Book Review: You Don’t Have to Be Mad to Work Here by Benji Waterhouse

I have to admit to being a little skeptical about this one, after having seen an extract in the Telegraph that presented a patient experiencing psychosis with predictable emphasis on violence and aggression. But, I said I’d review this so here it is.

The book starts with a short preface about how psychiatry isn’t taken seriously by other medical specialties, alongside the dispelling of some myths. Waterhouse ridicules the idea that people with bipolar are prone to increased creativity despite a good deal of research suggesting that such a relationship is actually quite legitimate. We’re then treated to a section in which Waterhouse desperately tries to avoid taking on a patient who has just jumped from ‘Suicide Bridge’. Hoping that he’s jumped from the side that would place him with the other Crisis Team, Waterhouse is disappointed to learn that the patient is his. Ha. Ha.

We then start with Waterhouse’s first days as a psychiatric trainee, which includes experience of PAMVA (proactive management of violence and aggression) training, sometimes also called C&R (control and restraint) training. I’ve attended a few of these training sessions as an HCA, and I eventually became a PAMVA trainer. Waterhouse is right about the tone of these sessions, and how often people playing the role of ‘patient’ overdo it to the point where they no longer resemble patients at all. These sessions are often quite lighthearted, despite the dark undertones brought about by their purpose, perhaps as a way of coping. The result is often that staff don’t take the training seriously and thus, when actual violence occurs on a ward, they panic and risk hurting the patient. It would have been nice if Waterhouse went into this side of things in more detail, as well as his thoughts on managing violence on wards. This would have been especially interesting given that psychiatrists rarely ever engage in the restraints they so often commission.

The next chapter introduces Waterhouse’s clinical supervisor, Dr Glick. She is presented as a highly efficient, well-liked, yet unsympathetic character. This chapter is interesting because it presents Waterhouse as the only person on the ward who cares about patients. From his arrival and attendance at the morning handover to his accompanying Dr Glick to review Paige, a young woman with suicidal ideation and a personality disorder diagnosis, the impression is that the staff are totally lacking in empathy. This is a bold characterisation, and although there is unfortunately some truth to it, I’m unconvinced it’s as widepread as Waterhouse claims. At this point in the text, it appears as though Waterhouse is at the start of his journey toward a state of diminished empathy. His ‘Suicide Bridge’ referral seems to be occurring much later in the narrative timeline, at a point where he has inherited some of Dr Glick’s advice and outlook.

Chapter Three focuses on a lady with mania, who believes she is due to marry Harry Styles at 3pm on the day of her assessment, which also happens to be her birthday. We also learn, in passing, of a man due to receive an MBE who was wrongfully detained, as the award was mistaken for a grandiose delusion. Waterhouse does explore some meaningful themes here, like the power dynamic between clinician and patient (disrupted by this lady’s manic confidence and antipsychiatry leanings), and we also learn of Waterhouse’s personal feelings of loneliness and isolation.

The next chapter focuses on Gladys, an older woman with catatonia who refuses to eat due to Cotard’s Syndrome. Waterhouse focuses here on ECT (which he insists on calling ‘shock therapy’). While he ultimately concedes that ECT is effective, he lingers too long on antipsychiatric notions of ECT being unsafe, unsupported by the evidence, and so on. There’s mention of the old sham ECT trials, for example. We’re treated to a long list of his preconceptions, most of them erroneous.

Chapter five is about Anton, a man who presents with the symptoms of mild depressive disorder but whose depression resolves by getting back together with his ex boyfriend. Waterhouse explores the tension between pleasing his supervisor, by chalking up the improvement to fluoxetine that Anton never took, and acknowledging that sometimes symptoms clear up on their own due to a change in life circumstances. It’s, like the previous chapter, an appeal to antipsychiatry positions, and one can’t help but wonder if Waterhouse leans more in the antipsychiatry direction than any other.

The sixth chapter, Peggy, is about Waterhouse’s grandmother, who has dementia. The chapter also explores a history of mental illness in the family. This is the first chapter to strike me as sensitively handled, which is interesting. Although short, I found this to be an interesting and engaging section, free of the issues that plague prior chapters. Waterhouse writes gently and thoughtfully about both dementia and the more dismissive attitudes toward mental illness of the past. He also mentions being struck by his grandfather but is quick to minimise this.

Chapter seven is about Waterhouse’s attendance at a housewarming party, after having a conversation in seclusion with Jamal. Jamal has Truman Syndrome (or Truman delusion as it is given in the book). He believes he’s on a reality TV show. I’ve personally had this same delusion, and I found many overlaps in Jamal’s dialogue with my own reasoning and thought processes. Jamal also makes some astute points about race that lead Waterhouse to reflect on the greater incidence of psychosis diagnoses in minority groups, particularly among black men. He involves some important research, but it would have been nice to see more focus on social determinants of mental ill health in these groups. I don’t see Truman syndrome discussed all that often, so it was refereshing to see it mentioned here. We then follow Waterhouse to a house party, where he briefly tries to escape his professional identify as a psychiatrist. He uses this story to comment on how some diagnoses, such as ADHD, can be treated as fashion accessories that downplay the severity of serious mental illness. Waterhouse is quite right, and voices like Jamal’s are often absent from the conversation around mental health. People with serious mental illness are often too busy being ill.

Chapter 8 is about Graham, a man with bipolar affective disorder who is experiencing a grandiose delusion that he’s the son of God. In an interesting creative choice, Waterhouse introduces Graham as the son of God in the chapter’s opening paragraph. It reads of sarcasm, but is likely just bathetic, comic positioning.

I’m 30% of the way through the Kindle edition at this point and fear the review may become very long if I proceed in this chapter-by-chapter manner. As a result, I’ve decided to place the book down for a while. I hope to finish it but am not deeply enthused about doing so. Based on what I’ve read so far, it’s looking for comedy in the wrong places and inviting readers to share in that mistake. I understand that it’s being met with the usual fanfare of any traditionally published book, but it hasn’t resonated with me in the way that I’d genuinely hoped it to. Like Waterhouse’s standup, something just feels a bit off and at times even perverse.