Patrick McGrath's latest novel, Asylum, is a brilliant addition to the literature of fiction set in public psychiatric hospitals. The author's style of writing, which has been described as Gothic, is particularly suited to describing heightened emotional states, poor judgment, and behavior disconnected from external reality—in short, the experience of what we, peering in from the outside, view as psychopathology. Interestingly, McGrath's novels are always in the first person. The narrator, a subtle presence, reveals as much by indirection as by direct narration.

In The Grotesque (1989), his first novel, the narrator is a mute, paralyzed country squire describing his destruction at the hands of his sinister butler. "In the absence of sensory information, the imagination always tends to the grotesque," the narrator observes as he spins his convoluted tale. Before he was paralyzed, he had devoted his life to studying a dinosaur fossil; afterward, his preoccupations become increasingly bizarre.

More interesting to mental health professionals is Spider (1990), a brilliant portrayal of the inner world of a person suffering from schizophrenia. Spider is deinstitutionalized. He is living in a group home; he is cheeking his medications; he is sinking deeper into psychosis; and his psychiatrist has decided, during a routine medication check, not to hospitalize him.

According to Spider, his idealized mother was killed by his malicious father and replaced by a prostitute. Spider got the notion that they wanted to kill him as well. He killed his new mother and spent the next 20 years in a forensic hospital. (The years in the hospital, before chlorpromazine, are well described.)

Along the way, Spider matter-of-factly discloses a immense array of psychotic experiences, from hearing the chattering of imps in the attic to feeling his innards shrivel. By the end of the story, the reader, initially believing Spider's account, becomes aware of how Capgras' sydrome has complicated the picture.

The narrator of Dr. Haggard's Disease (1993) is Haggard, a surgery resident who falls in love with an enchanting older married woman. After a ecstatic interlude, the affair is discovered and ended. While Haggard is hospitalized recovering from a hip fracture inflicted by his lover's husband, he develops a morphine addiction and is fired from his residency. His lover develops an obscure ailment and dies.

Starting a new life on the south coast of England, Haggard meets his lover's son, now a Royal Air Force pilot in the Battle of Britain. Eventually Haggard believes that something is transforming the RAF pilot into a woman, who happens to resemble Haggard's dead lover.

What is this disorder, the "Dr. Haggard's disease" of the title? Haggard fancies it might be a hitherto unknown endocrinopathy that is transforming the pilot. More likely, Dr. Haggard's "disease" is his protracted grieving over the disastrous love affair, which, magnified by his morphine addiction, leads him to delusionally conclude that his dead lover is returning to him in the body of her son. In Dr. Haggard's Disease, McGrath's rapturous prose heightens the lush overtones of self-preoccupation and detachment from reality that saturate the tale.

Reviews of McGrath's latest novel, Asylum, have been favorable and, drawing on the opening line—"The catastrophic love affair characterized by sexual obsession has been a professional interest of mine for many years now"—have focused on the theme of sexual obsession. That is the story of the main character, Stella Raphael, who is the wife of the assistant medical superintendent of a forensic hospital in the English countryside and who embarks on an imprudent affair with a patient.

McGrath, the son and namesake of a former medical superintendent of Broadmoor, the venerable English forensic hospital, clearly is intimately familiar with the world of a forensic hospital. In Asylum, McGrath's narrator depicts all sorts of boundary violations. This theme is probably the one of most interest to the professional community. These violations multiply and later in the story are intensified by the question of how to treat a forensic patient who had been a high-status member of the staff community.

According to the psychiatrist-narrator, the hospital "is a desolate sort of a place, though God knows it's had the best years of my life. It is maximum-security, a walled city that rises from a high ridge to dominate the surrounding country. . . . It is built on the standard Victorian linear model, with wings radiating off the main blocks. . . . This is a moral architecture, it embodies regularity, discipline and organization. All doors open outward to make them impossible to barricade. All windows are barred."

Asylum's tale is played out mainly within the structure of this "moral architecture," embodied in stone, by psychiatrists and their wives, by staff, and by patients. It is against this structure that the actions of Stella—and, more interestingly, of the narrator, Dr. Peter Cleave—resonate. Cleave is an elderly, long-time hospital psychiatrist who starts as a human manifestation of the asylum's moral structure.

"With the custodial staff I have always projected a sort of patrician affability," Cleave says. "They like it. They like structure and hierarchy. They know me well. I have been here longer than any of them." At the same time, he is genuinely fascinated by his patients' psychodynamics, and he believes individual psychotherapy can cure the criminally insane.

McGrath lays out the escalation of boundary indiscretions that lead to Stella's downfall—from her fairly innocent encounter with the patient Edgar Stark, through progressive secrecy and intimacy, to intercourse. At crucial points in the affair's development with Stark, an artist and sculptor convicted of killing his wife, Stella numbs her misgivings with alcohol, descending from social drinking to repeated intoxication.

