The Devil You Know

by Gwen Adshead

  Sometimes people who interview me will ask how I combat my negative feelings about patients, an idea which suggests emotions require action. I know that the opposite is true: ‘feelings aren’t facts’, as I often repeat to trainees, and they will pass. There’s no battle involved, other than the mindfulness required to keep presenting a neutral expression and posture. In fact, I think I welcome any strong feelings I may have because they can be so revealing of the other person’s state of mind, as illustrated in so many of these stories. I’m sure my adverse emotional reaction to David was actually part of the reason I broke my usual rule about only seeing private clients for short-term work. He wasn’t overtly nasty, nor did he appear to be depressed, but I couldn’t shake the feeling that there was something darker here behind his ‘performance’. Given what I’d experienced with other patients, including women like Lydia and Zahra, I was worried that he was blocking me from seeing something important. I noted that he missed the odd session too, without any prior notice, or would arrive late without much explanation, actions that could signal aggression.

  On one occasion he was on time but in a temper, talking about a row with Helen, his (long-suffering, as I imagined her) office administrator. He was back at work now and blaming her for whatever had happened that day, suggesting she was ‘chippy’ because she was unmarried and middle-aged, ‘past her prime’. The same might have been said of him, I thought but did not say. I was so aware of identifying with Helen and trying not to feel outrage on her behalf that I almost missed a significant and apparently offhand comment that it was David’s birthday that day, and his children hadn’t been in touch with him. I resisted a passing urge to say, ‘I can’t imagine why not,’ and simply asked him how he felt about that. ‘I’m not upset, if that’s what you’re getting at,’ he said. ‘Upset?’ I asked. David raised his voice at me, which he’d never done before. ‘Oh, come on, Doctor. You know what I mean. I won’t be crying myself to sleep tonight. I’m not sad about it.’ He gave the emotion great emphasis, as if it were ridiculous.

  ‘So,’ I asked, ‘if not sad, then what do you feel?’ He told me he was angry that ‘after all I’ve done for them’, they ‘couldn’t be bothered’ to call and wish him a happy birthday. ‘How hard would it be?’ And then he was off on a rant: ‘I worked to give them all that I had, more even – the best schools, tennis lessons, the lot. Lucy was never academic, but I wanted Tom to go to medical school and he had the brains for it, but what did he do? Drama and media studies, of all things, and now he plays the piano in pubs and clubs for a living, teaches a bit on the side. What a bloody waste – I gave him everything. I can’t fucking believe it.’ He paused for breath then, his face flushed with feeling.

  These were painful emotions, right up at the surface where we could see them, presented in more emphatic words than I’d ever heard from him. It was a long speech for him too, and although it seemed as entitled and demanding as usual, I thought I heard an agonised longing for a son who would be like him. I would tread with care in my response. ‘David, are you angry that your son didn’t want to go into medicine, after you followed your own father into the profession?’ He shrugged. ‘I couldn’t say.’ I tried not to let that catchphrase irritate me and went a little further: ‘Do you wish you’d been closer to your own father?’ But even as I said it, I thought it might be off the mark. David smiled in a way that was downright unpleasant. ‘You people think you’re so clever. Well, I’ll have you know, Dr Adshead, I was perfectly close to my father, and he was proud of me. And rightly so. He was just a country GP, never built a successful business as I’ve done, never published.’ The dialogue had taken a wrong turn, just when I thought we were getting somewhere. My heart sank as he spent the rest of the session telling me about his latest article in the British Medical Journal and reviewing all his other professional achievements.

  I was beginning to think that David could not – or would not – use what I had to offer. Success in therapy, as we’ve seen in other cases, means accepting that something about your mind and beliefs may have to change. His mode of engaging with me had a narcissistic quality, though I wouldn’t say he had a personality disorder or any other kind of mental illness. Rather, he was dismissive and grandiose, with a way of dealing with others that made it hard for him to ever allow himself to be vulnerable. This is common enough among people in leadership roles in a competitive and capitalist society like ours, particularly in males, when they have the added challenge of dealing with cultural ideas of masculinity that define strength as never showing weakness. But as every one of the foregoing stories attests, vulnerability is absolutely essential to the therapy process. The more open someone is, the more possible it is for them to reach an acceptance of their self and change their mind for the better. I feared that David might not get there.

