As I walk onto any one of the locked psychiatric units at our hospital I am immediately struck by the hum of intense activity. It’s like the startling feeling of stepping out of an air-conditioned apartment into the steamy height of a New Haven summer. Across from the nurses’ station, a psychologist interviews a patient retelling the story of constant childhood molestation as rivulets of mascara run down her cheeks. A confused nineteen-year-old man recently diagnosed with schizophrenia talks to an unseen critic telling him he should just “end it all.” In the heavily-fortified clinical station nurses enter vital signs, psychiatric technicians rapidly discuss overnight events and psychiatry resident physicians like myself collect all this data in order to present our patients’ clinical profiles on morning rounds.
While this bustling environment might suggest a power differential in which patients are at the mercy of their treatment providers, such an interpretation could not be further from the truth. The days of psychiatrists wantonly admitting patients against their will has been replaced with a legal procedure that firmly puts patients’ rights first. The question of whether a patient possesses “psychiatric disabilities and is dangerous to himself” is reexamined daily to ensure that the patient can be treated in the least restrictive environment possible. Just as the patient’s commitment criteria are constantly being reevaluated, long-term management strategies run alongside. Psychological and pharmacological therapies are used together to stabilize patients and transition them into outpatient treatment where their long term psychological needs can be met. Additionally, as many of our patients are in dire financial straits, housing and vocational opportunities are aggressively pursued by the treatment team’s social workers.
Perhaps you’re saying yourself, “This all sounds way too normal. Where are the screams? The shackles? And where, oh where, is ‘Nurse Ratched’?!” These are questions that have plagued the perception of psychiatric inpatient treatment since Ken Kesey’s seminal work One Flew Over the Cuckoo’s Nest and the classic movie adaptation. Certainly the screams occur. I wish I could say there weren’t situations in which patients need to be forcibly restrained. However, these events happen far less often than might be expected.
Just as our colleagues in surgery and emergency medicine note that fiction wildly dramatizes certain elements of their fields, inpatient psychiatry is also a victim of such inaccurate portrayal. In fact, much of inpatient psychiatric care involves a lot of routine work, like any other medical unit. We admit patients, treat them, and discharge them. That’s not to say incredible things don’t happen, of course. The reality of a locked inpatient ward is less outwardly dramatic than fiction but perhaps even more potent. True transformations occur during psychotherapy, medication management sessions, and art therapy classes. When a patient who has been kicked around his entire life finds an empathic ear, the click of connection is almost audible during a session. When just the right medication or psychological therapy falls into place, the heart and soul of inpatient psychiatry emerge. These moments don’t photograph well and similarly don’t move books or sell movie tickets. Pictures of cruelty sell better than the truth, unfortunately.
Despite the well-worn image of the inpatient made into a zombie by mind-numbing agents, I’m pleased to say that our patients, on balance, do well. And they are doing better with every passing year. Emerging medications have made patients’ lives outside of the hospital less encumbered by severe side effects such as drooling and confusion that previously served to isolate and stigmatize. Long-acting forms of our medications have been developed to help patients who are unable to manage having to take pills on a consistent basis. While celebrity rapid-detoxes and costly boutique psychotherapy treatments seem to command widespread interest, I am more excited to hear everyday people tell me that they have been admitted to an inpatient unit during a crisis and our now able to return to the satisfactions of life and work while managing their illness through a combination of therapy and medications. Although images from Cuckoo’s Nest and the like persist in the minds of many, I think the future holds an intense change in perception of the inpatient psychiatric ward. As our government has now recognized the increasingly high cost of lost productivity due to mental illness, perhaps the average inpatient stay will increase, the funding for outpatient care will similarly climb, and patients will have a greater shot at wellness. Such an outcome may not make for a great movie but is high drama nonetheless.
This piece originally appeared in HUM Magazine.
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