The Glass House

Book 0: Menzies Mental Health

by Anne Buist, Graeme Simsion

Genres: General Fiction

Synopsis

A compelling, addictive novel for readers of Eleanor Oliphant is Completely Fine told with heart, humour and insight by Anne Buist and The Rosie Project's Graeme Simsion

Psychiatry registrar Doctor Hannah Wright, a country girl with a chaotic history, thought she had seen it all in the emergency room. But that was nothing compared to the psychiatric ward at Menzies Hospital.

Hannah must learn on the job in a strained medical system, as she and her fellow trainees deal with the common and the bizarre, the hilarious and the tragic, the treatable and the confronting. Every day brings new patients: Chloe, who has a life-threatening eating disorder; Sian, suffering postpartum psychosis and fighting to keep her baby; and Xavier, the MP whose suicide attempt has an explosive story behind it. All the while, Hannah is trying to figure out herself.

With intelligence, frankness and humour, eminent psychiatrist Anne Buist tells it like it is, while co-writer Graeme Simsion brings the light touch that made The Rosie Project an international bestseller and a respected contribution to the autism conversation.

'Highly engaging. Brings alive the frontline of mental health care' PROFESSOR PATRICK MCGORRY AO, AUSTRALIAN OF THE YEAR, 2010

Release date: March 27, 2024

Publisher: Hachette Australia

Print pages: 352

Sample

It’s an unremarkable Victorian terrace in an inner suburb of Melbourne. Only the closed curtains on a summer morning suggest that anything is amiss.

Behind them, the open living space is in disarray. Household items are scattered on the floor: cooking pots, cleaning products, a baby’s rattle. But there has been method in their placement. Below the sink, three rows of tinned food mark the start of a trail that runs to the front door: literal stumbling blocks for an intruder who wanted to take the shortest route to the kitchen bench.

A woman – small, dark-haired and visibly agitated – enters from the back garden in her dressing-gown, carrying a pot plant. She deposits it in the hallway outside the nursery, then fetches a stool from the kitchen. She climbs up with the plant and balances it on top of the door.

A laugh – unnatural, fractured – escapes her. It’s partly the image of the booby trap going off, partly a perverse satisfaction that they’ve chosen the wrong woman to mess with, and, perhaps, the only way her mind can deal with what she has to do next.

Back in the kitchen, the baby carrier is sitting on the bench. Matilda was crying all night and now she’s crying again. Sian pulls a kitchen knife from the block.

If I’d wanted an image to sum up everything that’s disturbed me in my first three weeks of acute psychiatry at Menzies Hospital – and, in a strange way, what I’ve loved about it – I have it now.

A slight woman in a Tweety Bird nightie and untied blue satin dressing-gown is walking down the white hallway of the Mental Health Service’s Acute Unit, flanked by two uniformed police officers. Powerless, vulnerable, and probably with no idea why she’s here.

Acute psychiatry is the emergency medicine of mental health: for the stuff nobody saw coming. Until someone close to them becomes paranoid or overdoses or begins cutting themselves. Or waving a knife around, as Sian Tierney, the woman being brought into the ward, did a few hours ago.

Today may be the lowest point of her life. In the next hours and days, we’ll have a chance to do something about it: to work out what disease or situation is behind the crisis, to treat it and to find a path forward.

The cops, a tall male and a wide female, swaggering to accommodate the equipment on their belts, look relaxed – smiling, chatting – but they’re not touching her. Seems wise. I’m reading in her body language the irritability that sometimes accompanies psychosis.
Don’t poke the bear, guys.

The Crisis Assessment and Treatment Team briefed me over the phone. No previous psychiatric episodes – meaning only that she’s not in our system, not that she’s never had one. Not coherent; her name was provided by the neighbour who’d seen her behaving oddly in the street and called the police. The police called the CATT guys. When she pulled a knife on them, they called the police again. The police took her to the Emergency Department, who sent them on to us. And it’s still only 11 am.

The female officer leans in and says something to Sian that I sense is meant to be reassuring.

