Dr Gwen Adshead & Eileen Horne
(Faber, £16.99, 368pp)
“I like to think of the mind as a coral reef,” says Dr Gwen Adshead. Her long career as a forensic psychiatrist, working with some of the most violent offenders in British society, has required “adeep dive below the surface, into a darkness where things of great beauty as well as danger might appear”.
Her new book The Devil You Know, co-written with dramatist Eileen Horne, invites readers to join her on that plunge into minds that initially seem scarily otherworldly. But in her calm company, we’re encouraged to make sense of serial killers, child sex offenders and arsonists, not as the monsters of sensationalist fiction, but as “survivors of a disaster where they are the disaster, and my colleagues and I are the first responders.”
Greeting me with an inviting smile and a birdlike nod, 60-year-old Adshead (pronounced Ads-head) proves a lively conversationalist when we connect via Zoom. She receives my questions like a series of gift-wrapped parcels, weighing and turning them, unpacking her answers in a collaborative conversation, curious to see if we might hear the rustle of fresh insight into ideas she’s been working through for decades. I can see how effective this attitude would be in therapy.
“I wanted to write about evil and cruelty for a public audience,” she says. “To create an intimate space where the reader could come in and sit with me while I was working, to give people a proximity to something that perhaps we normally avoid. We all of us have the capacity for cruelty and violence in us. Secretly we all know that. What we are trying to say with the book is that it is probably better to get to know your own devils. If you can get up close to that in yourself then maybe you can understand that there is less difference
between you and somebody who has killed than you might think.”
The book takes us into the room with eleven case studies, composites of the “types” with whom Adshead has worked. There’s a married narcissist who strangled his ex-lover when he found out she was dating again. There’s the young man convicted of an unprovoked stabbing, traumatised by the civil war he witnessed as a child in Eritrea. And the middle-class woman who stalked her therapist and attempted to poison his dog.
Although she doesn’t put many personal details in the public domain to prevent her patients from googling her, I can tell you that Adshead was born in New Zealand in 1960 and raised in a Christian faith that’s still deeply important to her. Her academic parents both suffered from chronic health conditions, which drew her to medicine. Once at medical school, she tells me she was drawn to psychiatry because, “when I came to it, there was something familiar in the question: ‘what’s going on for this person?’ You can’t always tell by looking, I had always disliked people making assumptions about what I was thinking based on my hair or what I was wearing or my skin colour.”
She struggled with the way general psychiatry “seemed to involve judgements about normality and difference, and diagnoses which patients didn’t always like or accept” and trained as a psychotherapist so she could spend more time talking to patients. After completing a Master’s in medical ethics and law at King’s [London] she began working at Broadmoor when the facility’s psychotherapy department was very well-funded.
There she learned that many of the people we call “evil” are damaged in a way that means they struggle to see other humans as real. “We often think about a lack of empathy as being cold,” she tells me. “But it’s very often a distortion of reality; they are moving through a world in which other people are cardboard cut-outs. Knocking one over doesn’t really matter,” she says. Inhabiting such a psychological landscape is unenviably “flat and monochrome. The development of empathy brings colour and a third dimension. But when the numbness goes it is usually replaced by a lot of pain.”
Adshead’s mentor, Murray Cox, was the psychiatrist who brought the Royal Shakespeare Company into Broadmoor. He encouraged Adshead to embrace her love of literature and she encouraged her patients to express themselves through metaphor. Quoting the Polish poet Wislawa Szymborska’s faith in poetry as “a redemptive handrail”, the psychiatrist helps her patients visualise anger as “dragon’s breath” and dissociation as “dropping off”.
PHOTO: PHILIP VANOUTRIVE
“We often use metaphors to say things that are difficult,” she tells me. “Shakespeare is particularly good at that – especially when it comes to violence and murder. ‘I’m afraid to think what I have done/ To look on’t again I dare not’ [Macbeth] is as good a description as I know when it comes to avoidance of thinking back for some people. Because it would be scary. If the line comes to my mind in therapy I might ask: ‘Do you think you’re afraid to think about what you’ve done?’ to see if it helps unpack another thought.”
When meeting a patient for the first time, Adshead tells me she will usually begin by asking a question along the lines of: “So where does the story start for you?”. It’s an approach she came to after many years, when “it became clear that often people with mental illness had been interviewed in the same way using the same medical questions by different people for years.” She could find the answers to those questions, along with details of their crimes, by looking through the paperwork.
“So I found it more interesting to see what happened when you gave people a bit of space to tell the story in their own way.” She says that responses are surprisingly variable. Some will offer a chronological account of their lives. Others will begin with the crime, or the reason they’ve decided to come for therapy, which is only offered to those whom the authorities believe will benefit from it. Some are depressed and submissive; some are manipulative, keen to spin a self-aggrandising line; others are raging through desperate denial.
“Many of the people I meet are in a very strange situation,” she says. For those who’ve been in and out of institutions their whole lives it’s fairly normal. But those who’ve never been in trouble with the law or never been mentally ill before are pretty stunned by the whole process. We have to be very careful with them. When they realise what they’ve done then there’s a risk of suicide.” As she notes in her book, a person can be an ex-florist or an ex-husband. But nobody can be an “ex-murderer”. When you kill another person, you also kill part of yourself.
Revisiting her old cases, Adshead tells me she was struck by “how difficult it can be to find the right words during a difficult conversation. What IS the right thing to say when a killer tells you: ‘I just wanted to be beautiful?’ or ‘I wanted to kill her, but I didn’t want her to die.’?”
Although several female patients are featured in Adshead’s book, she says that only five per cent of murders are committed by women. “What I have come to conclude is that it seems to take much more for women to become violent. There are more cultural obstacles. Violence is so normalised for men. We don’t seem to be at all concerned by the huge numbers of young men getting into a fight on a Friday night, but we get very exercised about domestic violence. Why don’t we care about violence between young men? It causes terrible grief and trauma. So where are the voices rushing in to say: ‘Jim don’t hurt Nick’? If a man was hitting a woman in that way there would be lots of people getting involved, calling the police. If we could shift that needle it would help.”
As the mother of two sons, she believes the situation would be improved if schools put more effort into helping boys use emotional language. “Women are encouraged to put feelings into words, assumed to be good at it and praised for it. Whereas if a lad says he feels sad, angry, hurt, it’s less likely to be admired.”
Although it’s often a painful read, The Devil You Know is a hopeful book. Firmly moral, Adshead makes no “excuses” for the crimes of her patients. She believes “a justly applied punishment can be redemptive, if it offers a chance to make good.” But she does stress the importance of understanding how childhood trauma or neglect can lead to terrible events down the line. She wishes more support was offered to people before they cause serious harm to others and she closes her book with a plea for much more investment in mental health support services. Like coral reefs, she says, the human mind can bleach and wither under environmental stress: “But science has shown they can be responsive to intervention and made more resilient.”
Dr Gwen Adshead has worked as a forensic psychiatrist and psychotherapist in the NHS, prisons, secure hospitals, and in the community. She has published and lectured widely, including as visiting professor at Yale and as Gresham College Professor of Psychiatry. In 2013, she received the Royal College of Psychiatry’s President’s Medal