The other side of psychosis

MEMOIR: MOLLY McCLOSKEYreviews The Locked Ward: Memoirs of a Psychiatric OrderlyBy Dennis O'Donnell Jonathan Cape, 341pp. £16.99

WHEN DENNIS O’DONNELL was invited to leave his job as a nursing assistant caring for elderly men with dementia and go to work in the intensive psychiatric care unit, or IPCU, of a large hospital in central Scotland, his first response was, “I don’t know if I’m the man you want. I can’t fight.” The charge nurse at the unit who was wooing him said, “I don’t need fighters. I need people who can listen.”

O’Donnell’s first clue that he might, in fact, be doing more than listening was the five-day control-and-restraint course that preceded his entry into ward 25. The course was designed to teach nurses how to protect themselves and how to restrain violent individuals without injuring them; all of the patients on ward 25 were sectioned – meaning compulsorily admitted under a section of a mental-health act – and the nurse O’Donnell was replacing had, quite accidentally, broken a patient’s arm while restraining him.

O'Donnell spent seven and a half years working on ward 25, and his experiences there form the basis of The Locked Ward, a memoir he wrote with the stated aims of correcting misconceptions about the mentally ill, educating people about serious mental illnesses and how they are treated, and celebrating the human beings who populated the landscape of the most interesting job he ever had.

In describing daily life on the ward, O’Donnell presents a series of case studies that flesh out the abstract labels of mental illness. Among these are people who suffer from a wide of range of disorders: endogenous and reactive depression, schizophrenia, paranoia (a symptom that apparently can be present in more than 80 medical conditions), manic depression, sexual disinhibition, drug-induced psychosis and more. There is even a psychopath who sneaks into the ward: “He had a thing about IPCUs, secure units and high-security hospitals. He liked to get himself in there and cause ructions.”

A “staggering number” of women (and a couple of men) find themselves in ward 25 because they have been unable to cope with the scars of childhood sexual abuse – which makes the problem of mixed-sex wards all the more glaring. O’Donnell recounts several instances in which female patients (and staff) are subject to aggressive sexual harassment.

All of these people and their stories are, to varying degrees, interesting. But none of them is quite real. “Let’s make it clear,” O’Donnell writes, “that the patients I helped nurse are not the people the reader will meet in these pages. The patients in the book are all fictions . . . Similarly, my colleagues on the ward make no appearance in these pages . . . The people are fictions, the illnesses and symptoms are typical, while the incidents and emotions are real.”

In order to ensure confidentiality, O’Donnell not only changed “names, ages, genders, nationalities, physical attributes and other aspects of personality” but has, in the case of some patients, split aspects of their presentation between several characters and, in the case of others, created composites of many actual patients.

This is an aesthetic and psychological problem rather than an ethical one; O’Donnell is completely transparent about his methods, and breaches of patient confidentiality would be unacceptable. It’s just hard to know what to feel when reading faction. Or maybe it’s just harder to feel, because each “individual” we meet becomes representative of a type – the wise, caring nurse; the ignorant, sexist nurse; the depressive patient; the paranoid schizophrenic – and a degree of engagement is lost.

Like just about everyone in the hospital, I loved “Edward”. Edward suffered from bipolar illness but was “almost permanently in a state of euphoria”. He had a habit of asking staff to look at his naked and very generous “manhood”; it is an indication of Edward’s charm that such normally off-putting behaviour was in his case endearing. But because I didn’t know how many people “Edward” was comprised of, he felt hypothetical, constructed for my edification.

We can care deeply about characters in novels; we can certainly care about real people; but it’s hard to get emotionally involved with figures who are presented to us as though they are real – this is, technically, a work of nonfiction – and yet who are not. There may be no other way to write a book like this, short of focusing on a handful of patients whose informed consent could be secured.

There are other quibbles. There is a lot of clunky humour: “When he looked at me, my sphincter puckered up so far into itself that, if I’d stuck a straw up it, I could have emptied a pail of dandelion and burdock via the back door.” And O’Donnell is reluctant to sink his teeth into the larger issues. On the subject of medication, and particularly antipsychotics, he writes, “I don’t know enough about these things to be able to take sides. I can only say that I saw our patients treated with a variety of medications and also saw improvements.” After that many years on a locked ward, surely he could delve a little deeper.

And yet. And yet. O'Donnell has walked the walk in a very difficult realm, and his motives here are honourable. We come away with a better understanding of life on a locked ward, and the book should contribute to a more open discussion of mental illness and of suicide. (Many more people, both in Ireland and the UK, die from suicide each year than from road accidents, and one of the valuable points O'Donnell makes is that serious discussion of suicide reduces rather than increases the risk of someone attempting it.) There are countless books on depression, fewer on manic-depression, hardly any that give an insight into psychosis, in all its variants. The Locked Warddoes so, with forthrightness and compassion.

Molly McCloskey's latest book, Circles Around the Sun, a memoir about her brother's experience of schizophrenia and its effects on him and on his family, is due for paperback publication shortly