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Changes: Dr Gwen Adshead

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Annie [00:00:06] Hello, everyone. My name is Annie Macmanus. Welcome to Changes. Before we get into today's guests, I wanted to look back a little bit at this series of Changes. It's been a rollercoaster ride of brilliant minds and compelling stories. We started with the first ever deaf winner of Strictly Come Dancing, the first deaf guest on Changes who helped us realise that we could change the podcast for the better with transcripts for those who are hard of hearing. We still do those now on my website. Joe Lycett joined us, one of the UK's most successful comedians who uses his comedy for change, particularly around LGBTQ+ rights. We had Hollywood actor David Harewood speaking about his experience with psychosis for Mental Health Awareness Week. We had Emily Eavis ahead of Glastonbury, an episode so many of you loved. Drag queen Ella Vaday doing our first ever live Changes. We had Kate Weinberg talking about her experiences of long COVID, the incomparable Irish writer Roddy Doyle, and the legend Róisín Murphy. We've had food critic and journalist Grace Dent on class and identity, that was one of the most talked about episodes of the whole series. So many of you got in touch about Grace. We had a Big Zuu on changing the face of television and most recently, Lady Unchained on her experience of the British prison system and life afterwards. Last week, the Irish actress Denise Gough had the most astounding story of change to tell, which I'm still getting messages from you about. People who are so moved by Denise's experiences and how she told them as well. So it's been a blast and there's so much more to come. And this week with regards to change, we are focusing on the idea of changing people's minds. Yes, we are diving into the world of forensic psychiatry with Dr. Gwen Adshead, one of Britain's leading forensic psychiatrists who is trying to change people's minds for the better. Now, Gwen works with the most violent offenders in the country, people who have committed all sorts of just unimaginable crimes. Serial homicide, stalking, sexual assault, arson, and Gwen has spent over 30 years providing therapy to these offenders inside secure hospitals and prisons. Her job is to help these people to better know their minds and in turn understand why people do what they do. She's worked for community services and in family courts, particularly with mothers who have been abusive to their own children in some way. And she's just co-authored a book called The Devil You Know: Encounters in Forensic Psychiatry. Last time I looked, it was in the top ten Sunday Times bestsellers, the paperback, which is fantastic. And it's so good. And the reasons why it's good is because as a reader you are brought into, in every chapter, a different violent offender, a composite of a violent offender. You're told of their offence, you're told of the motivations behind the offence, and then you meet them as Gwen meets them in the therapy room, you get your first impressions and you understand over time why they ended up doing what they did. So every character you're given the most unimaginable crimes, you know, people who've stabbed people to death, someone who murders his girlfriend by strangling them, a girl who sets fire to apartments while she's in them because she's so suicidal. People who are so broken and troubled. And by the end of each chapter, you have this kind of full 360 perspective on where they came from, how they grew into being people who are capable of committing such crimes. And you go from kind of, fear to empathy and from condemnation to compassion. That is the power of this book. It's not just changing the minds of the people that she's giving therapy to, it's changing the minds of the reader. It's so brilliant. This is one of the most interesting conversations we've had on Changes to date. I'm hoping it may change your mind and how you think about violent offenders, and also the concept of good and evil. That very binary idea of people being evil. So let's get into it. Delighted to welcome to Changes, Dr. Gwen Adshead. *Long pause*. You talk at the very start of this wonderful book that I've been reading and engrossed in,The Devil You Know: Encounters in Forensic Psychiatry, you say, "I've been privileged to witness the amazing capacity of our minds to change". So you are privy to that regularly in your job, watching how people change their minds about themselves and the world around them? 

Gwen [00:04:45] Yes. And it's one of the things that makes being a psychotherapist so exciting, so rich, so full. I'm very fortunate to be able to spend that time because not all psychiatrists work in the way that I do. I'm the kind of psychiatrist who works, particularly as a therapist, spending time listening to people. And so it is a privilege to sit and keep people company while they take their own mind seriously. And often people arrive in therapy and their minds are a bit all over the place. They've done something terrible or they've been through something terrible, often both. So in my world, a lot of what I do is helping people just to get used to the idea of thinking about their minds, and thinking about other people's minds too. And then that process of watching how people essentially almost have a new idea. Because so much of changing your mind is literally about having one new thought or one new idea, which then helps you take up a different perspective. And then once you take up a different perspective, all sorts of things are possible. 

Annie [00:05:58] Yeah. So these people that you're speaking of... I'm interested in your experience of public perception. What do you run into again and again Gwen, when it comes to what people say about violent offenders of this level? Those people that you deal with. 

Gwen [00:06:14] Well, I think there are two problems, really. One is the stigma about the people I'm working with. So they're often referred to in the public domain as monsters or 'those' people or- you know, just a variety of horrible words. But most of all, what comes across is the kind of contempt and the wish to reject and exclude those people. But the other side of that is that the people I work with have often internalised some of that, so they are also feeling ashamed and guilty. And of course, you know, to some extent they have things to be ashamed and guilty about. I mean, if you've done something terrible to somebody else, there is a kind of shame and guilt that comes with that. So I think that that is part of the problem, that people feel ashamed and guilty and rejected and that can raise questions or sometimes get in the way of people changing for the better. 

