The Devil You Know: Encounters in Forensic Psychiatry

by Gwen Adshead

revenge is a basic human impulse, a kind of wild justice that keeps us stuck in our fear and anger, mirroring the very cruelty we claim to abhor. This can be painful; there is wisdom in that popular notion that hating someone else is like taking poison and waiting for them to die.

I meet them at a turning point in their lives and help them to come to terms with a new identity, which may feel indelible; as one of my patients memorably put it, “You can be an ex–bus driver but not an ex-murderer.”

Some things I will ask you to look at will be hard to unsee, but I know from my own experience that gaining insight into experiences that are alien to us is transformative, and I will be by your side, working to turn suffering into meaning. Chapter by chapter, as the light grows stronger, I hope the reader will be able to visualize new possibilities for acceptance and change.

I’ve been struck by the fact that it is those that have known military occupation within the last century, like Norway and Holland, that have among the most humane, progressive attitudes to the mental health treatment of violent offenders.

Denial for Tony ran deep and allowed him to keep an awareness of his bad self out of his consciousness; if his violence were real, it would matter, and that would be unbearable. The fact that he had gone so far as to convince himself that he was protecting a potential victim from harm was pretty remarkable.

“If we do not transform our pain, we will most assuredly transmit it.”2

fear and trauma have to be transformed, or they will stay in the mind like an unsheathed knife, a real and deadly blade moving in unreal time, transmitting pain to others.

wise observation, often credited to Carl Jung, that “thinking is hard, that’s why most people judge.”

I didn’t want to make any assumptions. Again, I was working on keeping an open mind, holding myself “in the Bardo.” Keats describes the quality of thought this requires as “negative capability,” a mental stillness that hovers in doubt and doesn’t settle on obvious answers.

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 about 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.

Sometimes people are unlikeable because they don’t like themselves, a truism that extends well beyond forensic settings.

I would learn many times over as my career went on that it is always a greater act of compassion to empathize with someone you don’t like.

In the room with him I simply commented that it was interesting that he seemed to want to humiliate and punish a young woman, and I asked if it was possible this conflict with Amanda might have a link to his offense. At this, he dropped his head and twisted his hands together, looking defeated—a new posture for him. “Why do you always keep on about it?” His voice was so low I had to lean in closer to hear. I reminded him of where we were and that he had confessed to and been convicted of Julia’s murder. He shrugged, as if that didn’t matter. I went on. “But it seems this truth is difficult for you to look at, as if it’s easier for you to be hard on those who are trying to help you do that.” He lifted his head then, his voice angry and bitter. “They—you people—you really don’t care if I kill myself. No one cares.” I let that rest a moment, and then I saw that he was crying. Colleagues had told me he’d cried before in front of them, in a noisy and demonstrative way, but this was silent weeping, his shoulders shuddering, his cheeks wet. I made no attempt to stop him by offering words of comfort or tissues.

This phenomenon of unexplained bodily pain is common in people who struggle to express emotion and aligns with the theory that all emotions begin in the body.

But we had come through it to arrive at something better, and seen, not for the first or the last time, that it is only through a staunch belief in the possibilities of every human heart that we move forward, even if we go haltingly and sometimes stumble.

I knew the emotional significance of any human communication can take time to make itself felt. This is true for all of us,

I was moved when an officer I met recently commented that it was his view that “inside every violent prisoner there’s a good man dying to get out.”

There is truth in that, but it’s worth reiterating that we don’t always think that way about men with similar histories and offenses. Their anger and capacity for violence is always taken seriously, but we struggle with seeing women as dangerous to others because it is so rare for them to act those feelings out with violence. Most of the harm they do is to themselves, but Zahra’s behavior repeatedly put others in danger as well. Any difference in our sympathy toward her suggests we have a gendered view of evil, whereby men’s violence is seen as essentially different to women’s, which profits no one. If anything, it bolsters the pernicious concept that it is somehow “normal” for men to be destructive and violent, and that victimhood is part of the essential identity of a woman.

when victims of sexual abuse so often fail to get such support? And what good will it do anyway? I am asked such questions regularly, and part of my response is that depriving people like Ian will not improve services for victims.

Psychological explanations of the chaotic results of insecure attachment are not intended to provide any excuse for violence in either gender, but they are essential if we are to understand the meaning for a perpetrator and develop strategies for risk management and intervention.

As Kipling wrote, our feelings can deceive us, whether they are of triumph or disaster. This is why we need friends, families, and advisers of different kinds (including therapists, sometimes) to help us test reality and explore our emotions. Without that counterweight we can easily get overwhelmed.

Colleagues told me he had admitted to killing his father but had never talked about its meaning for him. He had spent years in a kind of mental isolation, which must have been painful. As a colleague of mine observed, insanity is building your own castle in the air and living in it; we’re offering to take down the drawbridge.

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.

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.

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 always stand in awe when someone takes ownership of a life-and-death story and there arises a shared sense of hope that radiates outward, 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.”

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