The Devil You Know by Dr Gwen Adshead and Eileen Horne

Reviewed by E.B. Heath

“Over the years, I’ve come to think of my patients as survivors of a disaster, where they are the disaster and my colleagues and I are the first responders.”

The cover reeks of sensationalism – the title, embossed starkly over the face of a sad little boy, gives the impression of lurid narratives concerning paedophilia.  But that is not the thrust of The Devil You Know by Dr. Gwen Adshead and Eileen Horne. Nevertheless, I do hope that the ‘lock-them-up-and-throw-away-the-key’ brigade read this book.  As a long-time fringe dweller of that brigade, I had begun to drift toward the centre, but Dr. Gwen Adshead has redirected my angst toward empathy.  As the cliché goes: knowledge is power; Dr Adshead provides knowledge about the mind, and that must be powerful.

Dr. Adshead is an English psychiatrist, specializing in forensic psychiatry, maternal violence, trauma, medical ethics and the treatment of doctors, examples of which are detailed in the case studies. She is also trained as a psychotherapist. Dr Adshead has worked in a variety of settings – mental institutions, prisons and private practice. She received the President’s Medal for services to psychiatry in 2013. Eileen Horne is a writer and dramatist.  Readers will know then that they are in capable hands!

The Introduction, written by Adshead, is an excellent entry into the eleven chapter-by-chapter case studies that follow. Here she outlines the appalling lack of funding afforded mental health services in the UK.  I might add that, according to one of Australia’s leading health researchers Dr Patrick McGorry, the Australian situation is the same if not worse.  Readers will easily draw the conclusion that, if enough funds were allocated to remediate mental illness in the early stages, it would save so much more needed to imprison or treat perpetrators in mental facilities.  And make our communities safer.

Adshead refers to a colleague’s useful metaphor of a bicycle combination lock to explain the mix of stressors that align to cause someone to become violent.   They are: sociopolitical, attitudes to masculinity, poverty, childhood adversity, and substance abuse.  Lastly, causing the ‘lock’ to burst open into violence is an idiosyncratic variable that resides in the perpetrator’s mind.  It could be as simple as a gesture, a smile, or a phrase, which holds a particular meaning.  It is the job of the psychotherapist to help their patients to understand this variable, and how it fits into their history. The case studies that follow illustrate how that final combination clicks into place, or what prevents it from doing so. It takes time. Occasionally Dr Adshead questions her own prejudices (encouraging readers to do likewise) and admits to a few misjudgments.

An omission in this collection is a crime influenced by ideology which may or may not spring from similar variables.

The case studies detail a broad range of crimes. Tony is a serial killer who decapitated his first victim. Gabriel, an immigrant from Eritrea, whose experience in childhood was nothing short of horrifying, randomly attacks a person he does not know.  Lydia has an obsession with her counsellor, stalking him and his family. Zahra sets herself on fire so endangering the lives of others. Ian sexually abused his sons, and David, a doctor, loses his family due to an addiction to child pornography.  Oddly, the crimes that brought about my membership of the throw-away-the-key brigade evoked the most empathy.  In the telling, I felt compassion for Ian and David, their loneliness and suffering emanating from their own childhood, was palpable.  Readers are given an insight in these two cases as to how early childhood attachment influences future relationships. Ultimately, Ian and David were not able to come to terms with their shame.  Adshead explains that incest and child abuse, for both victim and perpetrator, is experienced as if some part of them has died. They are doing something suicidal as soon as they abuse a child.  Shame is such a soul-eating emotion.

Adshead does not intend to minimize the trauma that her patients have caused, rather she is advocating for readers to realize our shared humanity.  She is hoping that society will expand empathy held for those with physical diseases to mental illness.  However, I suspect empathy will not ameliorate fear, and it is logical to be fearful of destructive irrational behaviour. Understanding rather than demonizing is a good start, but only pro-active support will make a difference.  Necessarily this includes campaigning for politicians to make funds available for on-going research, earlier intervention, and expanding professional therapy services within communities and institutions.

It is clear there is so much work to be done; mental health and illness represent an unknown territory waiting to be discovered.  To quote Dr. Adshead: It is only through a staunch belief in every human heart that we move forward.


The Devil You Know


by Dr Gwen Adshead & Eileen Horne

Allen & Unwin

ISBN: 9780571357604

$39.99; 320pp


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