Annie [00:07:15] Yeah. Because again, you know, you see in the papers and in the media of these people being resolutely bad people, evil people. And is there an idea of people kind of, not even wanting to entertain the idea that these people could be anything else but bad? It's just nice and easy to put them in a box. 

Gwen [00:07:33] It really is. It's so easy to put people in a box. And actually what you've said is very important, because I think that what that- putting people into boxes marked evil or monster does is to dehumanise people. So when we hear about somebody who's killed a child or done something else terrible or horrible or scary, killed three people or whatever it happens to be, I think there's a very strong wish to kind of push them away and not see them as human like us. Try and distance ourselves. 'They're not like us'. 'I'm I'm nothing like that'. 'That's not a person like me'. 'That couldn't be a person like me'. But that dehumanisation process is actually, ironically, something that allows people to do cruel things to other people. So actually we're, you know, that process of dehumanising is something that we have to be very careful about. 

Annie [00:08:30] Mmm, wow. There's a quote in your book where you say, "I have come to think of evil rather like beauty. It is formed in the eye of the beholder". Can you tell us a bit about this, please? 

Gwen [00:08:40] Well, what I was thinking about there is that I often get asked about whether I believe in evil or what I think about evil. But I guess what I've come to think of is of evil as a state of mind that any of us could get into. And it's much more like an adjective than it is a noun. I don't really like the idea of evil being a thing that's out there that some people are tainted by and some people are not. I think that all of us have the capacity to get into an evil state of mind. And in that state of mind, we could do terrible things to others while telling ourselves that we're right. So, I think that we need to be very cautious about assuming that evil is something that happens, again to other people or to sort of, weird individuals that are not like us. 

Annie [00:09:32] This is a nice time for you to explain your analogy about your kind of take on the human mind. You talk about it being akin to a coral reef. 

Gwen [00:09:42] Ahh, well, what I was trying to get at here is, is that it's a kind of reaction to the idea of the mind as a computer. 

Annie [00:09:49] Right. 

Gwen [00:09:50] And so people are often talking about the mind like downloads, uploads, files, software, hardware, this kind of analogy. And there are two issues with that. One is that people always use the current technology to explain the mind, but what it excludes is any kind of natural organic model of the mind. So the idea of a mind which is constantly active like a coral reef or a hedgerow or a garden where life is constantly active, things are happening in lots of different layers. There are some parts you can see, some parts you can't see, some things you're aware of, some things you're not aware of. But it's a living system. It's a relational system and things that change in one part of the mind, then change in other parts of the mind. So it seems to me that whatever metaphor we're going to use to explain the mind, a computer is a really bad one because computers naturally work in binaries. On and off. Algorithms. That's how they work and they're great. No problem with computer technology but I think it's a bad way to describe human beings, and especially the human mind and especially also the body-mind relationship, which is so crucial to people's experience. So I think about the mind very much in terms of either, say, a coral reef or sometimes a really complicated garden. There are lots of different parts to it. Something that's living. 

Annie [00:11:16] Yeah. Could you give us an overview of your patients? And I mean in a very broad terms. I know in your book, you know, you take care to make sure that we're presented with a nice variation of case studies of different types of people, genders and stuff. But in general, you know, can you give us some statistics in terms of who you look at mostly? And who you deal with? 

Gwen [00:11:38] Yes. No, I think that's a really good point, Annie. We did want- I very much wanted in the book to get across a spread of different people. But the reality is that most of my work is with young men born in this country, mainly white although people from- of African and Indian and Pakistani heritage tend to be overrepresented compared to community samples. But the majority of people who get into trouble with the law for violence are young white men, and they are young white men who often have a substance misuse problem and who often have a long history of struggling to get along with other people, struggling to keep the law, struggling to feel connected to other people. So, when we talk about violence perpetrators, the vast majority are going to be well, they're going to be men. That's about 85%, 90% of violence perpetrators. And then they're likely to be young. The peak age for commissions of violence is between about 18 and 35. So the majority of people that I've met in my working lifetime have been men. And they are men who find themselves at a time of their life- either they have been regularly getting into trouble with the criminal law since they were teenagers, and now their criminal rule breaking has escalated into something much more severe, much more disturbing. Or they are people who have suffered from poor mental health or their lives who've never been violent because most people that- the vast majority of people with mental illness are never violent to anyone, but people with mental illness whose mental state has deteriorated very sharply and who act violently in that context. And again, it's rare, but when that happens it can be- err suddenly out of the blue, it can be very destructive and can often involve family members. That's obviously a tragedy for them. 

Annie [00:13:48] Talking about the kind of- and I know again, it's very hard to generalise, but just trying to get an idea of those people who violently offend, who willingly cause harm and pain to others. Is there common patterns in terms of why people do things like this? Common motivations that you come across again and again? 

