The Devil You Know

Stories of Human Cruelty and Compassion

Gwen Adshead, Eileen Horne

• Publisher: Scribner
• Year: 2021
• ISBN:
  9781982134815
• Topic: Social Sciences
• Subtopic: Criminology
• Index: Social Sciences

In this "unmissable book" ( The Guardian ), an internationally renowned forensic psychiatrist and psychotherapist demonstrates the remarkable human capacity for radical empathy, change, and redemption. What drives someone to commit an act of terrible violence? Drawing from her thirty years of experience in providing therapy to people in prisons and secure hospitals who have committed serious offenses, Dr. Gwen Adshead provides fresh and surprising insights into violence and the mind. Through a collaboration with coauthor Eileen Horne, Dr. Adshead brings her extraordinary career to life in a series of unflinching portraits.Alongside doctor and patient, we discover what human cruelty, ranging from serial homicide to stalking, arson or sexual offending, means to perpetrators, experiencing firsthand how minds can change when the people some might label as "evil" are able to take responsibility for their life stories and get to know their own minds. With outcomes ranging from hope to despair, from denial to recovery, these men and women are revealed in all their complexity and shared humanity. In this era of mass incarceration, deep cuts in mental health care and extreme social schisms, this book offers a persuasive argument for compassion over condemnation.Moving, thought-provoking, and brilliantly told, The Devil You Know is a rare and timely book with the power to transform our ideas about cruelty and violence, and to radically expand the limits of empathy. "A welcome contribution to the literature of crime and rehabilitation" ( Kirkus Reviews ).

TONY

“Who wants to see a serial killer?” We were in the weekly psychotherapy department meeting at the hospital, where referrals are discussed and allocated. Most people had taken on a new case, and we were on to the last few. There was some brief laughter in response to the chair of the meeting’s ironic query, but nobody volunteered. “Really? No takers?” I was itching to raise my hand, but as the most junior person in the room, I worried that I might be seen as professionally naive or as having a prurient interest. I could sense the invisible collective shrug of my colleagues around the table. The public, stoked by popular entertainment and the media, are endlessly fascinated by those rare people who commit multiple homicides. But within my profession they generate much less interest. Rehabilitation into the community is never going to be an option for them. As one of my colleagues remarked to me, “What have they got to talk about except death?”

I had a lot to learn. It was the mid-1990s, and I had recently started at Broadmoor Hospital, an NHS facility set amid rolling hills and woodland in a picturesque area of southeast England, not far from Eton College and Windsor Castle. After qualifying as a forensic psychiatrist a few years earlier, I had welcomed an opportunity to come and work part-time as a locum (or “temp” doctor, filling in as necessary) at Broadmoor while I was completing my additional training as a psychotherapist. To build up my skills, I needed to spend as many hours as I could giving one-on-one therapy to patients while I was under supervision. It seemed to me that a man going nowhere would have a lot of time—and if he wanted to talk about death, well, that was on my curriculum.

It may be surprising that we were having this discussion at all. Attitudes to, and the resourcing of, mental health care for offenders, whether they are in the hospital or in prison, vary considerably around the world. My European and Antipodean colleagues work in systems similar to the UK’s, where some individual therapy is offered, but many other countries have none. I’ve found my American colleagues in particular always remark on the differences. Having visited a number of different countries to observe firsthand how things work, 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. Some studies suggest that experience makes it easier for them to understand these fellow human beings as rule-breakers who are ill rather than “bad people.”

“I’ll take the referral,” I said. “What’s his name?” I looked to my supervisor as I spoke, hoping he’d support me. He smiled his agreement. “Knock yourself out, Gwen,” one of the senior doctors chipped in. “I saw one of these guys in prison for years. All he did was drone on and on about his art classes and how good he was at painting still lifes…” That comment actually struck me as intriguing, but before I could ask about it, the chair was handing me the referral letter, saying, “He’s all yours. Tony X… killed three men, decapitation, I think. Oh—and by the way, he asked for therapy.” The older colleague gave me a knowing look: “Mind how you go.”

It was only later that my supervisor, a man of huge experience, told me he had only ever seen one serial killer himself, and that was for a psychiatric assessment, not long-term therapy. I was glad I would be able to access any knowledge and support he could offer as I went forward. To this day I greatly value that sense of being held by my colleagues and miss it when I’m working outside of institutional environments. I confessed to him that as a trainee, I thought I was lucky to get such an opportunity. Now I was beginning to feel a bit daunted. I went away to prepare as best I could, but soon realized that while there were a lot of lurid reports out there about serial killers, there was little available on how to talk to one, and nothing about how to offer him therapy.