  I also suspected that he had not always performed his self to other people in this way. Rather, his experience of childhood loneliness and emotional neglect had led to a tendency to avoid painful feelings, so much so that, as he reached adulthood, he taught himself to keep the ordinary human griefs and difficulties out of his psychological line of sight, or his ‘inscape’, as Victorian poet Gerard Manley Hopkins so eloquently put it. It seemed doubtful that more tolerance and perseverance on my part, for some indeterminate period, were going to alter his defences.

  I invited him to review things again, to reflect on his work with me thus far. He seemed to find this process uncomfortable and again made noises about how he was ‘fine’ and he ‘couldn’t say’. But I pushed a little, to try and get a response: ‘I’m aware that you’re still having nightmares. I understand you’re still not happy at work and counting the days till retirement. What is our work together doing for you, if anything?’ David acted as if affronted, accusing me of trying to get rid of him. Perhaps he was more attached to me and the work than I had realised. I picked up my notes and turned to the line I’d written down early on, when he told me he experienced his father as being ‘there and not there’. I asked if it was possible that was happening with us now. ‘You come, you talk, but I feel as if there’s much you can’t articulate, as if you are also “here and not here”. Can you help me to understand what that’s like for you?

  Sometimes the mere suggestion that therapy is not infinite can prompt people to reassess and bring out new thoughts, which is the essence of change. David did not respond to my question immediately. He sat quietly, hands in his lap, and took a few slow, deep breaths, as if self-soothing. After a while, in a low voice, he asked what I meant. What was it I thought he wasn’t saying? There was still a tinge of the bully there, a little challenge in his tone. I told him I had no clue. He smiled. ‘Well then’ – as if the matter was settled. I waited, listening to the clock measuring the time remaining, until another question came to me. He had told me some time ago that he had no idea why his wife had suddenly up and left him. Was there anything more to that story? Long experience had taught me that you never know what might happen in therapy, and I did have a concern that asking this might anger David. I wasn’t entirely sure it was the right course of action, but he had led the way, so I took the plunge.

  David appeared to arrive at a decision, slapping his palms on his knees. It looked like he was about to get up and leave. This was so unlike my work in forensic settings, where patients will rarely terminate a session – or if they do, it is often a sign of progress, showing they might be getting in touch with healthier ways to express ‘upset’, as I’d seen in cases like Tony’s or Zahra’s. Then David spoke, leaning forward, close enough that I could feel the warmth of his breath, his eyes locked onto mine. ‘All right, Dr Adshead, I guess I’ll tell you.’ He relaxed a little, settling back in his chair again, and after a moment he proceeded to explain to me that his wife Connie had always been ‘uptight’, what he’d call ‘a classic English prude’, if I knew what he meant. I didn’t nod, but I guess he thought I understood. One day, he told me, Connie ‘lost it’ when she found he had been watc
hing some porn on his computer. She’d gone to look up something in their household accounts, ‘or so she said’, and had stumbled on a site he had accidentally left open.

  Any psychiatrist will perk up their ears at things that occur ‘accidentally’. Carl Jung used the word ‘synchronicity’ to describe these kinds of acausal ‘meaningful coincidences’. I made a note of it for later. ‘That set her off,’ David was saying, rolling his eyes skywards. He described how Connie started crying, then there’d been a terrible row and she’d packed a suitcase and driven off to their daughter’s house, ‘making a big drama out of nothing’. He crossed his arms over his chest and glared at me as if I were his histrionic spouse. ‘The end,’ said his body language.