Gwen [00:14:10] Yes, very much so. And I think it's a good moment also to remind ourselves that violence is not one thing. It's lots of different kinds of things. And one of the worst things we can do is to treat all violence as if it's the same. So for example, across the world, one of the commonest types of violence is violence that supports the illegal drug industry. Where violence there is just purely instrumental, it's getting business done, eliminating the opposition. This is the kind of stuff that we see in Breaking Bad, and I don't see people like that at all because those aren't people who are necessarily sort of suffering. You know, they do the job, they take the time, generally speaking. But the kind of violence that I see most often is really a combination of things. And in the book we talk about a kind of bicycle lock idea where a number of things have to be in place for violence to erupt. And we've already mentioned a couple of them. So being young and male is one. Substance misuse is a big problem. It's a big risk factor for violence because it distorts reality. Because it's that combination of being overwhelmed, usually by horrible emotions like anger, rage, panic, shame, hatred. If you imagine a horrible mixture of all those emotions just sweeping through your mind and your brain and then your reality is also distorted, perhaps because you've taken drugs or because perhaps because you've had a mental illness or perhaps because you've just, your whole mind has got distorted that way over a period of time. And then the victim does something or says something that acts as a kind of trigger. And that's particularly true for people who've experienced lots of childhood trauma, because we know that about 50% of prisoners for example, have experienced very high levels of childhood trauma. So these are traumatised individuals which has distorted the way that they see the world, and then they use drugs and alcohol and then they're swamped with horrible, painful emotions. And then finally, the last number is often something very subtle, and then boof, the lock opens in a kind of catechism of violence. And then before you know it, you know, those people are dead. And sometimes the perpetrator will be standing there thinking, you know, how did that happen? What just happened? And I've lost count of the number of people I've seen who said it was all a bit like a dream. 

Annie [00:16:47] Wow. 

Gwen [00:16:48] While it was happening. And then I kind of woke up and realised what had happened. So I think it's quite difficult to generalise about violence because there are different kinds of violence and people use violence for different purposes. And one of the things that I wished I'd learnt a bit earlier on in my career was that violence is a communication from the perpetrator to the victim. And one of my jobs, in a way, is to try to work out what that communication was and help the person, the perpetrator, understand what they were trying to communicate to the victim, and know what they would like to say now. 

[00:17:25] *Short musical interlude* 

Annie [00:17:35] Reading the book, it just keeps coming back to, it seems, you know, even though everyone is completely unique in terms of their story and how they got to that point of violence, but it feels like there's a kind of common thread, which is this internalisation of pain and a manifestation of pain that then as you say, the bicycle lock erupts. It's like this Pandora's box. And I suppose your job is to reverse that process of holding things in and to allow, you know, the very basic level of therapies to get things out of a person and allow them to express themselves, right? And understand themselves. 

Gwen [00:18:13] Well, I really like what you said about pain, because I think one of the things that we don't really take seriously enough in our understanding of mental health issues is about psychological pain. There's a part of our brain that deals with physical pain, but we have another part of our brain that deals with psychological pain, the distress that we feel when bad things are happening to ourselves or other people. And I think you're absolutely right. A lot of people that I meet have internalised their psychological pain, you know, enormous levels of distress. But they become speechless. They're struck down by their pain and their terror, particularly from childhood. And they're unable to find those words. And then the violence becomes a terrible embodiment and enactment of that pain inflicted and projected out onto somebody else. And you are absolutely right, so much of what we do as therapists with violence perpetrators is to try and help them find words for their pain. Try and help them just look at their pain. Because sometimes the pain has been buried very deep. And this is a real trauma survivors dilemma, which is in order to understand your pain, you're going to have to have a look at it. 

Annie [00:19:32] Yeah. 

Gwen [00:19:33] But to do that, is itself painful and frightening. There's a famous line from a famous play about a murder in which one friend murders- a man murders one of his friends. And he says, "I am afraid to think what I have done, to look on it again I dare not". And that's exactly what happens in my work. I work with people who are afraid to think what they've done and to look on it again. And they're frightened to go there. So a lot of the work that I do to start with is about getting alongside people and saying, we are going to have to have a look at this. But I'm going to keep you company and we're going to take it at your pace. And we are going to accept that what you did, that what you did and what you have to look at is terrible. But we're going to go there together so you don't have to go there alone. 

Annie [00:20:30] So much of it is erm, I mean obviously it's the perpetrators fear of what they've done, but it's also the perpetrator's fear of looking at what happened to them that initially traumatised them in the first place for them to have this psychological pain. But can I talk for a second about your fear and if there is any? I mean, as someone who grew up being terrified of the bogeyman, of 'the man', you know, the predatory man, any young woman I know is always afraid of this idea of a predatory man, and growing up and trying to explore that fear and where it came from. I think personally, the most frightening thing about humanity is when people are not in control of their mind and they're completely unpredictable. And you're sitting in a room with people like that day in, day out, kind of facing these people who are consumed by pain. And it's this idea of pain being frightening, not just to look at, but to experience someone else's pain is frightening. How do you think you have been able to do this all these years and where do you think this comes from, this kind of resolve that you have? And this patience and this desire to understand people who have this much pain? 