Sian shakes her head, face set. She looks to be in her early thirties, perhaps five years older than me, but reminds me of some of the foster kids my family took in, delivered to our house overwhelmed and out of their depth. Attitude was all they had left.

Police, a knife, a person with mental illness. The consequences could have been way worse.

Omar, one of the nurses, steps out to meet them. He’s a big teddy bear with a tuft of corkscrew curls and a gap-toothed grin. His smart remarks and innocent expression have been circuit breakers on more than one occasion. I like him a lot.

He takes the paperwork from the cops and leads Sian into an interview room. I’m watching from the staff base, where we hang out to write notes, check test results and debrief. We being consultant psychiatrists, trainees, interns, nurses, our lone psychologist, social workers, occupational therapists and the occasional student. Plus me, a registrar, one step past house medical officer and two steps past intern on my medical career journey, working in psychiatry, but not yet in the official training program.

The staff base is crowded with computers, chairs and filing cabinets, with a reception desk at the entrance. Windows on all sides, like a fish tank. In fact, it used to be called the fishbowl, but patients assumed we were referring to their spaces rather than ours, and, understandably, weren’t happy with the implication of constant exposure and surveillance – and objectification. So it’s now the glass house.

There’s a noise behind me: Sonny, the martial arts instructor with schizo-affective disorder and a habit of exposing himself, has kicked the glass. Now he’s pacing, singing loud enough for us to hear: ‘We Gotta Get out of This Place’. In his current state, it’d likely be the last thing he ever did.

He’s in the High Dependency area: four bare-walled bedrooms and a common space with chairs bolted to the floor and a TV fastened high up near the ceiling. It’s for the patients who need a higher level of care and monitoring; in practice, that means those at risk of harming themselves or others. There’s a spare bed and, thanks to the knife, it’s about to be Sian’s. That knife has also disqualified her from a bed in a private facility, no matter what health insurance plan she’s on.

Omar joins us in the glass house and gives Sian’s file to my boss, Nash Sharma. He’s leaning back in his chair, legs stretched out, looking like a businessman at the end of a long day – stubble, open-necked white shirt, tailored pants slightly creased.

‘They did a drug screen in ED,’ says Omar. Most of our patients come via the Emergency Department. ‘No results yet. She says she hasn’t used. Ever, in her whole life.’

‘All yours, Hannah,’ says Nash, passing me the file. ‘I hope you realise I’m skipping an online course on bullying so we can do this together.’

The joke’s a bit close to home. The admin director’s position has been vacant since he was fired for bullying. If Nash is skipping a non-clinical training module, it won’t be the first time. And it won’t have anything to do with supervising me.

Nash catches my disbelief and smiles. ‘You know what turns people into bullies? Same as what we see with patients: there’s an underlying propensity, then along comes a trigger. Like trying to do a difficult job with inadequate resources, and then you’re asked to do just one more thing. Like a bullying course.’

We head to the interview room through the L-shaped Low Dependency area, which has views into two sides of the glass house. It serves the twenty-four inpatients who can be trusted, more or less, not to attack the furniture or each other. I suppose the glass walls to the garden are intended to create a feeling of space, but they only serve to highlight the high brick wall on the far side. Not much grows in its shadow. It’s still nicer than the concrete courtyard that the High Dependency guys get.

Sian is sitting forward in a stained vinyl chair, her blue eyes darting around the room. I sit opposite her, with Nash beside me and Omar off to one side, and give her a few moments to take us in, though I can sense Nash’s impatience. The interview room’s decor doesn’t inspire sharing of confidences: grey-tiled floor, nothing on the white walls except the emergency evacuation instructions. I remember how disorientating I found the Acute Unit when I first came here, less than a month ago. Without a mental illness.

I try to envision Sian in her normal life, out with a couple of girlfriends. She’s the bolshie one, dealing with the guy hitting on her friend. What is she making of us? Does she realise she’s in a hospital?

In the psych wards, we don’t wear white coats or scrubs. I’m in my usual short skirt and Doc Martens. My black fringe and glasses probably say law clerk more than psych registrar. Or government agent, if that’s what the voices are telling Sian.

