Reinventing the ER for America’s mental health crisis

the EmAWAY The ward at Fairview Southdale Hospital where I met Mitlyng is modestly sized at fifteen beds but is still one of the largest in the country. It is led by Lewis Zeidner, a clinical psychologist who has worked in emergency psychiatry for more than four decades. Zeidner, a mild-mannered man with silver hair, a trimmed mustache, and clear glasses, told me that before the ward opened, nearly half the psychiatric patients in Fairview Southdale were hospitalized; Now it’s only about a tenth. Most people are discharged home with a care plan and follow-up care. “A psychiatric hospitalization, even if voluntary, brings with it its own trauma,” he told me. “We try to avoid it whenever possible.” He had told me that I could monitor the ward if I agreed not to speak to patients and if I promised to omit personal details to protect their privacy .

around 9 AM, ward staff gathered in a private study room to discuss how each patient was doing. “Emergency ligating scissors” dangled from one wall next to a red button that would summon help if a patient tried to harm themselves; Another wall was covered with letters from former patients. “I look forward to better days of recovery and you are a part of it,” one read. Kevan Andish, a laid-back psychiatrist whose dark hair was graying at the temples, listened as a therapist told him about a patient who stopped her mood-control medication because she was convinced they were abortion pills; Her child’s school had reported her erratic behavior. The team decided to keep her overnight for monitoring and treatment.

Another patient, a depressed young man, had been brought in by friends who were alarmed when he began talking about suicide. School usually gave him a sense of structure and community; it was now break. Over the course of a few days, the team had adjusted his medication and he was getting better. Today was his birthday and he asked the staff to let him go to a football game with his family.

Next, the therapist told Andish about a manic woman who might benefit from another day of observation but was determined to leave. I tried to imagine the frustrations of a patient who wasn’t here by choice; For them, the relative comfort of the unit shouldn’t make much of a difference. “She told me that there are people like her who walk around all day, every day,” the therapist said. A soft laughter filled the room.

“She’s not wrong,” someone said.

“Shows good insight,” Mitlyng interjected. After reviewing her file, they concluded it was safe for the woman to be released.

After the scrum, I went back to the unit. A young woman with reddish hair, looking dejected in an orange gown provided by the hospital, slowly approached the nursing station and asked for a mask. A nurse smiled and handed her one. The woman I will call Emma shuffled back to her chair. (The EmAWAY Sometimes the ward allows patients to wear their own clothes, but only after checking for potential dangers to themselves or others, such as guns, drugs, belts, and shoelaces. Patients must give up their cell phones.)

Emma had come to the clinic two days earlier with increasing anxiety, depression and paranoia. She had eaten less than usual, slept little, and heard voices. Her partner had become concerned and urged her to get help. She had hardly spoken to anyone in the unit.

Mitlyng escorted Emma to a private counseling room with soft lighting. Emma climbed into a chair, pulled her knees to her chest and stared at the floor.

“Sounds like yesterday was tough,” Mitlyng said.

Emma wrung her hands. Finally she said, “Yesterday was tough. I kept hearing names and voices.”

“What did the voices tell you?” asked Mitlyng. “Did you recognize her?”

“They sounded like people I know,” she said barely audibly. “But I couldn’t tell who they were.”

“Are you hearing something I might not be hearing?” Mitlyng asked.

Emma struggled. She didn’t answer for a long time. Mitlyng put down her yellow legal pad and cupped a hand under her chin.

“I can’t think right now,” Emma said. “I am scared.”

“Have you ever been this scared?” asked Mitlyng. She stopped and leaned forward. “Have you had any suicidal thoughts?”

“I was thinking about hanging myself or getting into traffic,” Emma said tearfully. “But I’m scared of how it would feel.”

“It’s hard to talk about, isn’t it?” said Mitlyng. “You are safe here. I promise.” Emma took off her yellow mask and took a sip of water.

“Need a break?” Mitlyng asked. Emma nodded.

“What can we do for you today to make you feel more comfortable?” Mitlyng said.

Emma looked up for the first time. Her partner brought a letter for her and some clothes, she said. “Let’s see if we can bring them to you,” Mitlyng said, standing up. “If you want to speak to me, just tell your nurse. I’m always there to talk.”

I recently spoke to a woman named Allison whose husband has spent some time in the emerging marketsAWAY Unit where Mitlyng works. Allison first heard about the unit because she works as a nurse at an affiliated hospital. But when her husband’s depression suddenly worsened a few months ago, “I had no idea how to help him,” she told me. She secured an appointment with a therapist, but it was five weeks away. “I knew we couldn’t wait that long,” she said. Eventually she took him to the emergency room at Fairview Southdale Hospital; Half an hour later he was at the EmAWAY Unit. “I was so sad to leave him,” Allison told me. “The ER can be so traumatic in itself, and now he’s going to the psychiatric facility?” But within hours, a therapist called her and said that EmAWAY Staff had helped her husband arrange two appointments for the same week: one with a therapist and another with a nurse who could prescribe medication. He was starting to feel better; if they both felt ready, he could come home. “More than anything, it gave me confidence that we could handle this,” she told me.

For patients who are not discharged immediately, the ward offers forms of therapy that I have never experienced in an emergency room. Patients can discuss their goals in the morning, create art in the afternoon, and learn to meditate in the evening. Sam Atkins, a clinical coordinator who often leads the art groups, told me that in an exercise each patient decorates the outside of a mask with glitter to represent the face they are presenting to the world and writes on the inside about how they are really feel. The day I visited them, they were painting what Atkins called “pain stones.”

As a clinic manager walked through the department asking patients if they would like to join, I wondered how people would react to something this serious during a crisis. Some ignored the invitation, but two men and two women – including Emma, ​​now in a hoodie – gathered around a table covered with markers, crayons, paintbrushes and flat gray rocks. “Has anyone made tactile charms before?” Atkins asked the group. “They’re fun to decorate and nice to rub when you’re scared.”

A tall, bearded man sat down, splattered some black paint on a rock, then got up and walked away. Atkins stuck to it: “Does anyone enjoy making art in their spare time?”

After a long silence, Emma nodded. “Pottery,” she said. She looked around hesitantly, then asked, “What about you guys?”

One of the others, a dark haired man, looked up. “Sometimes I like to paint,” he said. He carefully painted on his stone a bird with green feathers, a white breast and an orange beak. “My bird died,” he explained. On the other side of the table sat a woman, her forehead in her left hand. Halfheartedly, she dabbed purple paint on a rock.

After half an hour I helped Atkins put away the art supplies. When I looked back, Emma was left alone at the table. Sunlight filtered through a window and cast its shadow on the mural behind her. She picked up her rock, which she had painted with pink and blue circles, and smiled. Then she got up and went back to her chair.

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