By: Jasmine Appleberry, MSW, LCSW
The phrase “psychiatric unit,” for many, conjures up horrifying images, such as One Flew Over the Cuckoo’s Nest. Having worked on psychiatric units, as an intern and as a full-time social worker, I see the unit as a nest, but not of cuckoos—rather of transitions, dreams, healing, and new lives. To be a part of that nesting place, which is both a temporary respite and a pivotal life stage, is to watch beauty unfold every day, and to be a part of it. It is not without frustration, pain, and disappointment, but it is also immensely fulfilling and worth considering, either as a learning experience as an intern, or as a full-time career.
The inpatient psychiatric unit is a unique environment, and unique career path, in many ways. As I have confronted the best and worst parts of this experience, I have settled on a love for this intense and interesting place, and a sense of what elements are crucial to know if one hopes to embark on this path. This career, like any in social work, holds many challenges and rewards. Some of the salient features of work on the unit are highlighted below. These may vary from unit to unit, but represent my own experiences.
Diversity of Workload: Want to work with individuals, couples, families, groups, organizations, and communities? You will have all these opportunities on an inpatient psychiatric unit. In fact, the biggest constant in my day is change: change from one activity to the next, from one case to the next, from one meeting to the next, with little warning. Being able to shift gears quickly is critical, as is tolerance for interruptions and frequent changes in plans. When you are able to move through the many different tasks of one day successfully, the hours flow by until the day is over but still vivid, and the long and varied list for the next day has emerged.
Diversity of Cases: It’s hard to estimate how many of my patients are dealing with which diagnoses. There is always a range in mental status and other characteristics. Since mental illness and hardship know no divisions, patients are of all backgrounds and communities. Some have had dozens of hospitalizations and have difficulty living independently. For some, their inpatient status is the mark of a dramatic life change that has sobered, scared, or frustrated them, and just accepting this change is much of the work of their stay.
Groupwork: All of these patients are brought together by various missing pieces: the puzzles of their lives have broken down, and much does not fit as it did before. Perhaps pieces have been missing or misplaced for some time. Sitting before the group leader are people unable to name the year, people who believe they are the president, and people who eloquently articulate philosophical concepts. In a mix of homeless and privileged, sober and addicted, depressed and psychotic, the great equalizer is crisis. Much as patients might bond over the restrictive rules, they build strong relationships based on the broken structure of their lives before their stay, and they together face the fears of returning. Watching the most diverse patients form the strongest of bonds, especially as groups unfold, is an ever-inspiring joy.
One-on-One Time: Sitting and talking with patients is very different than in outpatient psychotherapy, and there is little time for daily, extended conversations. So I find meaning and connection however I can, largely in initial assessments, which provide the opportunity for a social work view to be added to the medical model. Patients have gone through other interviews already, and they are still trying to integrate this new experience into their views of themselves and the world. They often bloom with a few words of reassurance, the chance to tell their story anew, and the opportunity to hear more about resources available to them. Some patients may be completely unable to connect initially but be very available a few days later. Either way, you’ve made a connection at a time when many people feel at their most disconnected. Being available to patients throughout their stay, in whatever limited ways possible, lends continuity to their experience, satisfaction for the social worker, and a valuable aspect to the treatment process.
Family Work: Families are often terrified, angry, despondent, confused, and anxious regarding their loved one’s situation. While doctors and other professionals on the unit simply don’t have time to speak with every family, we make it a point to (with patients’ permission). Our efforts are typically greatly appreciated. While I often hear from angry family members, the fury tends to abate as they have the chance to tell their own stories, fears, and perspectives. In such conversations, I explain a mystifying process, provide information, and gather pieces of the mysterious story that is our new patient, and provide those pieces to the team. Whether I learn of a history of head trauma, an addiction, a recent change in behavior, or a personality unknown to us, I get closer to understanding the person outside of this unit. In an environment where assessment and treatment happen quickly, my contribution is one piece of the plan for healing. In family meetings, the work of restoring basic communication, if not the work of restructuring a family, happens quickly and often successfully. The great taboo of mental illness is dealt with openly, usually with great relief and satisfaction. I participate in a rebuilding process.
