Marley A. Doyle, MD

Recently our inpatient  psychiatric unit moved into a brand new facility. The previous unit was  situated in an antiquated, historic building in downtown Chicago built by famed  architect Bertrand Goldburg. The “old” unit had the feeling of a small, sad  nursing home. It housed an exemplary specimen of Goldberg’s form-over-function  design with an intricate exterior, but oddly shaped, blind corners, shared rooms,  and windows that could not be cleaned (we never understood the exact reason for  this).

When the opening of a “new” unit  was announced, the staff was abuzz. The administration informed us that the  model for this new unit was “patient-centered care.” Translated, this meant  that the unit was to be about 3 times the size of the old unit with private  rooms and “therapeutic areas.” However, the exact nature and look of the new  unit remained shrouded in mystery, with only rumors to quell our curiosity. A common  conversation starter went something like, “I heard that the new unit will have  . . .  [insert an over-the-top  assumption].”

Before the grand opening, a tour  was provided to the staff and residents. The new unit was so large that we all  nervously joked about getting lost and not being able to find our patients.  Every room was beautiful, with faux wood floors, large windows, and unique  artwork. As we walked, we saw the meditation room, the workout facilities, the  art therapy room, the group rooms, and so on. We residents looked at each other  and said that we wanted an admission to the new unit because it was nicer than  our apartments. This unit seemed to be the exact opposite of our current  accommodations.

In the months and weeks  preceding “the move,” there was much preparation and nervous energy. We had  been preparing our patients and ourselves for this day. “Well, you know we are  moving, and it may be a bit hectic,” became a mantra to add to my repertoire of  “Any suicidal thoughts today?” or “How are the voices?” As for the mechanics of  the move, there was a militant regimen in place that was to be executed  perfectly. Patients were to be moved precisely every 3 minutes. The order of  the patients was fussed over for weeks. We knew that most patients would  tolerate the move without incident, but we were all worried about one  particular patient with severe obsessive-compulsive disorder.

Mr S had been on the unit for  nearly a month before the move and having a slow recovery. Mr S took 2 to 3  hours to put on his pants every morning because he could not put his pants on  if his socks weren’t right, couldn’t put his socks on if his feet weren’t  clean, couldn’t clean his feet without showering for nearly an hour, etc. We  had been using behavioral activation technique before to the move to streamline  Mr S’s morning routine but did not appreciate much progress. As moving day drew  near, there was much talk about how Mr S needed to get ready faster in the  morning because “he could not get left behind.” Of course, no one would leave  him, but there was such a tight schedule that there was concern that his  pathological behaviors may be disruptive to the schedule. He was, therefore,  put last on the moving list to give him the maximum time.

On the morning of the move, the unit  was like being backstage before the opening of a play, with frantic,  last-minute preparations before putting on the show. Before noon (when the unit  was scheduled to be locked forever), breakfast needed to be served, all  patients had to be rounded on, and all belongings located and packed. One  attending went around placing lavender-scented oil on staff and patients’ pulse  points (which was strangely comforting).

As soon as I got to the unit  that morning, I went to wake up Mr S so he could start getting ready. To my  surprise, he was already in the shower. I yelled into his room, “Okay, Mr S,  today is the day! I will come back and check on you in awhile.” After rounding  on my other patients, I returned to find Mr S sitting on his bed, looking  rueful, with his belongings on his lap. I shockingly exclaimed, “Mr S! You are  ready! Great job!” Mr S smiled shyly, though he had tears in his eyes and said,  “Well, I didn’t want to be left behind.” I assured him that this would never  happen, but I quickly excused myself hurriedly because of limited time.

Then, up came the curtain! The  time came to move the first patient. The feeling of excitement was palpable.  Along the path from the old unit to the new unit were privacy screens, security  guards, EMS workers (in case, God forbid, someone were to Code on the way), and  mental health workers. Each of us was assigned jobs; mine was to greet the  patients when they arrived and to show them to their new rooms.

One by one, the patients were  wheeled to the new unit. As the doors opened and the patients saw the new unit  with its circadian lighting, beautiful artwork, and clean windows, their eyes  lit up and they smiled broadly. As planned, every 3 minutes another patient  came through the door. After an hour, I began to feel uneasy. Mr S still had  not arrived. Was the stress too much? Was he still able to go? What would  happen if someone absolutely could not leave the old building? Then I heard the  security guard’s walkie-talkie: “Last patient is on his way. Over.” Shortly afterward,  Mr S was wheeled through the door, clutching his belongings tightly to his  chest. He blinked a few times and smiled. I showed him to his room and offered  to give him a tour of the new unit, which he accepted (but only after arranging  his belongings first).

We started by going around to  look at of the artwork. Mr S loved trains and architecture, so I thought that  this would be comforting to him. As we went around, he studied each picture in  detail. Finally, we came across a painting of the Chicago skyline. At this  point, Mr S began to cry. I asked why he was crying, and he said, “Instead of  seeing all of the ugliness in the world, I am seeing something beautiful. This  makes me feel that I can get better.” I was very much surprised by his  reaction. As residents, we had joked about this “artwork” and honestly, did not  see what the big deal was. Now, I understood.

As I left the unit that day, my  attitude toward my patients in particular and mental illness in general was  altered. In the generation of quick inpatient stays, rapid titration of  medication, and comprehensive follow-up plans, I never thought about how a unit  itself could be therapeutic. One would assume that the inherent structure of a  unit and interaction with peers would be therapeutic, but I never once thought  that one so aesthetically pleasing could trigger introspection.

As overworked, somewhat jaded  residents, we looked at the artwork as excessive and feared it would “spoil”  our patients to the point that they wouldn’t want to leave. The truth was far  different. In an internal world of “ugliness,” these portraits somehow made the  patients feel valued. They interpreted the artwork through the prism of their  experiences. As I continued to work on the new unit, I realized that the  artwork in the patients’ rooms often became a conversation piece. I would  inquire, “What do you think about this picture?” It took me a few weeks, but I  soon understood that I often obtained more insight into my patient using this  question than the standard, “Any suicidal thoughts?” and “How are the voices?”  This allowed me to see patients differently. Learning about their opinions,  thoughts, and fears was invaluable.

Ultimately, this experience greatly changed the  way I view inpatient psychiatry. It was an important lesson that I hope will  shape my future encounters within the inpatient unit, as well as the outpatient  setting.

Articles

Recently our inpatient psychiatric unit moved into a brand new facility. In the months and weeks preceding “the move,” there was much preparation and nervous energy. We had been preparing our patients and ourselves for this day. “

Author | Marley A. Doyle, MD

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Inpatient Psychiatry: The Interpretation of Changing Scenery