Gwen [00:21:46] Well, I think one of the things that you learn when you start to work with violence and people who perpetrated violence, is that violence is contextual. That most of the people I'm working with are not, as it were, such wildly, unpredictably and permanently in violent states of mind. They are often people who- the thought of being violent to the people who are looking after them, for example, in a secure psychiatric hospital would never cross their minds. It's one of the anomalies of working in a secure psychiatric hospital where we preferentially admit some of the people who've done terrible things, and yet the vast majority of our patients are never violent to anyone on a day to day basis, it's only a minority of people. And similarly, you know, I think the story of the predatory man is a really sad one, because of course the vast majority of men are not violent to anyone. And the persistent story that we get in all branches of media, that all men are dangerous to women at all times, I think is an extremely unhelpful one. And it's unhelpful because it's distracting from those men who really are likely to be violent and that we need to try and identify early on who they are and work with them early, instead of just kind of blanket- 'well all men are predatory', well it's just not the case. It's just not true. Again, it's one of those myths that, you know, we're much more in danger from people that we know than from strangers. You know, the vast majority of violence is carried out by a person, on a person who they know well.  Often a family member or friend or even an acquaintance. So actually, attacks by strangers on strangers are very rare. Which brings me round to the answer to your question, which is that when I go to see somebody who has been violent to another person, I think it's vanishingly unlikely that they're going to pose any danger to me whatsoever. Because I'm not their problem. You know, the person they attacked was their problem. I'm not their problem. And also, there are two other things. One is, obviously in the world that I work in, not so much in prisons but in insecure psychiatric hospitals, we do have a few people whose mental state is very disturbed and they are unpredictably violent. But they're only a minority, about 20%. I mean, it's a tiny minority, but also in secure settings, I don't take foolish risks. You know, I check out how somebody is. When I go to see somebody, I'll check in with the nursing staff. 'How's Jim doing today? Is he okay?'... 'Oh, Jim had a bad night. This might not be the best day to see him Gwen'. 'Okay, well, tell Jim I called and I'll be back tomorrow'. I don't want to have an incident, you know, I don't want to get involved because that's bad for the patients. Apart from bad for me. But I can promise you in a 30 year career, actually, the places that I got assaulted were in community settings or in outpatient clinics. Because if you work in an outpatient clinic, you have no idea what's coming through the door. Literally no idea. Well it's like these poor- 

Annie [00:25:12] Because you don't have this kind of ecosystem of care staff around them to tell you how they're doing or? 

Gwen [00:25:16] Well, there's that. But there's also the fact that, you know, in prisons and in secure psychiatric hospitals, we know that these guys have the potential for violence so we're ready prepared. And we also have a formulation and understanding of how that violence arose. So we're careful about these things. The other thing is that in prisons and in secure psychiatric hospitals, the perpetrators have had their power taken away. They've had their perpetrator role removed. They are now the ones who are constrained. They are now the ones who are vulnerable. They are now the ones who don't have any agency. A bit like a victim. So actually, they no longer have that power, and I'm part of a system that has power over them. Obviously, I don't go in and- 

Annie [00:26:05] Of course, exercise that power, yeah.

Gwen [00:26:07] I hope I exercise a therapeutic authority. You know, 'I'm doctor Adshead, I've been asked to come see you. How do you feel about sitting down and talking to me?'. And somebody says, 'why don't you...'. 

Annie [00:26:18] Bugger off! *Laughs*

Gwen [00:26:20] Why don't you go away doctor Adshead *laughs*. All right *laughs*. So I don't force myself on anybody. 

Annie [00:26:29] Yeah, I'm talking kind of about the idea of what you do, and this is a very crude way of putting it, obviously it's way more gentle, but the idea of stoking the fire of someone's pain. That sounds crude but people confronting themselves maybe for the first time in their whole adult life, confronting their crime, confronting their violence, that to me feels deeply frightening. It's kind of seeing someone do that. It's horrific in a way, because they're having to face their own horror. 

Gwen [00:26:58] I think that's absolutely right, Annie. And that's why we proceed very carefully. 

Annie [00:27:04] Yeah. 

Gwen [00:27:04] A person who suffers pain, if you hurt them unintentionally they may react with anger and threat because they're in pain. I mean, a lot of anger and threat is a defence against pain. It's a bit like, you know, if you step on a dog's paw unintentionally, they might snap at you. 

Annie [00:27:23] Yeah, it's exactly that isn't it, yeah. 

Gwen [00:27:25] It is. So a lot of the time we're talking about people in intense pain and fear. And that's where the technique comes in a bit. The practice comes in where you have to be going in and you're careful. You know, I look back on myself when I was training and think, you know, I was very clunky sometimes with people and I'd come in and say, tell me about what you're in for. And I didn't think about how shameful that might be for them or how difficult, or that it might be very, very painful and disturbing to have to tell a complete stranger that you killed three people. 

[00:28:00] *Short musical interlude*

Annie [00:28:18] Let's talk about radical empathy, because this is your process. Could you explain how you go about doing that? 