  ‘How long have you been looking at pornography?’ I asked. He waved his hand, telling me it had been ‘years’. I waited. ‘Several years, okay?’ ‘Since …?’ He allowed that it might have started when his children were small, when his wife became ‘obsessed’ with them, his tone pathologising her maternal interest and hinting at unfair neglect of him. That would have been at least twenty years ago, I calculated. ‘Would you call it a habit?’ I asked. David snorted. ‘It’s a hobby! Something everyone … I mean, come on. It’s not like it was back in the day, top-shelf-at-the-newsagent stuff – it’s everywhere. Free, all over the internet, “Hot Teens”, “Wet Schoolgirls”, that sort of thing, popping into your inbox at all hours.’ He paused, perhaps becoming aware of some change in the air or tension between us, and added lamely, ‘It’s not illegal. Everyone does it.’

  Now I had a problem. David was describing an activity that could potentially have a criminal aspect, and I needed to know more without sounding like an interrogator. I asked if he was aware that what he was suggesting had serious implications – he could be struck off or even go to prison.

  ‘Who’s going to know?’ he shot back. ‘I’m no fool. I’m careful about it, you know, and I only use my home computer. So.’ I was concerned that he might be using pornography that was illegal. As an experienced health care professional, David must have realised that if he confided to me that he was downloading child pornography, this was a crime that I would have to tell somebody about. Confidentiality between doctor and patient has its limits, even outside of secure institutions, as we’ve seen in the case of Sam and his parents; this is essential in the context of child protection. In the US, doctors are mandated by law to report any possible risk to a child, and even in the UK, where it is not mandatory, there is an expectation that doctors will act without compunction to protect children in danger. This is implicit in any case involving the downloading of child pornography, and in this particular instance it was exacerbated by the fact that David was a family doctor. I’d never found myself a situation like this before, and I knew I would need to seek advice about the next steps from trusted colleagues. I was sure doing nothing wasn’t an option. David was looking at me, tapping his fingers on his knee, as if irritated, waiting for my lead. He seemed as uneasy as I was about the turn this session had taken.

  I reminded him of my professional duty, adding that of course I wanted us to think it through together and consider what we might do next. He frowned. ‘So, Dr Adshead, if I told you – which I haven’t, by the way – that I was downloading violent, sadistic pornography involving minors, you’d have to report me? Is that it?’ By now I was familiar with the games he played and how he liked to provoke a reaction, so I didn’t give him a direct reply. Instead, I asked, ‘Where do you think we go from here?’ He looked crestfallen, as if he would have preferred an argument. Then he lapsed into a protracted silence, lasting several minutes at least. At one point, he dropped his head into his hands, raking his fingers through his hair as if to comb out his thoughts. It was the longest silence there had ever been in our work together.

  When he finally looked up at me, his face was serious. He cleared his throat. ‘Right. Well then. That’s what I’ve been doing. That’s why Connie left me.’ I encouraged him to go on, to say more. He spoke slowly, with pauses and halts to find words to say the unsayable, and I didn’t interrupt him. Initially, his porn ‘hobby’ had been a means of retaliating against his wife when she was neglecting him, but then it became a private way to de-stress himself. He would wait till she and the children went to bed and then go into his study, which he said he kept locked, ‘of course’, as if protecting his children in this way were evidence that he was somehow a good father. To me, it sounded more like consciousness of guilt about his activity.

  He found a whole world online, and for years he carried on looking at ‘pretty ordinary’ porn – women with big breasts, people having sex in various positions, ‘nothing odd or kinky’. At some stage, and he couldn’t quite pinpoint when it was, he found himself drawn to websites that advertised girls in school uniforms and the like. They were young, but not children. They were having sex with actors playing teachers and dads, men his age. I wondered if it affirmed his sense of self to watch vulnerable girls apparently enjoying sex or being degraded by men much like him.

  The story got darker, and I was reminded of the progressive quality of any addiction, that relentless search for greater highs, for more oblivion. He described moving from one ‘class’ of website to another, invited by fellow travellers into a world of cruelty and sexual exploitation involving children, even toddlers. It was hard to hear, but I imagined it was harder to say. His gaze stayed firmly on his hands in his lap as he described what he’d seen and how this habit had increasingly consumed all of his leisure time. In the last ten years of his marriage, he and his wife grew further apart, living almost separate lives. A few years before she left, Connie seemed to suggest she was aware of his ‘hobby’, but he denied it.

