Did Letby suffer from 'compassion fatigue'?Cheshire Constabulary/Getty Images

September 6, 2023   5 mins

When we look beyond the battle over identity politics, the great majority of us share a very clear idea about the way life should be lived. We should be allowed to grow and mature, then decline with dignity as we age, supported by “healers” — whether spiritual, mental or psychological — whom we trust to “do no harm”. With this in mind, it is perhaps the ultimate perversity that healers should intentionally seek not only to do harm, but to bring death. Perverse because it is a turning away from the sustenance of life — that one precious value we nearly all share — and towards death.

When we encounter murderous healers, as we have in the cases of the British GP-turned-serial killer Harold Shipman, the homicidal American nurse Charles Cullen, and now Lucy Letby, the instinct is to cry “monster!” and make every effort to distance ourselves from such horrific behaviour. Surely these people are mentally ill? Psychopaths, deviants: people totally unrooted in basic human compassion.

In reality, this doesn’t stack up. Shipman and especially Letby seemed to be confusingly normal people living mundane lives. They were well thought of — if that is, they were thought of much at all. Shipman was a former rugby player who expressed remarkably compassionate and forward-thinking ideas, very much current today, about care for people with mental disorders. Meanwhile, Letby has been characterised as “beige” — not a word that springs to mind for many serial killers. She was a fan of salsa dancing, adopting cats, and taking holidays with her parents while in her mid-twenties — and was so “nice” that doctors initially discounted her as a possible cause of the deaths. The explanations of her motives: that she had a crush on one of the consultants; that she feared never having children of her own; that she suffered from Munchausen’s Syndrome by proxy or psychopathic tendencies, seem contradictory.

In my many years of working with murderers, serial killers, and criminals with a range of complex mental troubles, I have learned that when things seem most confusing, the answer often lies in a person’s life experience, and especially in the “obstacles” they have tackled in their personal relationships. As psychoanalytic theory shows us, people are often poor narrators of their own reasons for doing things: instead, their actions tend to powerfully echo their life experiences. Harold Shipman, for example, at the age of 17 watched his mother die a slow and horrible death of lung cancer, eased only by the use of large amounts of morphine. This was exactly the method he later used to kill his own victims as they struggled (on the whole) with illnesses that they would have recovered from, something that as a GP he would have known.

When it comes to understanding this drive towards death, we must naturally start with Sigmund Freud. Freud believed that there were two “drives” in everyone’s unconscious: an Erotic drive towards pleasure, procreation and life; and a Thanatotic drive towards destruction, pain and death. Each is important because we all eventually have to face up to the temporality of sexual relationships and the inevitability of death. But unfortunately for those of us working in forensic psychiatry or psychotherapy, Freud wrote a great deal more about the Erotic than he did about death. This means that a lot of thinking about perversion — the turning away from life and towards death — has been filled in by other writers and psychotherapists since.

Estela Welldon, a forensic psychotherapist, writes particularly powerfully about “dancing with death”; the idea that for some people a closeness to death provides a kind of life-affirming excitement, a reminder that they are still alive. It doesn’t matter whether this is their own death, as is the case for people who self-harm or consider suicide, or the death of others who choose to express this outwardly (and certainly not always fatally if we think of extreme S&M sex play). Very often, this takes the form of what Freud called a “repetition compulsion”: a compulsive desire to recreate important circumstances from one’s past in a way that induces the excitement of the “death dance”, but provides a sense of control over it. Shipman is an obvious example, but I have worked with many male offenders who cannot seem to help but repeat upon their loved ones the violence they saw inflicted on family members by fathers they swore they despised.

For Letby, her own birth was a “near-death” experience; she was told that her life had been “saved” by the nurses who helped her mother through a difficult childbirth. This has been cited as the main reason Letby went into nursing herself. But what was it that appealed to her so much? A sense of debt to the profession, possibly, although it must have seemed awesome to her that another individual had such power over life, and that she herself could take on this power.

As someone who trains aspiring psychologists and psychotherapists, I meet a lot of “wounded healers”: those who chose to follow such a profession because of their own life experiences. There is nothing wrong with this, in itself, and of course talking therapies equip people with considerably blunter tools for helping and harming than those wielded by doctors and nurses. Yet several ambitious people I have trained have subsequently left the caring professions because the realities of working every day with suffering people can often be more oppressive and harrowing than it can be life-affirming. Young women who seem hell-bent on deliberately harming themselves; middle-aged men with depression so crippling they can barely mumble a sentence in their clinic session; people from migrant backgrounds who can barely speak English, but their distress and trauma seem to seep from their very pores and cause your voice to choke in your throat. All of these cases, day after day, and some of it reminding you of — even triggering — your own past traumas and obstacles. We politely call this experience “compassion fatigue”.

It shows great maturity to abandon your dream when you realise that your fatigue is so strong that you cannot continue. But I imagine that this must be even harder to do if you genuinely believe your life has been saved by the profession you have spent countless hours training in. In that case, where does this fatigue from a constant experience of death and near-death go? The natural, unspeakable response would be to try to exert some kind of control over it; to show that the life-affirming experience of her birth could be repeated through an equally potent act. But, lacking the skill to save truly sick babies, her only way to exert this power, to show that she still lived and her life was worth living, was to take the lives of others in her care. Quietly, and with minimal suffering, perhaps, but was this a choice of convenience rather than compassion?

As the respected forensic psychologist Naomi Murphy has said, to take life in this way is a callous, almost psychopathic response — but the uncomfortable truth is that it is also oddly human. Letby is not anything so straightforward as a monster or a psychopath. Confronted repeatedly with suffering and loss in a world she so fervently believed she belonged, her drive to sustain life became perverted into a drive to inflict death. Only in this way could she feel that her identity, her power — that instinct to care which, in others, kept her alive and then gave her a reason to exist — could be sustained.

It always astonishes me that while those of us working in mental healthcare are expected to receive regular, even daily, supervision and therapy to “detoxify” us from the psychic pain, those in physical healthcare — who, frankly, see far more death and trauma — receive no such consideration. In the face of suffering and death, which was already worryingly common at Countess of Chester Hospital long before Letby worked there, NHS workers are expected to simply get the job done. It feels unreasonable to suggest that, amid a staffing and funding crisis in the NHS, regular psychological support should be offered to those who regularly work with death. Yet at the same time, this would be one way to spot those for whom compassion fatigue had started to eat away at their empathy — and paralyse their drive to life.

Mark Freestone is Professor of Mental Health at Queen Mary University of London and author of Making a Psychopath. He is a consultant to several TV production companies including BBC America’s Killing Eve.