I make a start. ‘My name’s Hannah Wright. I’m a doctor here, and this is Dr Sharma, our consultant psychiatrist. Omar’s one of our nurses. Do you know why you’re here?’

Sian takes a breath. There’s the tiniest quiver at the edge of her mouth but her voice is forceful. ‘It’s a screw-up. The cops said I just had to talk to you guys and then I can go home.’

‘How about you tell us what’s been happening first, and then we’ll talk about what we’re going to do.’

She sits up straight, hands in her lap, and tries out a series of expressions, from aggressive to accommodating, before settling on slightly too bright.

‘I had a bad night’s sleep, that’s all. My partner’s away and I’m not used to … being alone in the house. Noises. You know what I’m talking about.’

‘What sort of noises?’

‘Nothing. Just the house moving. I need to get home and … I’ve got washing to put in the dryer. It’ll start to smell if I leave it too long.’

Amazing what you learn in this job.

‘Where’s your partner?’ I ask.

‘Interstate. Western Australia. Working.’

‘Would you like us to call him?’

‘It’s got nothing to do with … I mean, he’s at a mining site. He has his phone off during the day. Please. Just let me go.’ She’s radiating so much anxiety that I’m feeling it myself, but I’m no closer to understanding its source. Time for the checklist: mood, anxiety, psychotic symptoms, medical history, developmental history …

She answers all my questions, but too quickly. No, nothing out of the ordinary has happened. Family in Melbourne; no problems with them. She isn’t feeling sad; she’s just been sleeping badly for the last week. Because her partner’s away and there are things to be done. Which is why she has to get home. To get that washing in the dryer. Let’s get this out of the way and we can both get back to what we were doing.

When I ask her if she works, she rubs her hands up and down her bare legs, sinews taut. ‘I’m a union organiser. On a break at the moment.’

For mental health issues? She’s being cagey. Like she needs to do something or be somewhere. And not the laundry. Nash leans forward.

‘You seem pretty stressed,’ he says to her. His accent is mainly Californian, but there’s a trace of Indian; it’s a reassuring mix.

‘Of course I’m stressed – wouldn’t you be? My neighbour’s a … she calls the cops and I get hauled in here. I haven’t done anything wrong, and I want to go home. I have to get home.’ She’s wringing her hands, speaking faster.

‘Why the urgency?’

Sian seems to soften; there are tears forming in her eyes. I’m not sure how much control she has over these quick-fire switches. She whispers something and I pick up the word safe.

‘What we still don’t understand,’ says Nash, ‘is why you were out on the street in your nightclothes, and why you were carrying a knife.’

Incongruously, she laughs. ‘Must have put it in my pocket by mistake when I emptied the dishwasher. That’s what happens when you don’t sleep. I need to go home and get some. Sleep.’

Her eyes dart past Nash, over his head and to the door. It’s not easy keeping up a conversation while there are voices in your head: They’re out to get you; you’re not safe here. Not that she has admitted to hearing them, but it seems likely.

‘We need to talk to your partner,’ says Nash. ‘If not him, a family member.’

‘There’s no-one I can call.’

‘You told Dr Wright you had a good relationship with your parents and siblings.’

‘My parents are overseas, visiting my sister.’

‘And your other siblings?’

‘There’s only one other. I don’t speak to him. He’s a right-wing nutjob.’ Her body tenses; she’s so brittle she could snap.

‘I’m sorry,’ says Nash, ‘but we’re going to have to keep you here until we get the blood test results and are sure you’re safe to go home.’

In an instant, Sian’s expression hardens. ‘You can’t do that. You have no right …’

‘I’m afraid we do. Do you understand this is a psychiatric facility?’

The CATT team have put her on an assessment order. It’s the first stage in what they used to call being sectioned. Before that, it was certified. As in certified insane.

There’s nothing insane about Sian’s response to Nash’s question, unless you count the sheer intensity of it. Her desire to get out seems to have enabled her to summon the mental resources and eloquence she likely uses in advocating for her union members.