By definition, serial killers kill repeatedly, but there is no official agreement about the number of victims required for membership of this macabre club. Historically, there had been quite a debate about this, with some consensus reached around three or more, although public attention has always inevitably been given to the smaller subset of preternatural individuals who kill dozens of people in separate events. It was a little disconcerting to read about the medical professionals within their number, who had easy access and the means to carry out their crimes, often going unchecked and unsuspected for years. A cooling-off period or gap between killings is also an accepted criterion, and their victims are not thought to be randomly chosen. Spree killers, who may take the lives of a great many people in one day, tend not to be included in this category, and for some reason I’ve never fully understood, neither do the politicians and leaders responsible for the deaths of thousands or even millions of their fellow men.¹

From the vast volume of fiction, film, and TV devoted to the subject it would be easy to get the impression that killing multiple people is a common crime that’s happening all the time, everywhere. The data provide a different picture. There is evidence that serial killing can and does happen around the world, with reported instances on every continent, but even allowing for underreporting, poor or deliberately opaque data, and the ones that got away, we know that this kind of multiple-event homicide is vanishingly rare. I can’t give you definitive figures for this crime any more than I can for most other forms of violence; nothing is certain but uncertainty in this field, for a variety of reasons, from underreporting to different standards of classification and methods of data collection over time and different geographies. A search engine query about global figures for serial killing offers more than six million articles and answers. The majority of these will agree that serial killers are overwhelmingly male and an endangered species, falling into decline in recent years; this is in line with global crime statistics of all kinds, which demonstrate a slow decrease in all violence over the last quarter century.

One recent study that focused on the last hundred years, led by Professor Mike Aamodt at Radford University in Virginia in 2016, created a database which showed there were 29 serial killers caught and identified in the US in 2015, versus a peak of 145 per year during the 1980s.² Some FBI figures I’ve seen quoted put those numbers at a much higher level (over 4,000 in 1982, for example³), which only emphasizes the difficulty of data collection and a lack of universal criteria for comparison; but every source I’ve found supports the idea of a diminishing number. Some credit for this must go to improved detection and surveillance methods, and specialist units set up by different law enforcement groups to study and deter the perpetrators. Another major contributor is probably the widespread use of mobile phones and social media, which makes it much harder for people (whether victims or predators) to disappear without trace.

Law enforcement sources don’t publish country-by-country comparative lists of serial killers, but drawing from the same Radford study, the US is at the head of the pack by a considerable margin, claiming nearly 70 percent of all known serial killers in the world, and this is borne out by other sources I’ve looked at, from Wikipedia to various journalistic pieces. By contrast, England, which comes in second place, is at 3.5 percent, South Africa and Canada are next at about 2.5 percent, and China, with its vastly larger population, has just over 1 percent of the total. I don’t know why the US dominates in this way, but theories abound, from ideas about the lack of gun regulation there to their decentralized law enforcement to the dangers of American ultra-individualism. It may well be that the Americans are just better at detecting and telling us about them, thanks to a free press and a relatively open government. But the number of serial killers caught in the US per year is still tiny relative to the country’s total population of more than three hundred million, and it is also dwarfed by their “regular” homicide numbers. In one large American urban center, such as Chicago or New York, four hundred murders in just a single year are considered unremarkable. By contrast, that figure represents two-thirds of the annual homicide rate across the whole of England and Wales.

At the time I met Tony, I knew that there had been a few serial killers admitted as patients to Broadmoor, people with tabloid-generated pseudonyms like Ripper or Strangler. Although the majority of homicide perpetrators admitted to the hospital had killed only a single victim when mentally ill, these few repeat killers contributed to Broadmoor’s public status as a kind of grim receptacle of unspeakable evil. I knew that reputation, and it was enhanced by the hospital’s appearance as a red-brick Victorian fortress, although when I first went to work there, in 1996, the process of modernization had begun. I remember being struck at first by the seemingly endless doors and airlocks and gates, which required a complex assortment of keys that had to be drawn each morning at security and attached to my person at all times by a big, heavy leather belt. Initially it was cumbersome, but I got used to it. I actually developed a sentimental attachment to the extra-large belt I was given when I was pregnant with my first child, and I have it still.

