The Devil You Know: Encounters in Forensic Psychiatry

by Gwen Adshead

Mandatory minimum sentences and the wave of mass incarceration that followed, coupled with drastic cuts to mental health care services, have had far-reaching and dire social consequences both in the UK and around the world. Much has been written and said about this elsewhere by people far more expert than me; I will just say that we imprison far too many people, essentially to feed the public appetite for punishment, when only a small percentage of them are too cruel or risky to rehabilitate in the community.

These numbers are a reflection of serious problems of social and racial inequity in our world, coupled with increasingly punitive approaches to offenders, rather than any causal link between mental illness and crime.

The vast majority of people with mental illness will never break any laws at all, not so much as getting a parking ticket, and sadly they are far more likely to be victims of crime. The small cohort of people with an existing mental illness who do end up in prison after committing acts of violence do not do well there; conditions are difficult enough for someone of sound mind and body. The lack of resources means that only 10–20 per cent of prisoners will get the help and treatment they need, if they are judged to be grossly mentally ill. Even then, they may wait a long time for it; triage for the mind is not as straightforward as it is for broken limbs or gunshot wounds.

‘Maggie and Milly and Molly and Mae’ by e. e. cummings. In Firmage, G. J. (Ed.) (1972), The Complete Poems 1904–1962. Copyright © 1956, 1984, 1991 by the Trustees for the E. E. Cummings Trust (New York: Harcourt Brace Jovanovich).

By the 1970s, this kind of antisocial behaviour would be defined in DSM-3, the third edition of the Diagnostic and Statistical Manual of Mental Disorders, which is published periodically by the American Psychiatric Association. This behaviour is similarly described in the ICD, the International Classification of Diseases handbook published by the World Health Organization. Both the DSM and the ICD include a version of what is called antisocial personality disorder (ASPD), and most people argue that psychopathy is a severe form of this.

It is more accurate to say that a child who has lacked basic nurturing, living in an emotional drought, goes into a state of dormancy, or hibernation. They may detach from the reality of their world to protect themselves, and like a plant under stress from acid rain, or one that is planted in poor soil, their minds cease to grow and flower.

He could get rid of his own horrible feelings of fear related to his father by projecting them onto another person. I’ve heard many patients describe something similar, telling me how their violence helped them feel safer and somehow satisfied.

an internal split screen that acts as another kind of defence mechanism, which is sometimes known as ‘doubling’. The term was coined by Professor Robert Lifton in his 1986 study of Nazi doctors in the death camps, where he describes how they would have an ‘Auschwitz self’, one that was free of all moral standards, and a ‘human self’ outside the camp, where they were principled, professional family men.

The good self acts as a double for the cruel alternate self, which is usually hidden, as in the ancient idea of the good person and their evil doppelgänger. The Strange Case of Dr. Jekyll and Mr. Hyde is a classic literary example of this.

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.

Grover, C. and Soothill, K. (1999) ‘British Serial Killing: Towards a Structural Explanation’, British Criminology Conferences: Selected Proceedings, Vol. 2, p. 2.

vengefulness. Both victims and perpetrators need help for their psychological pain; as beautifully articulated by the American philosopher/priest Richard Rohr, ‘If we do not transform our pain, we will most assuredly transmit it.’2

a certain amount of psychological well-being is required for the self-reflective process of psychotherapy.

I had no training in EMDR, but I knew a little about it. First introduced in the US back in the mid-1990s, it is a technique that charges our memory system with a dual task involving attentional eye movements. The therapist moves a finger back and forth in front of the patient’s face, asking them to follow the movement while remembering and describing traumatic images and the feelings they evoke. Today, it has become the treatment of choice for people with PTSD flashbacks, and numerous studies conclude that the results can be impressive.5

survived. Here was a manifest reminder that 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.

Carl Jung, that ‘thinking is hard, that’s why most people judge’.

Brilliant quote

I was being asked to play detective, a kind of mash-up of therapist and Sherlock Holmes, boldly taking a magnifying glass into someone’s mind – as if that were even possible.

It is possible a male’s Y chromosome increases the risk of violence, but this does not explain why the majority of people with Y chromosomes are never violent. Some theorists have argued (more plausibly in my view) that male role expectations mean that the threshold for the use of violence is lowered, so that it becomes ‘normal’ for real men. A similar argument has been made for women: that it takes more for a woman to kill because it’s somehow unnatural in terms of feminine stereotypes and social norms. It is also suggested that the maternal and caring function of women in our culture might be protective against violence, making them more pro-social, a term which describes behaviours seen as helpful to other people, including sharing, cooperating with and comforting them. Ascribing mental illness as a motive when women commit murder may be the easiest response in a society that is ambivalent about women’s capacity for violence and wants to both condemn and excuse it in a way that doesn’t happen for men.

I knew this kind of turnover wasn’t unusual for mental health workers, who have long had higher rates of burnout than any other medical staff in the NHS, which in turn are significantly higher than in any other white-collar profession. This was once reflected in their compensation, but austerity cuts have put an end to that.

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.

The work in recent decades on childhood attachments that I’ve described, which builds on the work of Freud and many who followed, provides empirical evidence that there is a connection between a child’s early relationship with their parents and the way in which their mind develops. This in turn influences the function of the adult personality, including the ways in which people talk about themselves and those closest to them. Some research indicates that repeated exposure to abuse or neglect in childhood may affect the development of neural connections between those areas of the brain that manage emotions and support self-reflection.

Zahra’s parents provided her with all the physical and material necessities: shelter, food, clothing. But what Zahra recalled was constantly feeling rejected, judged and unloved. Her self-harm was a response to the anguish she felt about an attention that she would never command,

Gannon, T. A. (2010) ‘Female Arsonists: Key Features, Psychopathologies and Treatment Needs’, Psychiatry: Interpersonal and Biological Processes, 73, 173–89. And Dickens, G.,

Adshead, G. (2010) ‘Written on the Body: Deliberate Self-Harm as Communication’, Psychoanalytic Psychotherapy, 24:2, 69–80.

But for me, the narrative of a man like Ian has much more in common with the inexorable path Dostoevsky charts in Crime and Punishment: the gradual conception of a foul thing, its emergence into being and action, and the slow unwinding of consequences, the tortured aftermath.

Burns, C. (2017) ‘The Young Paedophiles Who Say They Don’t Abuse Children’, BBC online article. https://www.bbc.com/news/uk-41213657.

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

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

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).

Success in therapy, as we’ve seen in other cases, means accepting that something about your mind and beliefs may have to change.

McAdams, D. (2015) The Art and Science of Personality Development (New York: Guilford Press).

Parker, T. (1990) Life After Life: Interviews with Twelve Murderers