Gwen [00:28:24] Well, the idea of radical empathy has really grown out of my understanding that if we are going to help people change their minds for the better, we're going to have to go deep. So that means going to the root, the radics of things. We can't just stay with the superficial. And that's quite important because sometimes the superficials look pretty grim, you know, they've got multiple bodies or- But actually, we might have to go deeper. What lies beneath? And that's going to take time. You can't just barrel in. It takes time to establish a conversation, to establish a dialogue with someone where you can go deep. That's where going to the radics goes, the radical bit of it. But the other bit of the radical nature is that you take up different perspectives. And one of my jobs is to maintain enough distance that I can hold other perspectives apart from the patients in mind. So I hold in mind the courts perspective and the victims perspective, because that is really important. I'm only meeting this person because there's a victim somewhere and I have to keep that victim's experience in my mind. So that's the other bit of it that's radical, is that it's about holding different perspectives simultaneously, if you like. Does that make sense? 

Annie [00:29:41] It does. It really does, yeah. And it's empathy for all of the people, you know, for the victim as well as the perpetrator. 

Gwen [00:29:47] Absolutely. It's crucial. It's absolutely crucial that we don't, as a therapist with violence perpetrators, that one doesn't get into a kind of, I'm on your side and everybody else is against you. That would be- that really is dangerous and risky and fundamentally untrue and dishonest. So it can't work. 

Annie [00:30:08] One of the bits that really interested me in the book is when you talk about your sessions with this girl, Kezia. There's a thing that happens as the sessions progress where Kezia has this kind of soporific effect on you, where you start feeling sleepy during the sessions. And I wondered if you could talk about this and just the whole, what you learnt from that about what can happen to a therapist in terms of projected emotions?

Gwen [00:30:34] Yes, well, the first thing to say, where we start, is by a kind of understanding that if you work as a therapist, you have to be emotionally open to what's going on in the room and you have to be able to pay attention to your own emotions and emotional response to the person you're listening to, as well as what they're saying. This is why therapists have to develop their kind of listening skills and partly why therapists also have therapy themselves in order to have a working understanding of the kind of things that they're particularly sensitive to. Because sometimes, as you said so beautifully, sometimes my emotional responses will reflect something that another person is projecting into me. One of the ways that we manage painful emotions is to deny that we have them and put them on to other people. I'm not angry. You're the one who's angry. I'm not frightened. You're frightening. So that notion of projection is a very important way that human beings manage painful feelings and it gets people into trouble, because of course it kind of distorts reality and it disturbs the relational space between people. Before you've really established a good going therapeutic alliance, you know, sometimes all you get is waves of projection. Kezia was a composite. Like all the stories in the book, they're composites of multiple people I've met because of course I don't have- I'm not allowed to just tell other people's stories. So Kezia is made up of many, many people I've met who developed a severe mental illness, often in their late teens or early twenties and very sadly, very, very sadly in a disturbed state of mind when they were psychotic, when they had lost all contact with reality, often they had delusions, they often have hallucinations, and the ability to appreciate reality is just really gone. And in that state of mind, they can often come to believe that, for example, another person is a threat to them. And in this particular story, Kezia believed that a care worker in the hostel where she was living was was the Antichrist, and that she had to protect herself from the Antichrist. And so she killed this care worker. And the problem that she struggled with was terrible guilt, because although she knew that her mental illness had been the main driver of her dangerousness, her cruelty to her victim, nevertheless, she knew that she had done something terrible which she didn't want to think about. So what she was doing was two things, really, she was trying to go unconscious or try not to think about what she done, but I think she was also suicidal, which is a kind of ultimate unconsciousness. And so as she was struggling with those feelings of guilt and suicidality, she projected them into me and knocked me out. 

Annie [00:33:39] It's so powerful though isn't it. You must be so porous in that moment to kind of really take all this stuff in, to the point where your brain is shuts down. 

Gwen [00:33:48] Well, it's remarkable when it happens. And it doesn't, I mean, it doesn't happen every time, thankfully. It's rare to be completely taken over by another persons projections in that way. But it does happen. Probably the more common one is that people who feel overwhelmed by neediness and vulnerability and project and need to be rescued into their therapist. And if the therapist acts into that projection and says, yes, I'm going to rescue this person, I'm going to save this person, I'm going to be their protector forever, then you can get into a relationship which becomes very unequal and actually doesn't do the job and can lead sometimes to boundary violations. Nasty boundary violations. So that kind of projection is- it happens in different places. But that kind of unconsciousness and that- the word you used about porus is really important because I do think there's something about the boundary that each of us have between each other has always got to be semi permeable. If you think of all the people you love, you let something of them into your mind and you put something of yourself in your mind. And that's what relationality is. That's what relationships are. And particularly close ones. The boundary between yourself and somebody that you love is kind of semi porous and semi permeable. And that's why when somebody that you love is hurting, you feel so distressed yourself. It's not just about empathy. It's actually about that kind of attachment bond that's reverberating. And although I don't have exactly that kind of attachment bond with patients, there is a kind of attachment in which I'm committing myself to be open to their mind in that way. 