She turns to Omar. ‘I want this recorded.’

‘I’m sorry,’ says Nash, ‘but we can’t do that. Dr Wright will make a note of anything you want to say.’

She looks at me, hard. ‘I want you to record that I’m being held against my will and am not liable for any consequences of that decision. I am not insane, and I have a right to refuse treatment. I refuse any drugs. I refuse anything that affects my thinking. No hypnotism, no … electric shocks.’

The mention of electric shocks seems to have stirred something up. She stops, looking terrified.

‘No shock therapy. Under any circumstances.’ She looks at me, then Omar. ‘You’re my witnesses. I demand to go home. Now.’ She stops, apparently exhausted.

I ask for her partner’s number, and she hedges. It’s on speed dial in her phone, she says. Which is … guess where?

The police secured the house. No-one else home but ‘stuff all over the floor, like a madwoman’s shit’, they’d told Omar. Nice.

—

‘No drugs, no ECT, no hypnotism,’ Omar says when we’re back in the glass house. ‘Definitely no hypnotism. I guess that only leaves lobotomy.’

I wonder if he jokes with everybody like this or is just messing with the newbie.

‘What do you think?’ Nash asks.

Sian is now in the High Dependency common area, watching the door. Looking for a chance to escape?

‘What she said about treatment: paranoia?’ I say. You’re my witnesses is weighing on me.

‘Hard to tell,’ says Nash. ‘Could be the psychosis, but if I had to speculate, I’d say she’s like that when she’s well.’

‘She seemed totally freaked out about electroconvulsive therapy.’

‘May have had it in the past. May have watched some bad movies.’

‘But should we take some notice of her objections?’

‘The problem,’ says Nash, ‘is that she doesn’t believe she’s unwell, so she isn’t taking into account the single most important fact she needs to make a rational decision.’

‘I guess.’

‘In case you’re wondering about the recording, the reason we don’t allow it is that if it ends up in court, you’ll have some other psych picking apart our interview technique and our conclusions. Second opinion is one thing, that’s another.’

Carey, one of the admin staff, has wandered over, apparently having nothing better to do. In a place where you have to try hard to stand out, Carey succeeds. The androgynous look, overwhelming aftershave and all-red outfits – including a striped suit, hat and red-framed glasses – are just the beginning. Autism spectrum disorder has to be in the mix. They perch on a chair, too close, listening in.

I turn back to Nash. ‘She’s not telling us everything.’

He nods. ‘Signs on mental state?’

I summarise the results of my examination. ‘Perplexed, anxious affect. Guarded. Possibly responding to internal stimuli.’ Meaning voices in her head.

‘Which suggests?’

‘Drug-induced psychosis, bipolar one or schizophrenia.’ This is Carey. Diagnosis at ten paces, by a ward clerk.

Nash says what I’m thinking. ‘And you decided this how?’

‘I read the CATT notes.’

And now – like we need another opinion – someone else chimes in.

‘We’re talking about Sian Tierney?’

The new participant in our impromptu case conference has swiped in at the corridor entrance, so she’s on staff, but I don’t know her. Mid-to-late thirties and slightly taller than me – I’d say 170 centimetres – but only because she’s in four-inch heels. Which means she’s not nursing or medical. Glossy blonde hair, designer clothes: she looks like a Fox News presenter.

‘Who are you?’ says Nash.

‘Nicole Ogilvy. I’m the director.’

‘Of?’

‘Of Mental Health.’

It seems Nicole is our new administrative boss. If so, I didn’t get the memo. Or it’s one of the constant stream that arrive every day in my inbox that I didn’t have time to read.

‘I think you missed the turn,’ says Nash. ‘Offices are back down the corridor.’ This is my domain: you don’t come in here asking questions until you’ve introduced yourself and asked my permission.

‘You must be Dr Sharma.’ Now she checks my identification badge. ‘Good to meet you, Dr Wright. You’re going to see me around quite a bit, getting a sense of how the service runs.’

‘And Hannah will be trying to do her job,’ says Nash.

I’m enjoying this exchange more than I should be.

