On his first day as a trainee psychiatrist, Dr Benji Waterhouse –conflict averse, bookish, balding – receives a crash course in martial arts. A brawny ex-policeman with tumescent biceps exhorts the gaggle of junior doctors never to wear a tie unless they want to getthrottled, never to make a patient a cup of hot tea unless they want to get scalded, and to always sit in the chair closest to the door in case their life depends on making a quick getaway.
It’s the start of a litany of rude awakenings, documented in brisk and self-deprecating style. Waterhouse’s decision to specialise in psychiatry, for example, is dismissed by one medical consultant as “a waste of a perfectly good doctor”. A cardiologist tells him a psychiatrist is nothing more than “a social worker with a stethoscope”. Nevertheless, he arrives for his first job on an acute psychiatric ward buoyed up by the conviction that he is going to help his patients live happier and more fulfilling lives. The ward handover is dominated by a clipboard-wielding bed manager who sneers at the patients, belittles the junior doctors, and whose sole measure of success is how quickly he can pressure the team into discharging the inpatients. When Waterhouse meets his first patient – a young woman called Paige with a tortured history of neglect, abuse, prison, addiction and innumerable episodes of self-harm – the consultant in charge dismisses it all. “There’s no true mental illness there. It’s all just personality disorder and drug-seeking behaviour and there are no wonder drugs for that,” says the fearsome Dr Glick (names have been changed). Even Paige’s threat to jump out of her flat window is derided, since she only lives on the second floor.
That night, Waterhouse tosses and turns, haunted by the revelation that modern NHS psychiatry seems to be less about saving minds and more about saving bed space and finding plausible reasons to justify withholding care to save on resources. After only one day in psychiatry, he’s too horrified to sleep: “I had never imagined I’d query the legitimacy of people’s suffering, use phrases like ‘bed blocker’, and only offer them help if jumping from a certain floored window would create a big enough splat.”
If this sounds like a sentence Adam Kay could have written, that is surely not unintentional. Like Kay, Waterhouse has an alter ego as a standup comedian. He describes his memoir as a “fly-on-the-padded-wall account of my decade working in medicine’s most mysterious and controversial specialty”. In his medical school interviews, he confesses, he referred to cancer as a “growth industry” and told the interview panel he was “really looking forward to working with bodily fluids”. The book adopts Kay’s wildly successful formula of mordant wit, lurid vignettes and closet softness, all the way down to the wry footnotes that pepper many of the pages. Waterhouse even addresses the potential inappropriateness of using comedy in a book about psychiatric patients by making a gag about parity of esteem between physical and mental health: “If we’ll happily laugh at the shopping list of things found up people’s bodily orifices, surely we must also sometimes acknowledge the dark absurdity of the human mind?” A TV adaptation is in the works and Waterhouse’s publishers must be hoping he will do for psychiatry what This Is Going to Hurt did for obstetrics and gynaecology, namely, deliver a gazillion book sales.
Happily, nothing about this book feels derivative or stale. It has a freshness and verve that sets it apart. Unlike Kay, whose books about medicine burn with the savage desperation of someone destroyed by intolerable conditions of work, Waterhouse is still a practising doctor. He cannot let rip with mockery or derision. His humour, of necessity, is gentler and kinder. We find ourselves wincing, in real time, as this idealistic young clinician discovers the wretched inadequacy of NHS mental health services, the myriad ways in which they fail patients. Though his unnamed London hospital is filled with some of the most severely unwell patients in the city, there is neither a ward psychologist for talking therapy, nor sufficient staff to engage meaningfully with patients. Why not, he muses despairingly, “just fill a vending machine with antidepressants and antipsychotics”? Far from being a place where the sick are helped to heal, this therapeutic environment is little more than a holding pen with chemical restraints attached.
Waterhouse is inexorably sucked into the dystopian system, increasingly adopting the “robotic professionalism” of his seniors and learning to win their favour by conjuring creative ways not to admit patients. At one point, he even tries to wriggle out of seeing a smashed and broken patient in A&E by questioning whether they had chosen to hurl themselves from the left or the right side of “Suicide Bridge”. With luck, they’ll have landed in the postcode of the neighbouring psychiatric team, making them some other exhausted on-call doctor’s problem. Needless to say, this transformation from wide-eyed idealist into self-preserving cynic comes at deep personal cost. Waterhouse’s own mental health begins to unravel. Weekly sessions with a psychotherapist expose the darkness of his own, supposedly idyllic childhood. His thoughts of self-harm become more intrusive.
Without giving anything away, what is unwavering and beautifully described is the inspiration Waterhouse continues to find in his patients. He has that essential trait of all good doctors: a sincere and lasting tenderness for his flawed and frail, crude and complicated, broken and brilliant fellow human beings. Mental illness, he observes, is at least as much to do with the problems of living as it is with disordered biology – a point Rishi Sunak would do well to remember next time he pillories the alleged benefit scroungers of “sicknote Britain”. Too often, writes Waterhouse, it is “poverty, antisocial neighbours, crap housing, bereavement, loneliness, a lack of opportunity, purpose or hope” that cause his patients’ lives and minds to disintegrate. Imagine what a difference having a government that cared could make.
Ultimately, this is a campaigning work, both brilliantly funny and deadly serious. Waterhouse slams the “shameful” underfunding and a staffing crisis that has caused the number of psychiatric inpatient places to fall from 67,000 in 1988 to 18,000 in 2019, forcing patients to be sent hundreds of miles away to the nearest available ward. It cannot be right, he argues, that in one year alone, psychiatric patients in England travelled the equivalent of 22 times round the world for “out of area” beds. In laying bare the shocking inadequacies of modern NHS psychiatric services, Waterhouse demonstrates the hypocrisy of politicians who post memes about mental health mattering while skirting over the question of money. His book is humane, hilarious, eye-opening – and deserves to be widely read.
• Rachel Clarke is a doctor and the author of Dear Life. Her book The Story of a Heart (Abacus) is out in September. You Don’t Have to Be Mad to Work Here is published by Jonathan Cape (£18.99). To support the Guardian and Observer order your copy at guardianbookshop.com. Delivery charges may apply.