  When she finally found the evidence on his computer, it was just before their silver anniversary, and she told him she didn’t want to go ahead with the party they had planned. She wanted a divorce. But they made a bargain: the social event was important to him, a landmark, so Connie agreed to participate in this public lie, if he accepted that afterwards she would be leaving him and their marriage was over. Otherwise, she would tell their children and the police about what was on his computer. He agreed, but he still thought she was overreacting.

  A painful, heavy atmosphere had settled in the room. I took some time to think, feeling conscious that the end of our session was in sight and we needed a plan for managing what he had just told me. As if reading my mind, he glanced up at the clock. ‘Are you going to contact the General Medical Council?’ He sounded weary, his normal bluster gone. I didn’t reply immediately. ‘I will answer that, David, but first, can I ask why you’re asking?’ He looked confused. ‘My career will be finished … everyone will know.’ Then his tone became more aggressive and familiar. ‘Look, Doctor, my problem was no rest – which, by the way, you’ve not solved – and now what?’ With rising agitation, he heaved himself out of the armchair, glaring down at me, accusatory, back in command-and-control mode. ‘Are you going to make me out to be some kind of paedophile?’ He didn’t wait for an answer. ‘If you repeat what I’ve told you in confidence, by God, I’ll sue you in every court in the land. I’ve got some powerful friends, you know. I can make life difficult for you.’

  ‘Will you sit a moment, David?’ This was quite a disturbing turn, but I tried to keep my voice as level as I could. I was aware of the irony of longing for Broadmoor again, not only for the fellowship of colleagues and the clear boundaries, but for the sense of safety and ubiquitous security. There were no alarm bells within arm’s reach in this space. He snatched up his coat and moved to the door. ‘I’m off. You won’t be seeing me back here again in this shithole, you useless …’ – he struggled to think of the right insult – ‘… shrink. What a joke. Pointless, I knew this was pointless.’ He strode out, and moments later I heard his car door slam and the squeal of tyres as he drove away.

  My body was shaking, as if I’d been in a car accident or narrowly escaped one. I didn’t know what David was ca
pable of, but the sense of threat had been tangible. I tried to control a rising nausea with mindful breaths, sitting there for some time, knowing I had to make sense of what I’d heard and formulate a plan. Nobody likes to get another person into trouble, and David was in for a world of trouble if I reported this. But he had left me with no choice; by bringing his offending to therapy, he had put me in the dual role of investigator and bystander at a crime scene. As my physical anxiety subsided, my main worry was not for myself but for him. I thought he might become suicidal upon realising what he had done; there was no closing this Pandora’s box. He had just committed professional suicide in front of me – and he must have known it. Was that what he’d wanted from the outset, and it had just taken time to get there? Maybe he had merely needed to get his offence off his chest and genuinely thought that confidentiality rules protected him or that there was some grey area in the law. But that felt far-fetched to me for someone of his intelligence and experience.

  In another era, psychotherapists might have been expected to keep these kinds of disclosures secret, but as I’ve described, our society – including the GMC and the justice system – now puts great emphasis on protecting people from care providers, and of course anything related to the potential or actual abuse of children is seen not only as evil, but as a safeguarding emergency. I didn’t think David posed any risk to children, but I knew that wouldn’t matter in the minds of others. If he had been relying on the idea that he had done nothing wrong because he had never actually come into contact with a child, as some pornography users will argue, then he would find out how mistaken he was. Downloading child pornography has long been unequivocally seen as a criminal offence which supports the abuse of minors through encouraging the production of such images. There has also been an increasing amount of virtual child pornography (VCP, the computer-generated, highly realistic imagery that is also used by producers of adult porn) over the last decade, with some users claiming that no harm was being done to anyone if the ‘actors’ were not real. Thankfully, this disturbing idea has been met with a raft of criminal legislation in most jurisdictions, much of it also applicable to cartoon and drawn images. Of course, VCP does grave damage because the proliferation of all this material, however it is generated, normalises child abuse.