Once inside the gates, my early impression was of a university campus, with different buildings scattered about and walkways between them. There were carefully tended gardens and flowering trees. Best of all there was the terrace, which had a magnificent view over four counties. I’ve always thought it was a massive act of kindness to give those men and women a place to walk, with a perspective that invited broader thinking and hope. There were high red-brick walls that circled the perimeter of the grounds; I’ve always seen them as a valuable divider between my personal and professional life, enabling me to leave my work behind each night, to be held securely until my return.

On the day of my first session with Tony, I arrived early to check in with the ward staff and make sure that the room I’d booked to work in hadn’t been snagged by someone else; as in every hospital I’d ever worked in, there were not enough therapy rooms at Broadmoor and there was always competition for space. I also wanted to set it up to my liking, with the chairs placed well apart, the patient’s by the window and mine nearest the door. “Never let the patient block your exit” was a bit of lore I picked up as a trainee, and I stick to it even now. There’s also something important about allowing a respectful space for reflection between the participants; that notion of social etiquette we refer to as “not getting into someone else’s space” is just as important in therapy, if not more so. I fussed about with the angle of the chairs, as if exactly the right placement might help me make a connection with this stranger.

I felt nervous and knew I was flying by the seat of my pants. For one thing, I didn’t have a lot of information about him, beyond what I’d been able to glean from the referral letter. There was still a records department at the hospital in those days, and a clinician had the authority to walk in and request to pull files on their patient, but then, as now, there wasn’t a complete record. We could assemble a collage of their family background, education, medical history, police files, trial proceedings, or prison documentation, but always with gaps. Ultimately, we knew we could only really get to know a person by speaking with them and hoping they would open up to us.

Today, such background documentation is held on computers, not piled into dusty box files, but that doesn’t mean there’s a button to press or a code to type in that will unlock a trove of valuable material. If anything, it is harder to get useful details now, in this era of increased information governance and new legal privacy protections, than when I started out. We jump through hoops and have to rely on a range of people in different functions who may or may not be disposed to assist us. Sometimes I feel a little like one of those hapless private eyes in fiction who must manage to charm a friendly cop or otherwise shuffle around begging for reliable information in order to uncover clues. Maybe this is one reason why I enjoy reading detective novels so much in my leisure time: it is pure pleasure to sit back and let someone else do the problem-solving.

I was not even clear about what I was hoping to achieve with Tony that first day, or what the work would entail. How would we ever know if he was “better”? And what would that mean for a man who had three life sentences and was unlikely to be released until he was an old man, if ever? I was also having some qualms about “practicing” on another human being’s mind as part of my education. If what I was offering was pointless for him but helpful for me, wasn’t I mirroring some of his own cruelty and exploitative behavior? I reminded myself that he must have had some need or purpose in requesting therapy, and I would have to find out what that was, even if it might not be straightforward. Deceit is a hallmark of psychopathy, which is a severe disorder of the personality that I knew was associated with serial killers. I realized it was possible Tony wanted therapy merely to help fill the chasm of time that he faced in custody. “If that is the case,” I thought selfishly, “I won’t learn much.” Maybe I’d been foolish to take this work on—but it was too late to back out now. Out of the corner of my eye, I could see through the reinforced glass in the door that a man was approaching, escorted by a nurse, and it was time to begin.

“Mr. X? Good morning, I’m Dr. Adshead, thank you for coming to—” He interrupted me, his voice gravelly and a little brusque. “Tony.” It sounded like he might be anxious too. He allowed me to usher him in and direct him to the chair by the window, composing himself in a comfortable position without meeting my eyes. Gaze aversion is useful for all of us as a way to regulate intimacy, and I wouldn’t expect someone to make full eye contact at first. On the other hand, I knew Tony had worked as a waiter before his conviction, a role that required him to engage and to look strangers in the eye. I wondered in passing if he had made good tips. Was he charming to his customers? To his victims? I was conscious he might try to charm me.

I began by running through some important guidelines for therapy in secure settings. Chief among these was the principle that while he could expect some degree of doctor-patient confidentiality, if he told me anything that suggested a risk to himself or others, I would need to share it with the team looking after him. Our work together would be part of the care that his team was providing, and I explained that I’d be liaising with those team members on a regular basis, including the nursing staff, the team psychologist and the consultant psychiatrist overseeing his care. All of this was part of an effort to keep him safe and ensure continuity. Our meeting would last for fifty minutes, I told him, and we would need to adhere to that each time we got together.

