At parties, I used to explain to people who wanted to know what I do — I’m a psychiatrist — that caring for people with mental illness on a psych ward is like working in a place apart from the world. I don’t say that anymore. These days, the whole world feels like the psych ward. Everyone is discouraged by past harms and present fears. The people who need meds the most are the most reluctant to take them. Most everyone wants out, but many worry they will never leave, and everyone wonders how things will be on the other side.
And I certainly won’t be saying that at holiday parties this year, since I am quarantining with a breakthrough infection. Even if I was out of quarantine, most parties have been cancelled here in Colorado, where I live and work, because the state is entering its third wave of the pandemic. The state has fully vaccinated 69% of eligible people, but the hospitals are full, the Federal Emergency Management Agency is helping staff them, and the governor is enacting crisis standards of care.
In some ways, it’s the worst wave so far. In the first one, clinicians were galvanized. In the second, we knew the vaccine was coming. In this wave, we are short-staffed and short-tempered, exhausted by people threatening us for doing our best and threatening everyone’s health by declining vaccination.
It turns out that living with an endemic virus isn’t so different from being locked up on a psychiatric ward, and that if you want to get out of a restricted space you have to learn how to use confinement.
Psych wards are places where it’s hard to know when you can leave. When you ask when you will be discharged, my colleagues and I always answer, “When you no longer need to be here.” It’s a conditional answer that frustrates almost all recipients, even if it’s true. The evidence-based guidelines are just as conditional, recommending that you stay until the risk factors for acute danger are addressed.
In the pandemic, here we are, together, waiting out danger.
Psych wards are places that don’t have basic supplies. The nurses will take your shoelaces because you could use them to tie or bind yourself as an act of self-harm or suicide. It’s the same reason why there are neither knobs on the doors nor hooks on the walls. Hand sanitizer dispensers are often disabled because patients have been found crouching underneath them, triggering their motion sensors again and again so they can drink the measured doses for their scant alcohol content. (No matter what country songs say, hand sanitizer shots on the psych unit are the most desperate of drinks.) So you improvise, figuring out to how hold shoes together, open doors, and wash hands with what you have.
In the pandemic, amid widespread supply chain woes, we are all learning to improvise with what we have. Some real innovation will result from this forced improvisation.
Psych wards are institutional spaces that prioritize safety. The lights are always too bright. Someone is always monitoring your behavior. Safety trumps comfort — but there’s a reason for that: Even though people with mental illness are more likely to be the victims of violence rather than perpetrators of it, psych wards preselect for people experiencing thoughts of harming others. The Bureau of Labor Statistics says that while the average hospital worker is six times more likely to be intentionally injured at work than the average American worker, the average psychiatric hospital worker is 59 times more likely. Because intentional injury to workers is so common, when your illness starts to threaten the staff or the other patients, you will be asked to keep to yourself or take medications.
The next time those statistics are assessed, I suspect intentional injuries will rise across health care because so many nurses, physicians, and public health officials have been threatened and assaulted.
In the pandemic, when my health care worker colleagues and I talk about the necessity of masks and vaccines to ward off Covid infections for your family and for us, we are talking about similarly temporary restraints on liberty in pursuit of life-saving safety for you and us.
Psych wards work only when they are staffed by skilled nurses who help by being present. On every bad ward I have visited, the nurses were absent in one fashion or another. There were too few of them, or they didn’t have time for the patients, or they relied on policies instead of presence. The worst nurses had failed their way off medical and surgical wards and ended up in psych wards. On every good psych ward I have seen, the nurses chose to work there as a reactive act of altruism after a personal or familiar experience with the ravages of mental illness. They said consoling words, like “I cannot imagine what you are going through, but I’ll be here for you.”
Good nurses talk, sing, and problem solve patients out of difficult places. Unlike the unit’s televisions, which enrage or pacify, a good nurse can see and understand you. The good nurses align with you, not with your interpretation of events, by endorsing you, not your anger, helplessness, or paranoia. They recognize your emotions, but without sharing them.
Doctors like me come and go, making our rounds and then leaving. Nurses remain, day and night. At least they did.
In the pandemic, psych and other wards are short nurses more than ever before, with nurses being a significant part of the reduction of the American health care workforce by 450,000 people since the pandemic began. And while medications help, nothing is better than a good nurse, so we need to figure out how to get nurses back to the bedside.
