actually. It isn’t my mood, it’s my sleep. Quite simple really: I’m having trouble sleeping and the SSRIs [referring to a category of antidepressants] he gave me didn’t do a thing.’ I asked how long he’d had the problem. A few months, he told me, ‘or maybe a year’. I frowned inwardly. That’s a long time for anyone to be sleep-deprived, and it made me think that David’s issue might be complicated. ‘The referral mentioned something about troubles at work too. Is that related to the lack of sleep?’ David looked blank for a moment, then, to my surprise, he laughed, a harsh, dry chuckle. ‘Had to say something, didn’t he?’

  He gazed at me as if seeing me for the first time since his arrival. ‘I asked Giles to refer me to you in particular, Dr Adshead. Heard you on Radio 4 on my drive into town one day. Bit of a celebrity, aren’t you?’ In recent years I’ve done a few public lectures, mainly about working with homicide perpetrators, and once I was ‘on the radar’ of a few people in the media, I began to be invited to join panel discussions from time to time, talking about forensic work. I don’t mind doing this, but it is an unexpected side effect of my job, not something I pursue. Comments like David’s didn’t really invite a response, but his need to say it suggested he might be nervous and could also be attempting to use mild flattery as a way to establish a connection. I wondered, too, if it mattered to him that ‘his’ psychiatrist had some public presence or was well regarded.

  He was saying, ‘… and who doesn’t have troubles at work, eh? I mean, look at what we do and under what pressure. The NHS has gone to the dogs, and we’re left to clean up the mess. Thank God I’m retiring soon. Takes a special kind of nerve, this job, wouldn’t you say? Think about it: we’re extraordinary. We have to be.’ He crossed his legs and gave me what I’m sure he thought was a winning smile, and again I had that sense of him wanting to flatter or charm me, positioning ‘us’ as special because he needed to be. There was something controlling about all this, and I found myself recoiling inwardly from him. Of course, I knew that was clinically significant – something about his psyche was tweaking something in mine. Another reason I have such a limited private practice is that I like to discuss reactions like this with thoughtful colleagues who share an experience of the patient and can help me reflect. In an institution like Broadmoor or a prison, even working within the probation service or with the courts, I’m connected to others; in private practice I’m on my own. I was able to keep a neutral expression while still communicating interest and warmth with my body language, eye contact and careful listening and questions, but throughout I was aware that I was wishing I could get away from David, and curious as to why.

  I wondered if it was because he didn’t really want to be there – if, despite his genial presentation, he was feeling as I did. Why did we both want to get out of the room so badly? Probably we had touched on feelings and thoughts that were troubling to us both. As put off as I was by his manner, I would later reflect on what he had been saying about the NHS, and whether that had disturbed me. He was correct in saying that the health service has been sorely battered by years of cuts and restructuring, and faces an uncertain future, which is upsetting to anyone working in the field. I also had to wonder whether he was tweaking some concern I had about my own future, given our similar ages, as well as our shared profession. It can be discomfiting to be made to think about how little time lies ahead of us compared with what is behind.

  There’s truth in that old saying that doctors make bad patients, especially when it comes to mental health. This is a worry because rates of depression and substance misuse are higher in our field than in other professional groups, which contributes to an increased suicide risk. I have worked with doctors in general practice like David who are required to be all things to all people, with a huge workload. They truly can’t afford to be ‘mentally messy’. Mess is anathema to most doctors; our training emphasises scientific rigour and the need to be in control. Strength and dependability are highly prized; we are taught that like a ship’s captain, we are expected to be at the helm, not leaving the deck until the job is done. As a junior doctor I quickly learned never to call in sick, which wou
ld have amounted to letting the team down or risking being seen as weak. As the American poet Anne Sexton once observed of doctors, ‘they are only a human / trying to fix up a human’.1

  I’ve had an interest in the psychological needs of doctors for a long time, partly because I am a physician who’s had to struggle with the mess in my own mind, and I know how difficult it can be to ask for help or carve out time for self-care. I’ve had at least ten years of therapy, partly as a requirement of my original training, but also to help me to make sense of who I am and some of the difficulties I’ve faced in my life. I’ve struggled with depression, and in 2010 I trained in mindfulness-based cognitive therapy (MBCT), which is often used in the treatment of chronic depression. Mindfulness is a meditation practice based on Buddhist traditions, and I wish I’d come to it much earlier, as I’ve found it to be so helpful both personally and professionally. Reasoning that these practices might also benefit other doctors, I’ve since become involved with a few like-minded colleagues (one a Buddhist monk as well as a psychiatrist) in organising annual ‘Mindfulness for Doctors’ retreats.2

  My interest in working with fellow doctors also extends to those who get into real difficulties as a result of their struggles, to the point of transgressing rules or norms. I’m intrigued as to what makes colleagues who are by definition pro-social, helping and co-operating with others for a living, decide to ‘break bad’. Over the years, I’ve seen how different stressors affect doctors’ mental health, and the way their professional and personal identities merge in what is necessarily a performative job. It is no surprise that they are the embattled protagonists of so many television dramas.