The Devil You Know: Encounters in Forensic Psychiatry

by Gwen Adshead

their violence helped them feel safer and somehow satisfied.

Schadenfreude, or satisfaction at someone else’s misfortune, the word literally being a combination of the German words for harm and joy. This too is a coping mechanism, a flicker of relief prompted by someone else’s suffering.

I thought Tony might have been drawn to younger men who reminded him of his own vulnerability and need for care; perhaps when he killed them, he was killing off that part of himself.

I would find that it was typical for many people (not only violent offenders) to slip into the present tense when describing painful events. The psychological explorer in me finds this fascinating: such a distortion to temporal reality is a way of unconsciously signaling how live their memories are for them, that they are not filed away somewhere in the past, where they belong.

It’s part of the myth of violence that the victims are always fearful and ashamed, whereas the perpetrators are angry and callous. My experience is that there are many perpetrators who are ashamed and traumatized by their offense, and many victims who really struggle to manage their understandable feelings of rage and vengefulness.

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

Although it could happen, studies were showing that it was rare for the whole of a person’s mind to be psychotically irrational, and therefore it should be possible to reach out to a part of a patient’s mind that still had the capacity to reflect.

I had found over time that it’s really not necessary to know every detail of people’s pasts in order to treat them. I was grateful and humbled to have as much as he’d been able to give me.

Key mindset to have

Like the hero of Kipling’s poem “If,” I needed to try and treat those two imposters triumph and disaster just the same.

Profound!

I’m sure I was always curious about it, but I was gradually becoming able to let things happen in their own time—and even if I had known that the scar existed, it wasn’t for me to ask him about it. I was far more interested in why and when he might choose to show it to me.

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.

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.

It is important to grasp that most murders depend on the perpetrator’s particular relationship with the victim, and outside of that relationship the danger is minimal.

“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.”

Use this when helping with someone who is hurting others as they are trying to push loved ones away.

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.

I’d heard many people say in therapy that they had never thought of themselves as someone who could or would kill anyone, and how it can make you a stranger to yourself. I added that I had seen how people who had killed needed help to start thinking about the unthinkable, and how important it could be for them to articulate those feelings.

Although Charlie knew it was coming, on the day she had to go she refused to say goodbye to anyone and on her way out smashed all the glass out of the front door of the most stable home she’d ever known.

Some people who can’t manage their feelings will feel bodily pain or become depressed, internalizing their hurt, while those who self-harm or set things alight are externalizing it. Both types of activity can be seen as signal fires, calls for urgent assistance. This can become a habit that is hard to break, and it is a risky one. It is a grave error when people dismiss acts of self-harm as attention-seeking—as if that were a bad thing.3

Good therapists don’t probe for evidence of abuse or trauma, but instead listen carefully and attend to what their patients don’t say as much as what they do, noticing the all-important spaces between the words. Most of us will also want to draw people out about their positive experiences with parents and caregivers, particularly their memories of being attended to as children, held in mind, and known as an individual. These can have a neutralizing effect on adversity, building resilience and making therapy more likely to succeed.

I suggested that together we could think of reflections that we might add to her notes, as if it were a work assignment. As a result, I think she began to see her suicidal feelings as a problem for the non-suicidal part of her mind.

This apparent truism hides the deeper complexity in human relationships, where love and hate can be finely balanced, and ambivalence and ambiguity coexist with intimacy.

for someone trapped in a delusion, negative contact is better than no contact at all.

there have been several studies since then which have shown that nearly all stalkers have a history of insecure childhood attachment to their parents, more so than might be expected in the general population or even among other types of violent offenders.

It was similar to the scenario where someone makes a disorganized and preoccupied attachment in a romantic partnership; it is unreasonable to expect that a partner (someone who is not your parent) can make you feel safe, secure, and happy at all times. When they fail to do so, as they inevitably will, the disorganized individual feels hurt and frightened, which can lead to controlling behaviors and even hostility. That’s when the partner often decides to leave, which is then interpreted as abandonment and rejection, generating anger, hostility, and sometimes violence.

We concluded that the common denominator between women like this and violent offenders was their early attachment patterns, with high incidences of childhood abuse, neglect, and loss.1

Each case I’ve worked on has been unique, humanly rich, and always poignant. All of the women appeared to be making up stories about their children’s ill health or actively making them ill and lying about it. At the same time, they were baffled by the idea that they could harm the child, as if this were out of their psychological sightline.

When she’d gone, I reflected that she had unconsciously said something important about her own need to be a good mum. I thought she was expressing another layer of need too: she seemed to need her son in order to be an adult; without him, she reverted to being a distressed and frustrated girl, one who was probably quite fearful.

Maybe this is how a culture that places so much emphasis on mothers being “good” pretends that bad ones don’t exist.

It seemed to me that she was not suffering the loss of her children so much as the loss of her social identity as a mother.

Coherence in this context does not mean elegant prose; it refers to communicating with meaning in a reflective way.

Recognizing reality is worth celebration, anytime.

Here she corrected herself with an effort, switching to the first person, demonstrating that this was her story.

Then she came close to an admission of past guilt, even if she swerved back to the second person.

I just wanted to give them what I never had. But that’s another thing I got from the group, you know? How can you give anyone what you never had?”

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.

TV is a social unifier between people who may have little in common beyond their identity as patients or inmates.

Resistance can also come from a fear of the unknown, which is an ordinary kind of human anxiety that we all know.

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.

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,

people bereaved by homicide could have intense and atypical grief reactions that persisted for years, resembling symptoms of PTSD.

He described how a patient moves from “I don’t know what you’re talking about” to “It wasn’t me” to “It was me, but I was mentally ill at the time” to “I did it when I was mentally ill,” until they finally land on “I did it.” Cox called this coming to terms with one’s actions a “scala integrata.”

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.

as if the past were his only safe place and now even that was closed to him.

In the absence of such cooperation, 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.

For some doctors (and I think I may have been one of them once), choosing to study medicine in the first place seemed to be a way to avoid vulnerability, as if somehow being a doctor and a patient were mutually exclusive.

I fell back on my favorite question: “If this were a story, where would it start?”

Genius opener!

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.

Downloading child pornography has long been unequivocally seen as a criminal offense which supports the abuse of minors through encouraging the production of such images.

Of course, VCP does grave damage because the proliferation of all this material, however it is generated, normalizes child abuse.

most adult men and women who download child pornography are not exclusively or even primarily sexually attracted to children.