Psych wards are places where people say all kinds of things, because these units welcome all comers. I often find myself jotting down a powerful phrase, a striking sentence, or, in the case of a person with mania, a performative paragraph. Listening to them all, I am struck by how people with mental illness can magnify a cultural moment. Sometimes they distort it, but they often hear the messages rightly.
Psych wards have tables in the dayroom where a person can say something strange or provocative, giving voice to previously unvoiced thoughts, and they can do so safely — if the unit provides enough structure.
In the pandemic, we don’t have a shared dayroom with the right structure to remind us of our shared vulnerability. The place where we now commonly meet people different from us — social media — is designed to profit off our differences. To survive the pandemic, we need more in-person places where we can encounter people from different tribes.
Psych wards are places where people don’t experience you as yourself. No one ever does, of course, projecting past experiences to their present encounter with you. But on a psych ward it feels acute. You are likely to be experiencing negative emotions such as anxiety, discouragement, and uncertainty, rather than any kind of emotional equanimity. Reacting emotionally, a patient can experience a doctor or nurse or other health care worker as a lover, a jailer, and an alien — all in the same conversation.
When working on a ward, I listen to what a patient says, but also how and to whom. Are they talking to me or their unforgivable mother, their irresistible ex, or their hostile neighbor? When I listen to someone, I learn to ask myself, “Who is this person really addressing? How can I work with them so they will experience me more as myself rather than all that they are projecting upon me?”
In the pandemic, social distancing deepened social polarization. To defeat the virus, we need physical distancing, but the kind of social connections where people encounter each other as something closer to themselves.
Psych wards work best as immediate responses to acute emergencies, not regular responses to chronic problems. A few years ago, several colleagues and I examined the data on who benefits from being on a psych ward and found that hospitalization most benefited people with acute illnesses. The ward serves as a kind of temporary environment that prevents someone from making an irreversible error, like a fatal withdrawal from substances or a final overdose or suicidal act. What psych wards are least helpful for is helping people who have been in one many times before, because they are often the individuals who are refractory to the available treatments.
In systematic reviews, the best predictor of rehospitalization is previous hospitalization. A psych ward may feel good if you have an acute problem and are grateful to have a group of professionals rallying around you. It’s likely to feel terrible if you have chronic mental health problems, because you know the limits of treatment and have little confidence that this time will be different.
In the pandemic, the first wave of quarantine felt like bracing medicine but it was probably too late and too short, allowing the virus to become endemic. Later stages, with half-measures of masking and mandates and shifting rules and regulations to address a chronic reservoir, feel confusing and confining, like a hospitalization without an apparent discharge.
Psych wards are designed to motivate change. I am fond of the old joke: “How many psychiatrists does it take to change a lightbulb? One, but the lightbulb has to want to change.” Psychiatrists are most helpful to people ready for change — and few things motivate change like being hospitalized on a locked psych ward. I ask every patient “What changes would you like to make in your life?” Some patients readily identify changes, while others deny that any changes are necessary. Psych wards are architecture against ambivalence. Ambivalence resolves under the realization that you, yes you, are spending the night here and you can’t leave. Whatever vulnerabilities and habits have brought you to this point, it is time to change them.
In the pandemic, we are coming to realize — belatedly — that humans have lived with viruses and will always live with them. It is only those viruses that exploit human vulnerabilities and habits that induce pandemics. That is why pandemics are, historically, a time of great change. Any real change will feel uncomfortable, leaving some to fear that they are not ready, but we need to accept change so we can walk out.
Here’s the last parallel I’ll share: Psych wards should be put out of business. They are confining and uncomfortable. I wish we did not need them, but I work in them because they are necessary until something better exists. When I discharge patients, I remind them they can return if they need help, but share a hope they won’t need to. Together, we talk about the steps they can take to avoid rehospitalization. With the right patient, I share my wish that the culture wouldn’t need psych wards. I tell them, “Do what you can to put me out of business.”
It’s the same with the pandemic: Do whatever you can — getting vaccinated and rebuilding relationships are the best places to start — to put Covid-19 out of business.
Now, where’s that nurse so we can talk about other ways to get out of here?
Abraham M. Nussbaum is a psychiatrist, chief education officer at Denver Health, associate professor of psychiatry at the University of Colorado School of Medicine, and author of “The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine” (Yale University Press, 2016).
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