In the course of their relationship, Stark is able to smuggle alcohol into his ward. This transgression is discovered, and at a staff dinner Stella learns that Stark is suspected. One passage from that occasion illustrates an essential point for administrators: "`All very tiresome,' said [the superintendent] in that slightly weary tone of voice he employed when something happened in the hospital that was annoying rather than alarming, one of the petty problems that interfered with the practice of forensic psychiatry; though one might argue that these sorts of problems were precisely the stuff of the practice of forensic psychiatric medicine, institutional forensic psychiatric medicine, that is."

The next day Stella tells Stark he is under suspicion. Stark escapes, using a set of her husband's clothes, including a set of hospital keys. Stella's role is instantly suspected, and the world of the Raphaels collapses.

Stella begins to travel to London for assignations with Stark, now in hiding. Cleave notices, and he confronts her one day with his impression that she is still seeing Stark. Stella immediately flees to London to move in with her lover. As her plight becomes increasingly desperate, she increasingly resorts to alcohol, deadening her ability to rationally consider her choices. Eventually she is arrested and returned home. Her husband is fired and finds work in an remote Welsh asylum. As her hopelessness and depression increase, Stella's alcoholism grows. Tragedy strikes, and through the intervention of her friend Cleave, now the medical superintendent, Stella is committed as insane.

And what of Dr. Cleave's role in all this? The boundary errors are not only Mrs. Raphael's. From early on, Cleave is aware of the relationship between Stella and Stark; it takes him longer to suspect the sexual component. He chooses not to intervene, to further his psychotherapy with Stark. After Stark escapes, Cleave confronts Stella with his suspicions about her affair rather than using the information to help capture the fugitive patient. This warning gives Stella the chance to run off.

And after the tragedy, Cleave says he is convinced that he is the man best qualified to treat her. "And while bringing her back to the hospital might seem unorthodox, or even, given the circumstances, positively dangerous, I was in a position now to make it happen."

They embark on a treacherous course of psychotherapy. Cleave notes that to Stella "nothing was simple anymore. I was the doctor, she the patient. We were on opposite sides. She required a strategy." Inauthenticity becomes the core of Stella's strategy.

Referring to Stella, McGrath eloquently describes what I would call the Insanity Acquitee's Predicament: "Her behavior now followed a predictable course. She began to cultivate a different attitude toward time. She had to think in terms of months, if not of years. She had to find a way to manage her impatience. With her medication reduced it became a problem tolerating boredom, and she was quite well aware that a single outburst of frustration would undo weeks of painstaking self-control.

"Nor must the effort be visible to the attendants. A calm, good-natured demeanor, amiable but not hysterical, composed but not depressed, this she knew was what we wanted to see, though what made the masquerade so difficult to sustain was not knowing how long was long enough, never being certain whether we noticed how well she was doing, and trying to cope with the idea that she was going to rot up here, grow old and die on the admissions ward. . . .

"You ceased to be mad when you began to behave as though you weren't in a madhouse, as though you weren't locked up with no real idea when you were getting out again. Once you appeared to accept these conditions as perfectly satisfactory, then you were seen to be improving and they moved you downstairs. This of course is a patient's perspective. From our point of view, the self-control involved in making these calculations and then acting on them is a necessary first step in getting better."

Cleave notes that "despite the fact—or because of it?—that I was, to Stella, far from the neutral figure generally considered appropriate to perform this sort of dynamic psychotherapy, I was becoming more convinced each time I saw her that the transference was occurring as I wanted it to, that she was shifting her dependence onto me. The thought gave me a peculiar and rather complicated satisfaction, which to my deep regret I failed properly to analyze at the time."

And then Cleave escalates his own boundary violations. They meet in his office rather than on the ward. Cleave, the superintendent, offers Stella Raphael, his patient, a gin and tonic. Over the drink, Cleave discloses his intent to retire. Then he proposes marriage, depicting it as a safe harbor, an asylum for her. Over the next few weeks, she lets him believe that she acquiesces. But tragedy strikes again, and Cleave is left with only Stark's artistic renditions of Stella.

Given his part in the development of the tragedy engulfing the Raphaels and given his ambiguous sexuality—he lives alone, he knows he is suspected of being homosexual, and at one point Stark calls him "an old queen"—what motivates Cleave? At the end, Cleave is left alone, and he reports, "I have not retired as I planned to. I still have work to do. Edgar remains on the top ward in the Refractory Block. . . . I now possess all the drawings he made of her in the studio, and also the sketch done in the vegetable garden. . . . I also have the head. I have had it fired and cast in black bronze. I keep it in a drawer in my desk. . . . It is a thin, beautiful, tiny, anguished head now, no bigger than my hand; but it is her. I often take it out, over the course of the day, and admire it. So you see, I do have my Stella after all."

And Asylum ends with Cleave's disconcerting remark, "And I still, of course, have him."

Patrick McGrath is an extraordinarily perceptive observer of those with psychiatric illness and of those who care for them, particularly in forensic hospitals. He uses his literary talent to tell compelling—although hardly upbeat—stories. His literature is an excellent fictional depiction of our work, its possibilities, and the effect of its failures.

Dr. Carmel is director of medical affairs of the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services and is former superintendent of a state hospital that included the state's only forensic unit.