Annie [00:35:37] So in that moment you found yourself asleep. 

Gwen [00:35:41] Knocked out, yeah. 

Annie [00:35:42] So what happened next? 

Gwen [00:35:43] Well, I mean, I'm sure your listeners and you know, we all know that terrible feeling of fighting sleep. 

Annie [00:35:52] Yeah, very well. 

Gwen [00:35:52] It's really horrible. It is a horrible feeling when you really don't- So I was fighting that for a moment or two thinking, oh my goodness, what's going on? Why am I feeling so sleepy? And then I was probably only out for seconds, you know 10 or 20 seconds, tops. And when I woke up, she was looking at me. She was actually looking at me with a kind of concern and a kind of worry. But also I then felt very kind of ashamed and muddled. And of course, in those circumstances you have to be honest and I said, Kezia, I think I fell asleep just then. What did you see? She said, I think you were asleep, and that's really interesting, I think we're going to have to think about that. And I said, did you feel sleepy? And she said, no, not at all. But what I did first was to explore, what was it like for you to see your therapist falling asleep? There are a number of things that she could say, but I think mainly she said, I thought you weren't interested in me. I thought you were bored. But she said, I was also concerned about you. I know you're a doctor, I wondered if you'd had a busy night. *Laughs* and a lot of people I work with, particularly who've never been violent in their lives before until the psychosis hits, which as I say is really uncommon. I can't emphasise that too much. Most people who are psychotic are not going to be violent. But if you- that tragic, tragic situation where you become seriously mentally unwell and kill, but you've never been violent before and you probably won't be again, you know, these are people who have not lost their ordinary empathy and compassion. She was worried about me, that I might not be well. And we had to keep working on it because it did happen from time to time and then I was working supervision, trying to understand it. So it took me a bit of a while to work out that there was something in the room that was knocking me out and then trying to work out what that was. And that took a bit-. 

Annie [00:37:41] And what was it?! 

Gwen [00:37:41] I think it was that she was suicidal. I'm confident that she was suicidal. If she had not been projecting that unconsciousness into me, she would have been overwhelmed by feelings of wanting to end her life. Because she was mentally unwell, because she was mentally struggling, she didn't have the psychological space to be able to manage that horrible feeling of being suicidal. Then of course, being suicidal is a really horrible feeling, you know, feeling like your life doesn't matter, feeling you're hopeless and helpless. Feeling that you're a worthless kind of person because you've done something horrible. Those are horrible feelings to have. So rather than have them herself, rather than think, 'I might as well end my life', she put something into me which was about ending thought. And I did. My thought was switched off. My mind was switched off. 

[00:38:34] *Short musical interlude*

Annie [00:38:45] How do you walk away at the end of a working day and put it behind you, Gwen? 

Gwen [00:38:51] Well, I'm lucky I think, to work in a place- in places that have big walls *laughs*, and they also have kind of rituals of going in, a bit like an airport. You know how in the airport there are kind of rituals of going into a place? And I think for me, that's been a big part of my work that my- 

Annie [00:39:13] So doors, heavy doors are locked behind you. 

Gwen [00:39:15] Heavy doors, heavy big walls, go into my car, you know, sit down. You know, I have a little drive home. And by the time I get home, I've reminded myself that the work I do is only part of my life. A very interesting and important, important to me and rich part of my life which I feel very privileged to do, but it is only part of my life. 

Annie [00:39:38] It feels like it must seem so difficult to not carry this extra layer of sadness with you all the time when you're just aware and privy to other people's sadness. You know, you have this heightened awareness of the kind of dark corners of the human mind. 

Gwen [00:39:57] You are right. It is sad. You know, people often talk about, as you said to me earlier, now aren't you scared? Aren't they all mad and bad? But the overwhelming feeling, generally speaking, is sadness. Sadness of wasted lives, lost lives, the lives that have been taken by people, I mean, people who've killed in particular, not only have they taken somebody else's life with all the massive impacts that that has way beyond who they are as people, but including their own families, as well as the families of the victim and everything else, but actually, their own lives have ended as suddenly as their victims. They can never go back to the way that life was before. So, what lies ahead is a completely different life now that they've killed. And it's a life that initially begins with going to prison and going to court and all of that kind of stuff. But at the end of it, you know, at the end of it will be some kind of long term detention in a place that is not like ordinary life, doesn't have any of the pleasures of ordinary life or very few. I mean, it's not hellish and it shouldn't be. People still can listen to music, can get education, can interact with people, but it's not a life that any of us would choose because it lacks freedom. It lacks freedom and social acceptance. To be in prison or in a psychiatric, secure psychiatric hospitals is not a happy life. These are people who are not having a cushy number, you know, that kind of funny myth that grows up. 

Annie [00:41:44] It's kind of like it must make your job harder in that there's very little hope. So how do you help someone feel hopeful about their future when they've murdered? 

Gwen [00:41:57] Yeah. No, your- I mean hope becomes a duty. 