Nicole ignores Nash’s barb and gestures toward Sian, sitting alone in the High Dependency common room. Sonny is pacing in the concrete courtyard. ‘Does she have a history?’

Nash looks like he might explode, but doesn’t say anything – lets the silence speak for itself. Carey decides to help out.

‘No record on CMI under the name and date of birth she provided to the CATT. In case you were unaware, CMI is the client management interface that records mental health admissions. And CATT stands for Crisis Assessment and Treatment Team. Although the word “team” is frequently added – redundantly.’

‘I was aware. Thank you …’ She trails off, waits, but Carey doesn’t offer their name, and the badge poking out of their red shirt pocket is the wrong way around.

She gives in. ‘Who are you?’

‘I’m Carey Grant. Non-binary, so they is the appropriate pronoun.’

‘What do you do here?’

‘I’m Professor Gordon’s research assistant.’ Ah. I did not know that. I’m still getting my head around who’s who in the glass house.

‘And you’re researching what?’

‘Professor Gordon and I are investigating patient perceptions of the admission process. I also manage his data. And perform various other tasks.’

‘Who pays you: us or the university? Don’t bother – I can guess.’ ‘Good. Because it’s confidential.’

‘Of course it is. So, unless you can show that you don’t report to me, I have a job for you. I’m guessing you’re pretty good with computers?’

‘I’m guessing that your guess is based on a stereotype which we should be avoiding here, but yes.’

Amazingly, Nicole nods and smiles, but her tone is condescending. ‘You’re quite right. Thank you for calling it out. But CMI only covers public psychiatric admissions in this state. Is that correct?’

‘That’s correct.’

‘Use your data management skills to find if she’s been admitted privately or interstate.’

Nash’s hand bangs down on the bench, hard enough that Carey jumps. Omar and a couple of the other nurses are barely suppressing grins, and Sonny, back in the common room, starts thumping the glass. Nicole just looks at Nash and waits.

‘This is my patient we are talking about.’ Nash’s voice is calm but emphatic.

Nicole is very still. ‘And this is my mental health service, which I have been brought in to drag – apparently kicking and table-thumping – into the twenty-first century, as per the Mental Health Commission recommendations. One of those is integrated patient treatment, which we can’t deliver if we don’t know the history.’

‘You’re proposing to use a busy person to do what a phone conversation with the patient’s partner will resolve in thirty seconds.’

Omar looks at me: ‘You got a plan for getting that number out of her, Hannah? I think we’re going to need the truth drugs.’

I shake my head and Nash turns back to Nicole. ‘If Carey finds something relevant, they report it to me. Here, in this ward.’

‘I may join you for the case meeting,’ says Nicole. ‘Does four o’clock work?’

Nash holds it in, for now, and nods.

As Nicole walks away, there’s some shouting in High Dependency, and I follow her gaze to see that Sonny has undone his pants and has his penis in his hand. I’ve seen him do this in front of a female patient before; she barely reacted. But Sian is right in his face. Giving it to him. Sonny has a history of violence: he’s not a guy to mess with.

I’m right behind Omar as he runs in. But by the time we get there, Sian has won. Sonny is zipping up, apologising.

‘Lucky we took the knife off her,’ Omar says, miming to Sonny what she might have done with it. He escorts Sonny to his room and I’m left with Sian – who turns her anger on me.

‘You saw what just happened. This place is the definition of unsafe.’ She lays it out: Why should an unwell person have to deal with shit that would never be acceptable anywhere else? She’s going to sue. She’d be safer at home. In fact, if we let her go …

I’m sympathetic to what she’s saying and impressed with her taking it up to Sonny and now to me. But she’s not going home.

Omar, back from settling Sonny, interrupts. ‘That was pretty gutsy of you,’ he says to Sian. ‘But be careful. You’re not in Kansas anymore.’

Perhaps it’s this realisation, along with her unaccustomed powerlessness, or maybe it’s her inner psychotic thoughts, but when I get back to the glass house, I see that Sian has retreated to her bedroom and is banging on the wall with her fist. The nurse hurries over, but by the time she gets there, Sian has sunk to the floor, like a child needing a mother’s comfort.

