Inpatient Psychiatry: The Interpretation of Changing Scenery

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.