TThroughout my career, people have asked me why I do what I do. I am a psychiatrist and forensic psychotherapist; I have spent three decades working with people in safe prisons and hospitals who have committed violent crimes. I give therapy to those who struggle to articulate unspeakable things and accept their new identities as criminals.
This means listening without judgment to things that in any other circumstance would produce horror and revulsion. For example, a man’s account of how he killed four people and cut off one of their heads to make the removal of the body more manageable, or a woman’s insistence that the victim he stabbed was possessed by a demon. A man who insists that his ex-lover made him jealous recounts how he strangled her; A young mother blames “useless” medical professionals for her baby’s multiple trips to the ER. Why should we help “those people”? Aren’t our resources better spent helping your victims or other law-abiding citizens in need of treatment? These questions reveal a lot about the society we have created.
“Why wouldn’t we help?” is my usual answer. Here’s a nuance that some people may not want to acknowledge: In prison, the identities of victim and perpetrator are not always different. Most of our prison population qualify as both; recent studies in the UK Y the United States confirm that the majority of convicted offenders have an experience of trauma, abuse and violence at least four times greater than the general population.
The way a society treats the least of its members is a kind of barometer of justice. In the United Kingdom, as in many other countries, the punishment for infringement of the criminal rules is deprivation of liberty. Once someone is incarcerated, we are committed to helping them change and be less risky. Aside from a small subset of extreme cases, it is reasonable to believe that most offenders are able to return to the community after serving their sentence and live a productive, crime-free life. This is a concept enshrined in UK law since the Prison Act of 1779, which made the rehabilitation of prisoners a function of all prisons.
But that mission is not always fulfilled. Our justice system and prison programs designed to reduce recidivism often fall short. The resource endowment is insufficient; the most recent survey from the National Audit Office indicates that among prisoners in England and Wales, up to 90% have poor mental health, including post-traumatic stress disorder and depression. Perhaps only 10-20% of the most acute cases are seen by a forensic professional like me. Once released, ex-offenders face economic and social problems that can quickly bring them back indoors. Inside women’s prison property, for example, more than half of the women they face homelessness when they are released.
People overcome violence in what is known as the “age-crime curve”: most violent offenders it will give up over time, and rule breaking and harmful behaviors will decline rapidly after age 35. Treating young people effectively in jail makes them less likely to return in the future. And given the costs of keeping someone incarcerated (around £ 40,000 per year), providing therapy is time and money well spent: practical and compassionate in equal measure.
In my role as a forensic psychiatrist, I coordinate medical treatment in safe psychiatric hospitals, including Broadmoor, where I have spent much of my career. I also offer therapy, individually and in groups, to patients who want to see how their minds work. The process can be entertaining and difficult. Many of my patients lack emotional vocabulary and struggle with confidence.
But there are often breakthroughs, however subtle, and there is hope. I have met a jealous man who strangled his lover from self-righteousness and suicide to acceptance and a willingness to take responsibility for his actions. I have seen a woman go from being a victim of her mental illness to someone who reduced her risk by gaining a new understanding of her “demons.” Taking initiative is the first step toward recovery, and I am constantly honored when I see the changes that may follow.
I sometimes work with legal colleagues to assess a person’s state of mind for family or criminal courts. In family court cases, like the one about the young woman who blamed the doctors for her baby’s “mysterious illness,” I will recommend treatment. But it is often not available to mothers in need, another sad indicator of our society’s priorities. In criminal cases, the psychiatric evidence that I provide does not lead to people getting a more lenient outcome or a “comfortable” transfer to psychiatric care. The notion that a safe hospital is better than prison reflects how little many of us know about the double stigma of being a criminal and being mentally ill.
I can attest that most prisoners recoil from the prospect of being “freaked out” (sent to psychiatric care from prison or directly upon conviction) because of the stigma this implies and because they have more autonomy in prison. Prison can be boring and scary at times, but they usually leave you alone to think your thoughts. When I did group therapy sessions for homicide perpetrators, the inmates talked about watching the Big Brother TV show and compared it to their lives in the safe hospital. His time is very structured and people like me scrutinize his every move and thought. I wonder if that “comfortable” notion stems from the widespread belief that anything should be better than jail. Or perhaps the word “therapy” is associated with pampering, like a spa massage, rather than a hard, painful gaze at parts of your mind that you’ve been avoiding all your life.
Doctors go to suffering without judgment. We are not concerned with absolutes, but rather pay attention to what we can discover through listening, observing, and testing. Although there will be people who cannot or do not want to change their minds for the better, I have found that most violent criminals are interested in understanding how they got into this mess and how they can do better in the future. We know much more today about the miraculous capacities and plasticity of the mind, particularly the still developing young mind. We also have a wealth of research evidence on what types of therapy can make a difference. Not using such knowledge would be a kind of madness on our part. We all want the world to be a safer place. I suggest that the urgent question about the treatment of violent offenders is not “Why bother?” but “Can we afford not to?”
Dr. Gwen Adshead is a forensic psychiatrist and psychotherapist, and co-author, with Eileen Horne, of The Devil You Know
George is Digismak’s reported cum editor with 13 years of experience in Journalism