—

I’ve started typing up Sian’s notes when Nash’s mobile rings. ‘Yes? For god’s sake, can’t you …’

I’m only hearing one side of the conversation, but it’s enough to work out that the psychiatric nurse over in ED can’t do whatever it is Nash wants. He sighs. ‘I’ll be there in a few minutes.’ As he ends the call, he laughs. ‘Come with me.’

‘What’s happening?’

‘There’s a member of parliament insisting on being discharged. The nurse doesn’t want to get it wrong.’

‘Why’s he here?’

‘Jumped in front of a truck. On purpose, obviously, or they wouldn’t be calling us.’

‘And he’s refusing treatment?’

‘Physically, he’s fine, but apparently the truck’s not: don’t ask me why. So the driver was unhappy – road-rage unhappy. Someone called the CATT team, who brought the politician here, and the police brought the truck driver.’ Nash grins. ‘Our man isn’t out of danger yet.’

‘You want me to observe?’

‘I want you to make sure the truck driver doesn’t run into the politician— again. Can’t rely on the ED team; they’ll be flat out.’

‘On a Monday morning?’

‘The psych team are on a training day.’

‘What about Sian?’

‘Write her up for five milligrams of olanzapine stat.’

I guess that’s Nash’s way of telling me he’s diagnosed her as psychotic, and that her passionate speech about declining drugs and other treatment has meant zip. Intuitively, I agree with his assessment, but we’ve hardly got a full history.

‘Not too much?’ I say. It’s a big dose for a small woman who may not have had it before.

Nash shakes his head. ‘She’ll sleep like a baby.’

—

The Emergency Department is at the other end of the campus, in one of three new glass-and-steel towers. We cross the tree-lined road, then negotiate corridors and stairs because Nash doesn’t want to wait for the lift.

The state-of-the-art facility has two large workspaces of nurses and white-coated doctors surrounded by cubicles full of patients, relatives, trolleys and machines. A year ago, as a house medical officer getting a taste of different specialties, I worked in a place like this. For a while, I thought emergency medicine might be my career.

There’s a room, rather than a regular cubicle, for psych patients, with a window in the door. Nash looks in.

‘That’ll be the politician,’ he says. ‘The triage nurses will know where your truck driver is. If he’s settled down, you should be able to send him on his way.’

He knocks on the door of the psych room then enters, and I turn to see Carey striding down the hallway toward me. What are they doing here?

Carey at least seems to know what I’m doing here. ‘You’re seeing the truck driver, aren’t you?’

‘That’s the plan. But –’

‘Prof wants you to find out if he’s aware that the person he almost hit is a VIP. He’s hoping the answer is no, so probably not a good idea to ask directly.’

‘Thanks for that advice.’ And thanks for the heads-up that Prof’s involved. He and I have some history. I’m trying to stay out of his way for the next six months, at least until I get into the training program.

‘Actually,’ says Carey, ‘he’s not really a VIP. Xavier Farrell, backbencher. More an IP.’

‘You are looking for me?’ The voice – with a strong accent that sounds Middle Eastern to me – is coming from a cubicle adjacent to the psych room; its entrance is around the corner.

Carey smiles. ‘If that’s the truck driver,’ they say, ‘we know the answer to Prof’s question.’

I pull back the curtain to see a man of about forty seated inside: solidly built, eyes so dark I can’t see his pupils. A brief smile reveals crooked teeth.

He stands up and introduces himself as Ahmed. He’s been waiting for the nurse, who has presumably been distracted by the IP.

‘I can go now? I’ve settled down.’ He smiles broadly; he’s heard what Nash said. Out in the waiting room, there will be people literally screaming to be admitted but, like Sian and Mr Farrell, this guy only wants to go home. Everybody wins.

Nevertheless, now that I’m here, I feel I should do a risk assessment to determine whether he is a danger to himself or others. And for practice. With any luck, it won’t take long; I still have my inpatients to see, results to check and a family discharge m. . .