Book review - You Don’t Have to Be Mad to Work Here: a psychiatrist’s life

Denise Winn reviews 'You Don’t Have to Be Mad to Work Here: a psychiatrist’s life' by Dr Benji Waterhouse (Jonathan Cape, 2024)

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Stand-up comedian and practising psychiatrist Benji Waterhouse may seem to play his subject for laughs but the humour that courses through this enjoyable book serves to home in attention on something less savoury. Yes, he says, it is great that mental health is now so much more ‘out there’ but, as he puts it, “the focus tends to be at the milder, more palatable end of the spectrum. Things like anxiety, depression, OCD, autistic spectrum disorder or the increasingly diagnosed ADHD. Those with chronic, severe labels deemed messier, uglier or outright feared – such as schizophrenia, bipolar, personality disorder or substance-misuse disorders – receive less attention.”

This book focuses on the people dumped with the latter labels, bringing to life what it really means to live with severe delusions, homelessness, dangerous partners and inability to manage overwhelming emotions and killing addictions. Having started out with touching trust in psychiatric diagnoses and treatments, Waterhouse ends up far more cynical about what he can achieve within the overloaded, overcrowded, red-tape-trussed system he is working within.

He enters a world that is not without compassion but where it is imperative not to let the revolving-door patients (known as ‘frequent flyers’) get admitted and block a bed (“there’s nothing we can do anyway”); where the first question to ask when phoned by A&E to see someone who has failed in a suicide jump is whether he jumped from the north or south side of the bridge – it might, with luck, be the other crisis team’s patch; and where, whatever else isn’t done, it is essential to enter a diagnostic code, otherwise the trust won’t get paid.

Every chapter focuses on a particular patient’s story, interwoven with wry commentary on the state of mainstream psychiatry. It is through an amusing episode involving the often violently psychotic Jamal that Waterhouse raises Jamal’s ‘paranoia’ about the preponderance of black psychiatric inmates and cleaners and caterers but dearth of black consultants, and bittersweet comedy highlights the tragedy of an elderly mother trying to care alone for a heavily built, belligerent schizophrenic adult son. The author ridicules himself for standing on a chair dismantling a noose in someone’s home and walking out with it, ignoring the bathroom cabinet full of potentially lethal medicines and row of chef’s knives in the kitchen, having secured a ‘promise’ that the would-be suicide will take himself to hospital.

In one powerful story, fellow junior psychiatrist Nafisa tearfully tells how she allowed a patient with severe depression to go alone (no staff available to act as escort, of course) to read in the park, as it was a nice day and he seemed happy. Instead he drowned himself. She found out that the book he had been reading was Sylvia Plath’s The Bell Jar.

“Millions of people have read Sylvia Plath and don’t go and put their head in an oven afterwards,” muses Waterhouse. “But I’m quietly wondering if in the inevitable investigation into what happened, people will discount the understaffing and the fact that Nafisa was forced into a level of responsibility she is not trained for and scapegoat her as a bad psychiatrist. Statistically, being a ‘foreign doctor’ probably won’t help in her favour either.” Yet Waterhouse does also accept that sometimes, for those truly out of control, there is nothing for it but seclusion and restraints and enforced medication, horrible though that all is.

No surprises here, but a powerful, moving – and very amusing – read.