I tend to keep to this boundary even though forensic hospitals are very different from Sigmund Freud’s comfortable consulting rooms. He initiated the fifty-minute session, or “therapeutic hour,” perhaps so that he could meet patients on the hour without them crossing over in the waiting room, or maybe he just wanted a break. Unlike Freud or most psychotherapists working in private practice, I don’t see people back to back in the course of my work, so I don’t need that buffer. Every day is different, but it would be unusual for me to see more than two or three patients in a day, partly because each session has to be written up in detail afterward, and also because I have to make time to liaise with the other colleagues who work with the patients I see. I had learned by this time that the first five or ten minutes after a session are invaluable for jotting down memorable phrases or ideas that emerged in the session, while they are fresh in the mind. I don’t take notes while people are talking, not least because it can make the interaction seem more like an interrogation than a conversation; it’s also not a good idea if the patient is paranoid, for obvious reasons. Most forensic therapists train themselves to memorize their sessions. When I was working with Tony, I was still honing this skill, and I was anxious to work hard at recalling some of the exact words people used in order to retain key images, metaphors, and their language of self. I found it helped me to divide the session into three chunks, to try to keep things from getting jumbled in my memory. That wasn’t always straightforward, and it would remind me of Larkin’s observation (paraphrasing Aristotle) that the novel, like a tragedy, has “a beginning, a muddle and an end.”

Tony nodded along as I talked him through the preliminaries, seeming neither concerned nor particularly interested. I thought he had the look of an actor—not a leading man, more the nondescript fellow hovering behind the powerful boss’s shoulder. His hairline was receding, but his bare forearms and hands were furred with black curls, with more sprouting from the neck of his T-shirt. He was short and stocky, verging on overweight; it is difficult for our patients to avoid putting on extra pounds, as exercise is somewhat limited, the food is starchy, and certain medications cause weight gain. He wasn’t showing any hostility or resistance, but after I’d finished my explanations he stayed silent. He just sat there with me for a long, long time, probably several minutes, and I wasn’t sure what to do.

Today, I’m not sure I’d let such a silence run for so long, especially in a first session with a patient who could be anxious or paranoid and might experience it as threatening. But at that stage in my training, I’d learned that a psychotherapist shouldn’t speak first, instead letting the patient start the session as they chose. I waited, and after a bit, I found I didn’t mind the silence. Nor apparently did Tony, who sat idly picking a hangnail on his thumb, not looking at me. And yet I had a sense he was taking the time to size me up, considering whether he could trust me. Eventually, I thought of a way out. “What kind of silence is this for you?” I asked. He jerked his head up, startled. Then he broke into a friendly, open smile. I could see how attractive he might be, how he would easily convince you to order the daily special or another glass of wine. “Nobody’s ever asked me a question like that before.”

I told him therapy could sometimes involve odd questions, trying to hold eye contact with him as I said it. His eyes were so dark they appeared almost black, as if the pupil were a broken yolk that had spread into the iris. He let his gaze drift off to one side, over my shoulder, toward the glass panel in the door just behind me, which looked out on the corridor. There were sounds of life out there, underscored by the hum of the ward TV, which was always on—usually tuned to MTV in those days. I heard people talking, a low and indistinct murmur some way off. Closer to hand, someone’s voice rose in complaint to a staff member outside, and we both listened until they moved off. Then he answered me: “I was thinking that it was kind of peaceful in here.” I thought I detected the careful diction that I associate with those for whom English is their second language. “This ward is so noisy,” he said. “Is it?” I asked. I had the sense he wasn’t just talking about that moment, that he had a larger point to make.

“There’s a man in the room next to mine who keeps shouting in the night and—” He stopped himself, as if he needed to monitor what he said, perhaps wanting to make a good impression and not appear to be a whiner. “I mean, I don’t want to complain, it’s better here than in prison, but I don’t sleep well… so it’s nice to sit quietly for a bit. And Jamie, that’s my primary nurse, he said this was a good thing for me to do, and he’s a good guy. I trust him.” I thought, but didn’t say to Tony, “But there’s no reason for you to trust me at this point,” and made a mental note to talk to Jamie as soon as possible. Tony’s comment reflected how important the role of the primary nurse can be; they offer individual support sessions to their patients and usually have the best understanding of their state of mind. My work has to be integrated with the work of the nurses, who spend so much more time with the patient than I do, and I have come to rely on their observations and greatly respect their insights.

Over time, as this case and others will illustrate, I’ve seen just how essential it is for the nurses and the therapist to work in tandem so nothing is missed—much like teachers and parents must liaise to help children develop and grow. This is not to say our patients are childish (although some seem stuck in their memories of childhood), but the demands of a secure environment inevitably limit patients’ autonomy and liberty, which can leave them feeling like children and dependent on professionals to help t...