A guided tour of a psychiatric ICU
I was recently reminded of this article that I wrote two years ago after visiting an acquaintance in the psychiatric emergency ward of a Montreal hospital. I tried to get it published in a local newspaper at the time, but I’m not a journalist and have no idea what I’m doing, which probably contributed to my failure to accomplish that. But, I think it should at least see the light of day somewhere, so I’m sticking it here along with all my other unpublished writing. It’s mostly unedited from the version I wrote in 2023, save for trimming it down in places and anonymizing the institution.
Little content warning - this is a super depressing text.
Disclaimer: This text describes my personal observations and the experiences as reported to me by a friend during her stay in a psychiatric intensive care unit in a Canadian hospital. While I have done my best to represent events accurately, this is not a formal investigation, and I cannot verify all details. Any opinions expressed are my own and should be understood as personal impressions rather than definitive statements of fact.
Intro
On September 4th, 2023, I received a text from a friend, Amy, that I had not seen in over a year. “I’m in the hospital. Do you know anyone who could help with a psychiatric discharge?”
The next day, I found myself at the security doors of the brief psychiatric intensive care unit of the hospital. This was not the first time I’d wandered my way through its hallways to these doors. I had been here once before, years ago, to drop off a bag of clothes to my roommate at the time, who suffered from panic attacks and suicidal episodes. I had included a book and a bar of chocolate, not knowing how else to help. That time, the security guard took the bag from me, and I went home. About a year later, she passed away.
At that time, severe psychiatric episodes scared me. I didn’t know how to help, or even if I could. I didn’t understand what the problem was, let alone the solutions. This time, I was not afraid – at least not afraid of psychiatric episodes. I was equipped with years of reading, introspection, and personal experiences that had made extreme states much less scary and much more understandable - and not from a biological lens, but from a human one1. Psychiatric institutions, on the other hand, sometimes made my skin crawl.
The visit
Entering the ICU, I quickly found Amy. The unit as a whole was very small, with maybe fifteen rooms arranged in an O-shaped hallway. The staff worked in a glass-walled island in the middle of the space, with grates through which patients could ask questions and communicate. Amy, happy to see a familiar face, was subdued and spoke mostly in hushed tones. During that visit, she was afraid of other patients repeating what she told me to the floor staff. In general, she said, she tried to draw the attention of the staff as little as possible, which included not spending too much time isolated in her room, not being too active or agitated, and electing not to try to use her bedsheet as a yoga mat in order to exercise and meditate.
She promptly took me on a tour of the floor and explained her experiences and observations to me. Her room was barren, with a small desk and a narrow mobile hospital bed. The wall at the head of the bed featured a scar of chipped paint and plaster, where the bedframe had presumably been repeatedly rammed. On one wall was a large, faded crayon drawing, unsuccessfully washed off, whose ambiguous forms unsettled me until Amy pointed out that it seemed to be a butterfly. The blinds were half-closed, with a view out onto some shrubs and bushes, and the windows firmly sealed. On the windowsill, with her belongings, was a urine sample and a French-language pocketbook about Julius Caesar. Amy explained to me that when she asked for reading material, this was all that they were able to provide. A significant number of pages were missing, torn out by previous patients. She happily accepted a book I grabbed for her before leaving home, a spare copy of the Fellowship of the Ring.
The hallway was bland and featureless. Walking through, I was able to observe the nurses and administrative staff working inside. No one here seemed to pay me much attention, let alone the patients. The handful of times Amy leaned into the service windows to ask a question, it took several moments before a staff member turned their gaze to address her, and on occasion none did at all. They were equipped to observe everything that was going on but seemed deeply uninterested in doing so. On some level I don’t blame them – being in this place with eyes open was already starting to drain me. On one window, the only spark of colour was an LGBT poster: “You are in a clinical milieu that is inclusive, humble, and safe”.
In the rec room (also the lunchroom), there were two puzzles laid out on tables. One patient was drawing with a mechanical pencil in a cheap coloring book, the kind with nothing particularly interesting inside. This seemed to be the extent of the tactile entertainment and art supplies. High on the wall was a low-resolution television with a dim, burnt-out display. It played an endless stream of French-language reality TV. In the whole unit, I was shocked to find not even as much as a fake plant, and the only artworks present were a couple of large, pixelated blue-green prints representing nothing in particular, maybe the hazy outline of a beach.
Apparently, while the patients are allowed access to books and art supplies, as well as presumably games and magazines, the stock had been thrown out during early COVID, probably due to the uncertainty around the means of transmission. In the intervening three years, no substantial donation had been made to replace these items, and it seemed that the staff and hospital administration had not bothered to provide anything. The next day, I grabbed a selection of old books, and brought them in a bag with a sketchbook, some graphite pencils, and charcoals that I had been hoarding at home. Why had no-one thought to do this in three years?
I stayed for lunch. The microwaved ICU meal contained a tolerable beef stew, some barely edible steamed vegetables, a green soup that was somehow both bitter and sour, and a scoop of mashed potatoes that was shockingly unpalatable (I’ve had unseasoned, unpeeled mashed potatoes that were way better). A small black tea and a pudding packet were also provided.
The darkest aspects of the space, Amy alluded to in a few careful words. She felt a pattern of sadism in some of the staff, and said she felt distinctly uncomfortable during the too-often instances where she was required to undress. In this “brief” intensive care unit, some patients had been staying continuously for weeks. One woman with motor control issues struggled to eat and was not assisted. In her near week-long stay, she observed crisis situations and violence that were managed by significant police presence. Her total impression was of a place designed not to help people, but to sedate and control troublemakers.
