It would be difficult to produce a dull book on severe mental illness. It has always been a subject of fascination: in the eighteenth century Bedlam, Britain’s oldest psychiatric hospital, would open its doors to allow the paying public to gawk at the ‘lunatics’ held there. With this book, and with more enlightened aims, Dennis O’Donnell opens the doors on a modern-day Bedlam: the Psychiatric Intensive Care Unit (PICU), which houses those patients considered too disturbed and too risky for other inpatient mental-health wards. O’Donnell worked for seven years as a nursing assistant on a Scottish PICU, and this is a memoir of those years. It was written, he says, by way of tribute to the patients: ‘Their bravery and resourcefulness were simply staggering … What’s not to admire?’

The story is structured around the most memorable patients and events on the ward, with discussion along the way about the main diagnoses found there (schizophrenia, bipolar disorder, depression, personality disorder) and the treatments and care provided. Within a few chapters we have met Grace, who is intensely paranoid; Bill, who dresses bizarrely and talks in rhyme; and Donnie, so gripped with religious delusions that he assaults himself brutally one morning because he looks in the mirror and sees the devil looking back at him. And it only gets stranger and more hair-raising from there. We read of delusions and hallucinations, violence and hypersexuality, attempts at suicide and escape, and restraint and forced medication. We watch O’Donnell’s career follow a trajectory common among mental health workers: from fascination and intense involvement, to exhaustion with the patients and frustration with management, to the decision to quit.

It is an entertaining book: O’Donnell can tell a good story, and has material most writers can only dream of. But it is debatable how far he succeeds in his stated aims of humanising and paying tribute to the patients. He brings them colourfully to life, and his affection for many of them is evident, but it can all get a bit cartoonish. We hear about a lot of very strange behaviour, but are not given much encouragement to think with seriousness about what it might be like for any adult to be repeatedly gripped by mental illness and detained under the Mental Health Act – about how terrifying, humiliating, and traumatic it might be, about what it is like to be reduced to the position of dependant or naughty child: cared for, scolded, and at times physically invaded by ward staff. Instead we hear about Lawrence, ‘extremely mad and extremely violent’, around whom ward staff wear gowns, gloves, and face guards because he is ‘effervescent with HIV, Hep C and various other unpleasant letter combinations’ and is fond of spitting; and about the sexually disinhibited, manic woman who burst a blood vessel in her eye having unusually vigorous sex with a stranger in an aeroplane toilet. She, along with just about every other female patient described in any detail, is described as highly physically attractive: that is certainly not this reviewer’s experience of inpatient mental health wards.

And O’Donnell’s attitude to certain patients falls rather short of the ‘unconditional care’ advocated by the ward manager. He acknowledges this:

Most people are easy to get on with or at least tolerate … some you wouldn’t piss on if they were on fire. So it was in the ward, and why should it be any different? My whole thesis is that we shouldn’t expect people with mental disorders to be too different from anyone else.

With respect, that is a foolish thesis. The difference is that people detained in a PICU are considered to suffer from disturbances of mood, cognition and perception serious enough to absolve them of responsibility for their actions, and to warrant depriving them of their liberty and doing things to them that would be spectacularly illegal if done to anyone else. And they are on fire, if by ‘on fire’ we mean ‘in serious trouble’. And O’Donnell was being paid to provide assistance of a rather better sort than pissing on them.

Still more troubling are certain staff practices that O’Donnell seems to regard as unproblematic, but that would be considered serious misconduct on many other PICUs. Misbehaving patients are ‘roared’ at, ‘bellowed’ at, or given ‘bollockings’. One patient is ‘decked … with a flying tackle’ while trying to retreat to his room after assaulting a cleaner. Aggressive or violent patients are mocked, threatened, and sworn at. O’Donnell makes the helpful point that the patients on the PICU could some day be any of us, or our loved ones, but seems to forget the implications of this: suppose your mother became wildly mentally ill and was admitted to a PICU, where her illness made her aggressive and violent. How would you want her to be treated? Not in some of the ways described here.

Despite these flaws the book is a welcome contribution to the tradition of memoirs of mental illness. That’s because it is written not by a sufferer but by a member of the ward staff: one of the ground-level, round-the-clock mental health workers who daily dole out meals and meds, sympathetic ears, inappropriate bollockings, and physical restraint. These are the people who spend more time than anyone else with the severely mentally ill – apart from the severely mentally ill themselves, of course – and so their perspectives should be heard and their authority acknowledged.