Reinventing the E.R. for America’s Mental-Health Crisis

The EmPATH unit at Fairview Southdale Hospital, where I met Mitlyng, is modest in size, with fifteen recliners, but it is still one of the largest in the country. It is led by Lewis Zeidner, a clinical psychologist who’s worked in emergency psychiatry for more than four decades. A soft-spoken man with silver hair, a neat mustache, and clear-frame glasses, Zeidner told me that, before the unit opened, nearly half of psychiatric patients at Fairview Southdale were hospitalized; now, only around one-tenth are. Most people are discharged home with a care plan and follow-up. “Psychiatric hospitalization carries its own kind of trauma, even when it’s voluntary,” he told me. “We try to avoid it whenever possible.” He had told me that I could observe the unit if I agreed not to talk to patients, and if I promised to omit identifying details, to protect their privacy.

Around 9 A.M., the unit’s staff gathered in a private workroom to discuss how each patient was doing. On one wall, “emergency ligature cut-down shears” dangled next to a red button, which would summon help if a patient tried to harm himself; another wall was covered with letters from former patients. “Looking forward to brighter days in recovery and you are part of it,” one read. Kevan Andish, a serene psychiatrist whose waft of dark hair was graying at the temples, listened as a therapist told him about a patient who had stopped taking her mood-stabilizing drugs, convinced that 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 young man with depression, had been brought in by friends who were alarmed when he’d started talking about suicide. Ordinarily, school provided him with a sense of structure and community; it was now on break. During the course of a couple of days, the team had adjusted his medications and he’d improved. Today was his birthday, and he was asking the staff to let him go to a soccer game with his family.

Next, the therapist told Andish about a woman who was manic, and 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 her, the relative comfort of the unit might not make much difference. “She told me that there are people like her walking around out there all day, every day,” the therapist said. A gentle laughter filled the room.

“She’s not wrong,” someone said.

“Shows good insight,” Mitlyng chimed in. After reviewing her chart, they decided that the woman was safe to discharge.

After the huddle, I wandered back into the unit. A young woman with ginger hair, looking despondent in burnt-orange scrubs provided by the hospital, slowly approached the nursing station and asked for a mask. A nurse smiled and handed her one. The woman, whom I’ll call Emma, shuffled back to her recliner. (The EmPATH unit sometimes allows patients to wear their own clothes, but only after a search for potential dangers to themselves or others, like weapons, drugs, belts, and shoelaces. Patients must give up their cell phones.)

Emma had come in two days before with spiralling anxiety, depression, and paranoia. She’d been eating less than usual, sleeping little, and hearing voices. Her partner had grown concerned and urged her to get help. She’d hardly spoken to anyone at the unit.

Mitlyng walked Emma to a private consultation room with soft lighting. Emma climbed onto 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 hard. I kept hearing names, voices.”

“What were the voices telling you?” Mitlyng asked. “Did you recognize them?”

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

“Are you hearing something right now that maybe I wouldn’t hear?” Mitlyng asked.

Emma fidgeted. For a long while, she didn’t respond. Mitlyng put down her yellow notepad and placed a hand under her chin.

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

“Have you been scared like this before?” Mitlyng asked. She paused and leaned in. “Have you had any thoughts of suicide?”

“I’ve thought about hanging myself or walking into traffic,” Emma said, tears in her eyes. “But I’m scared about how it would feel.”

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

“Do you need a break?” Mitlyng asked. Emma nodded.

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

For the first time, Emma looked up. Her partner had dropped off a letter for her and some clothes, she said. “Let’s see if we can get them to you,” Mitlyng said, standing up. “If you want to talk to me, just let your nurse know. I’m here to talk anytime.”

Recently, I spoke with a woman named Allison, whose husband spent time in the EmPATH unit where Mitlyng works. Allison first heard of the unit because she works as a nurse at an affiliated hospital. Still, when her husband’s depression suddenly worsened, a few months ago, “I had no idea how to get him help,” 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 department at Fairview Southdale Hospital; half an hour later, he was in the EmPATH unit. “I felt so sad leaving him,” Allison told me. “The emergency room can be so traumatic, in and of itself, and now he’s going to this psychiatric unit?” Within a few hours, though, a therapist called her to say that EmPATH staff had helped her husband to schedule two appointments for that same week: one with a therapist, and another with a nurse practitioner, who’d be able to prescribe him 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 immediately discharged, the unit offers forms of therapy that I’ve never encountered in an emergency department. Patients can discuss their goals in the morning, create art in the afternoons, and learn to meditate in the evenings. Sam Atkins, a clinical coördinator who often leads the art groups, told me that, in one exercise, each patient decorates the exterior of a mask with glitter, representing the face they present to the world, and, on the interior, writes about how they really feel. On the day that I visited, they would paint what Atkins called worry stones.

As a clinical manager walked through the unit, asking patients if they’d like to join, I wondered how people in crisis would respond to something so earnest. Some ignored the invitation, but two men and two women—including Emma, now in a hoodie—gathered around a table that was covered with markers, crayons, paintbrushes, and flat gray stones. “Has anyone made worry stones before?” Atkins asked the group. “They’re fun to decorate and nice to rub if you’re feeling anxious.”

A tall, bearded man sat down, squirted some black paint onto a stone, and then stood and walked away. Atkins stuck with it: “Does anyone like making art in their spare time?”

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

One of the others, a dark-haired man, looked up. “Sometimes I like painting,” he said. He carefully painted a bird with green feathers, a white breast, and an orange beak onto his stone. “My bird died,” he explained. Across the table, a woman sat with her forehead in her left hand. She half-heartedly dotted a stone with purple paint.

After half an hour, I helped Atkins put away the art supplies. When I looked back, Emma remained at the table alone. Sunlight poured in through a window, casting her shadow on the mural behind her. She picked up her stone, which she had painted with pink and blue circles, and smiled. Then she got up and walked back to her recliner.