Twice, she tried to introduce me to the psychiatrist as a character reference and to talk about activities and community she would have access to outside of the hospital. Both times were turned away by a nurse, promising to call me later, with my phone number taken down on a torn corner of a piece of paper (on the first day) and an adhesive label (on the second day). I did not receive any calls.
One person familiar with the institution explained to me that the psychiatric ICU, as opposed to the long-term psych ward of the same hospital, was not designed to help people get better, but to contain the psychotic or suicidal episode, to discharge them as quickly as possible, and to discourage them from returning. This philosophy seemed to have some merit on the surface, but quickly devolved into contradictions.
If the goal was to discharge people quickly, why were there patients who had been there for weeks? Why was one seemingly healthy man staying there voluntarily, washing his clothes in the hallway sink and drying them on his windowsill? In addition, how was a hostile, barren place supposed to contain psychotic or suicidal tendencies? How was a dismal, humiliating, and alienating environment supposed to help stabilize people and allow them to return to their lives? Finally, to discourage people from returning by providing an almost intentionally inhospitable service – wasn’t that manipulation? And wouldn’t it make people feel more helpless, more desperate, more uncared for once back on the outside? Wouldn’t that exacerbate the problems of someone with psychotic tendencies who lacks a stabilizing presence or a safety net in their lives, or someone with suicidal tendencies who often feels a total lack of hope for the future?
Leaving the ward after a long goodbye and almost two hours of wandering and talking on the tiny floor, I exited the double set of security doors. I was suddenly blasted with something I didn’t expect – the warm, bright lights of the main hallway, which had struck me as completely unremarkable on the way in. The white concrete walls and bare office spaces populated by medical and nursing students had seemed ugly and industrial on the way in, but compared to the inexplicably dim, cold lighting of the ICU, it felt full of life and warmth.
I took the elevator to the main entrance. It had a self-respecting look to it, with the large windows, nice burgundy trims, a café, and a cute bookstore in the corner. I went to the book nook to talk to the older white-haired lady behind the counter. I started talking about the ICU and the lack of books in the unit, and quickly shifted to my observations on the hopeless, depressing atmosphere, and the lack of apparent logic of the space. The bookstore clerk entertained me compassionately. Finally, I felt my jaw start to quiver, and I excused myself and left. I made the 30-minute trek home in the blazing midday heat instead of taking the bus.
Postscript
My visit to the psychiatric ICU offered me some first-hand experience of problems with the psychiatric crisis management system that I had, until this point, only either heard about second-hand, seen in investigative reports (such as BBC Panorama’s recent exposé), or read about in books. One of my friends, having voluntarily admitted himself to the psychiatric ward at another local hospital years ago, only to be involuntarily detained for two weeks, said to me, “That’s not a place you go to get well”.
There is nothing in the unit that could provide a natural stabilizing presence to someone going through an acute psychotic or suicidal episode. There were no books, art supplies, games, animals, or plants. There were no paintings, music, warm lighting, or comfortable furniture. No options for exercise or movement, and access to the outdoors was heavily restricted. There was no counseling or therapy, just daily meetings with the psychiatrist (with the doctor and nursing staff apparently changing from day to day, bringing into question the possibility of a reliable assessment of progress). The only things that were provided in this place were surveillance and medication – this, for the people most in need of compassionate care.
A lack of practicing professionals, and money to pay them, is a significant problem in mental healthcare. But it is not the only problem. Our approach to mental illness, and our framing of it as a primarily individual (and often biological) problem rather than a social and environmental one, has led to the adoption of expensive individualized therapy, whether psychological or biochemical, as the only legitimate means of treatment. Authors like Gabor Mate and Johann Hari have recently tried to bring attention to the massive impact of social determinants of health, like loneliness, poverty, discrimination, and childhood relational trauma, which dwarf the token predictive power of genes and brain-based biomarkers. An effective mental healthcare system needs to extend into all branches of society, and focus on prevention – through healthy social milieus – rather than expensive, and often ineffective, individual treatment.
For people in acute crises, there are also more compassionate – and much less expensive – methods of treatment that have been developed. For example, the Soteria model, developed in the 1970s by the head of schizophrenia research at the NIMH and abandoned after funding was withdrawn despite positive results, rethinks psychosis as a problem needing social rather than biochemical treatment. Small halfway houses were run by a psychiatrist and staffed by non-specialists, who were selected and trained for their ability to compassionately and non-judgmentally “be with” people experiencing psychotic episodes. Treatment focused on communal activities and talk therapy, with antipsychotic medication being used on a voluntary and as-needed basis. The space, rather than a sterile hospital ward, was a warm, home-like environment. Today, the model has been replicated in several other countries, and one currently exists in nearby Vermont. This system regularly finds comparable symptom reduction to standard care, but with massively reduced reliance on medication. As well, it shows greater increases in social and occupational functioning, as well as less relapses and better long-term outcomes. And all this on a much tighter budget, with nightly stays at Soteria Vermont costing less than a third of a night in the hospital.
As a community, a city, and a province, we can do much better than what I described above. It’s time to look for better, kinder, and more sustainable ways to look after each other.
2025 Addendum
When I wrote this, I focused my analysis on wrong-headed paradigms of understanding and caring for mental illness, and downplayed the lack of funding put into the institutions. I would now put them on more equal footing. There are a lot of people trying to do good work in mental healthcare, but the resources are scarce. Basically, it’s all fucked. From where I’m standing now, it seems like both issues stem from austerity and privatization / the for-profit incentive, which promotes drugs over community and strips funding from the unprofitable public health sector. But I’m a neuroscientist, not an economist, so take from that what you will.
Footnotes
1 R.D. Laing and Alice Miller were two particularly huge influences at this time.