Collaboration: Many social work careers involve interdisciplinary teams, but rarely is the chance so prominent to benefit from everyone’s input. Doctors, nurses, mental health workers, occupational therapists, psychologists, students, and social workers sit side by side in a rich discussion. If autonomy is highly important to you, this may be a struggle, as psychiatrists are the primary providers in this environment. However, never have I known such an opportunity to learn, discuss, and share, and the frustrations and mysteries of cases are dealt with together, constructively.
Linking to Resources: Patients often come to the unit isolated, underprivileged, and confused. They feel they have no options; together, we work to discover them. Every patient is an opportunity to provide outlets, supports, and information. Social workers also have the key role of scheduling outpatient appointments and coordinating services. To find patients suitable follow-up, in their own languages, at a reasonable fee, in a reasonable time, is a great challenge, and satisfying when achieved.
Quick Rewards: Although the rapid pace of a unit can leave one gasping for air, it also involves fast progress. In a contained environment, changes in medications, psychotherapy, and other approaches can happen quickly, and the structure itself can be stabilizing. In the space of (for instance) a week’s time, a person can begin to carry on an appropriate conversation again, or want to live again, or lose fears of persecution. Having worked in outpatient mental health, I know how many real-world obstacles patients face. Away from these outside stressors, patients can practice new skills, gather support, and utilize numerous treatments, intensively and powerfully. Many face great difficulties at discharge. Some do return. But the moments of connection and insight that occur are carried with them. We are in the business of hope and new chances. That renewed hope emerges in the words of patients and touches me every day.
Challenging Realities: I am keenly aware of the difficulties to which patients must return. I struggle with my own unfulfilled desires every day, for my patients and the world. I wish for safe housing, rehab beds, comprehensive outpatient services, and solid support networks. Many of these dreams are elusive. We may have to discharge patients sooner than is optimal, because of insurance. But we discharge patients with skills and with whatever resources we find. Many patients do build new lives out of this momentary nesting ground.
Unfinished Stories: Social work always involves unanswered questions and incomplete tales. We often wonder what has happened to our former clients. In a hospital, a great portion remains untold. I sometimes wonder how outpatient treatment is proceeding. In general, no news is good news. I don’t have weekly updates, and I’m not able to watch goals unfold over months or years. But I do have a crucial moment in someone’s life.
Safety Issues: While it would be foolish to pretend risk is limited to certain environments, this setting does involve sporadic violence, both emotional and physical. I am lucky; I am not required to intervene when someone throws a chair. The staff here is well-trained. But I do need to understand how acute illnesses can affect patients’ self-control. I need to be prepared for anything, especially to de-escalate a situation quickly. While people with mental illnesses are more likely to be victims of violence than perpetrators, emotional and behavioral dysregulation are common symptoms here. Fortunately, we have terrific resources, especially the staff, and the contained environment. In spite of the unpredictability, I feel safer here than I did while working alone in the community.
Shared Space: Don’t expect a lot of privacy or independence on an inpatient unit. Desks are often situated together. The pressure to meet deadlines and work within the treatment plan is significant. Much of the unit experience, whether in groups with patients or in teams with staff, is about building new truths, and new treatments, together. Magic happens every day, and it is shared, discussed, and sometimes debated. You may have to prove yourself to a team that knows little about your skills or training. But your value can shine through.
On my desk, a scribbled, never-ending list unfolds, based largely on interruptions that became priorities. The power, the intensity, and the hopefulness of my work keep me always curious to see the next page. Each day is a new learning experience, a new opportunity to connect, and a new perspective on this nest, this shelter, this healing home that constantly evolves to encourage growth. The days of long-term inpatient treatment are largely over, but this unit inspires me just as it is, with all its rapid-fire charms and challenges. At the end of the day, I am exhausted, but deeply satisfied to be a social worker.
Jasmine Appleberry, MSW, LCSW, received her MSW from Boston University. She completed a field placement on an adult inpatient psychiatric unit in Massachusetts and is currently employed as Clinical Social Worker on the adult inpatient psychiatric unit of a Rhode Island hospital.