Annie [00:42:02] Right.

Gwen [00:42:02] Actually. Hope is very interesting. It's a very interesting human phenomenon. Much more interesting than evil, really, because- 

Annie [00:42:12] Talk to me, Gwen. 

Gwen [00:42:13] *Laughs*. Well, because hope is also something that, you know, human beings can't do without. We can't live without hope. And yet hope is something that we have to work on. We have to look for. We have to have faith in. Hope is something that we relate to, that we try and believe in. And it's part actually, it's part of being attached to people, it's part of love. In a loveless world, people need to be able to give and receive love and hope is part of that. So, I think you're absolutely right, Annie. One of the biggest challenges in forensic mental health and working with offenders is keeping hopeful. And often that's something about keeping our goals and expectations small. Sometimes for me, I'll be hopeful because a man has actually managed to come to the session. Sometimes it's the first time somebody uses a metaphor to describe what's going on for themselves. That's a great moment, because that means that they're using their mind. Rather than just sitting there looking at me under slightly narrowed eyes, saying, well, you know what's happening? Aren't you going to fix me then? You know, what are you going to do? You've got to fix me up. And I'm saying, I don't think I'm going to be able to do that Mr. thing, but I'm interested in what's, you know, what would you like fixed? *Laughs* and what would fixing look like? So it's my job to try and- 

Annie [00:43:44] Engage their minds. 

Gwen [00:43:45] Engage, engage the mind. And I'm going to use language to do that. There's something about trying to help people to just say a word or two about what's going on for them. 

Annie [00:44:02] As a therapist, how has your understanding of what you do changed over the years? 

Gwen [00:44:09] Oh, wow. In so many ways. And that's partly because being a therapist is a bit like learning to speak another language. Because psychiatrists are trained in medicine, we speak the language of medicine. So when I initially started off as a psychiatrist and a psychotherapist, I tended to talk the language of medicine. You know, I tended to ask people about, you know, how they were feeling and what was wrong and what's been going on and a kind of general medical conversation, which is fun. There's nothing wrong with that as far as it goes. But it didn't leave much room for silence or reflection. It didn't leave much room for, 'I wonder what's going on today' and 'what's on your mind today, Jim?'. Rather than, 'what's wrong?'. 

Annie [00:44:57] Yeah, how can we make you better? 

Gwen [00:44:59] How can we make you better? How? 

Annie [00:45:01] As opposed to just, how can we engage your mind? 

Gwen [00:45:04] Yeah. How can we engage your- what's, I'm genuinely, you know, I'm genuinely interested in what's going on for you and see if you can tell me what's been going on for you. What thoughts have you been thinking? But to develop that self-reflective capacity, I had to develop my own self-reflective capacity. So I had, like many therapists, I had quite a lot of therapy myself. And that was very useful. 

Annie [00:45:28] And what did you learn about yourself in that? 

Gwen [00:45:30] In my first round of therapy, I learnt something about why I'd become a doctor, which was something to do, I think, with growing up with two parents who had both had physical health problems and were quite vulnerable in some way. And I was an eldest child and eldest children tend to be slightly overrepresented amongst the medical profession because they tend to be the third ones that take charge and try and be useful in the household. And then my second round of therapy was about why I was wanting to be a group therapist or why I was interested in other minds and how other people saw me. And then of course, I learnt things about myself that I didn't know because there's always something about ourselves that only other people will know. 

Annie [00:46:12] Of course. 

Gwen [00:46:12] It's a complete myth that we know ourselves or can ever know ourselves completely. There's always an aspect of ourselves that only other people will see. So other people saw my competitiveness. Other people saw my tendency to talk too much. Some other people saw compassion. Other people saw things that I hadn't thought of myself as having. Good things about me that I didn't know. But most of all, I learnt there about the music of interpersonal relationships and dialogue, the fact that when you get a group of people together, you're getting something like an orchestra, lots of different voices merging, lots of different kinds of psychological music happening. And you as the group conductor, literally have to be looking again at the high notes and the low notes and everything and the melody in between. So I learnt about the complexities of my mind and the mind of others. And then my last round of therapy, I learnt something about the importance of psychological pain and the importance of speaking aloud. That sometimes the only way to know what you really think is to say it aloud. But, and this is a really interesting but, sometimes it's just by describing what you're feeling, does in a way bring about a bit of processing. It allows the first kind of step into emotional processing to begin. So I learnt that for myself, something that I needed to get, it had taken me a bit of time. And then the last thing I learnt, I trained as a mindfulness based cognitive therapist, and the mindfulness training was incredibly helpful for learning something about how emotions and thoughts are in constant motion but they don't make up our entire self. We can watch our thoughts and emotions passing across our mind and that kind of ability to be aware of your states of mind is really helpful. Really, really helpful. Changed me a lot. 

Annie [00:48:13] Do you feel like, you know, talking about the thing that happened with Kezia, you're at your, Gwen's, ability to be completely open and make yourself vulnerable in that way. You know, to allow other people's emotions to be projected onto you. That feels to me like a very rare skill and something that not every therapist will have. 

Gwen [00:48:36] Well, I do think it is a bit like playing a musical instrument. Really. It is. And there are some people who are naturally talented at listening. 

Annie [00:48:50] But there has to be an element of strength in yourself in order to do that, right? 

Gwen [00:48:53] I'm not one of them is what I was going to go on to say. I mean, because I had to learn how to do it. The reason I say there are people with a natural talent is because I do, I work for a wonderful charity called The Listening Place, which supports people who are suicidal. And we get volunteers there who, you know, who don't work in mental health services or psychological therapies at all, but just have a kind of natural gift for listening and being open which is astounding. But I think that most of us have to grow that ability. It's never done. There's always more to learn about the human mind, including my own. 

Annie [00:49:29] How has the system around your work changed since you've been practicing? And also, I'm going to ask the horrible question or maybe it's good, I don't know how you feel about it, but I feel like it's hard. How would you change it to make it more effective? 

Gwen [00:49:47] Well, I have worked through a period of massive change in the mental health services in the NHS. I started working at a time when business models were being introduced in the 1980s. And I'm not saying that business models have no place in delivering health care, but they work very poorly in mental health services because mental health services need long term services. It's not like a hip replacement. Mental health services are about building relationships, and you can't have a system which builds on, 'right, you can come in and we'll give you a six week package of care, which by the way, you'll have to wait 18 months for *laughs* but until then you'll just have to sit there waiting and we'll discharge you at the end of it, and then you won't be able to come back for two years'. It's all about rationing, but actually it defeats itself because you end up making more problems than less. So the change that I would make is to rebuild those services. We obviously need to employ many more people, stop getting rid of the well-trained people, train up the less trained people. We've had significant cuts to mental health services, particularly in the last decade. So I'd like a reinstatement of all that money, please, and a reinstatement of all the therapists, the experienced people who were got rid of. 

Annie [00:51:12] But also, the floodgates have opened like, the need for mental health is so much more. 

Gwen [00:51:17] And it's good that we take mental health seriously, but it's a bit hollow if you know, you're going to say we take mental health seriously, but you don't provide the services. So the one thing we could do is to reinstate the services that we had to the level that we had in say, 2007, 2006. And also to stop with packets of care. Go back to a model in which you work with the same team in the communities you work with when you went into hospital. It's a continuous service. You can see them in outpatients for ten years if you need to. Because if that's the thing that keeps you working and functioning, that is the most cost effective thing there is. And that's what's so frustrating about it, because what we have here is so inefficient. The other fairly simple thing we could do is to bring back day hospitals. Not everybody needs to be a long term inpatient in psychiatric hospital, and for many people it's not a good thing. But we need many more day hospitals where we could offer a range of therapies, group therapies, occupational activities, education. We've got masses of stuff that we can do. And one of the great things that's happened in the last 25 years is we now have a really good evidence base for how different types of psychological therapies help people and change people's minds for the better. So we're in an excellent place to start. Just stop. Just stop running these services into the ground and trying to force people into private medicine. We need to stop doing that. That's just not a good idea. 

Annie [00:52:47] Yeah. Last thing I'm going to throw at you, Gwen, and this is again a quote from your book. "It is only through the staunch belief in the possibilities of every human heart that we move forward, even if we go haltingly and sometimes stumble". 

Gwen [00:53:02] Yeah. I do believe that. Human hearts and minds are extraordinary. And I've just been so privileged to be part of a profession, the part which just means relating to people and engaging with people and seeing how miraculous hearts and minds can be, even in a situation of great sorrow and tragedy. 

Annie [00:53:28] Well, thank you so much for this book which has been so enlightening and I think will really help change people's minds about what they see in the media. 

Gwen [00:53:38] Oh, I hope so. 

Annie [00:53:38] Violent offenders. It's such an insight, such an insight into the human mind and how violent offenders come to be. And I just loved reading it so thank you, Gwen. And thank you for your time and your wisdom. 

Gwen [00:53:50] Thank you for your lovely feedback, Annie, and it's been a great pleasure to talk to you. Thank you for asking me to talk with you today. 

[00:53:56] *Short musical interlude*

Annie [00:54:00] There you go. Gwen Adshead. What a fascinating episode. So grateful to Gwen for her wisdom and experience. Personally, I haven't committed any violent crimes in my life, but I would love Gwen as my therapist. Don't you think she'd be amazing? Spread this around to anyone you know who is a fan of therapy, who's an advocate of that process of understanding your mind and kind of doing the work. The book is incredible. I really recommend it as a read. The Devil You Know: Encounters in Forensic Psychiatry by Dr. Gwen Adshead and Eileen Horne. It's out now. We'll put a link in the show notes for you. It's a Sunday Times bestseller. It's doing so well. Next week, we will be back with a new episode of Changes Revisited. Looking back at some highlights from former series which you may have missed. Thank you so much for listening. Follow and subscribe to Changes. Leave a rating where you can. This episode was produced by Louise Mason through DIN Productions. Thanks so much, seeya!