What happens on a psychiatric ward? Considering that such a large proportion of the population suffer from mental health issues (1 in 4 is the oft-quoted statistic), it surprises me how little is known about these clandestine microcosms.

Both in my current role as a consultant forensic psychiatrist, and my innumerate previous years of training, I’ve worked on dozens of wards; from the UK to Australia. As one might expect with a public service, the layout of the ward, the quality of care and the ward routine varies significantly between disparate wards. As does the atmosphere.

So, how do people end up on these psychiatric wards? In essence, in the UK, when there are serious concerns about an individual’s mental state, this is brought to attention by another professional (e.g., a social worker or a general practitioner), a family member, or even by the patient themselves. There are numerous forms of deterioration that can raise concerns. For example, somebody could be severely depressed with thoughts of suicide, or lacking the volition to eat. Someone could be very paranoid to the extent that they are uncharacteristically aggressive or even violent. Somebody with dementia could be wondering onto the streets with no regard for their own safety. These are all examples of patients who, on balance, are unlikely to be able to cope or function in the community.

What does being sectioned involve? No men in white coats. No straight jackets. No big van. Lots of paperwork. Detaining or ‘sectioning’ somebody under the provisions of the Mental Health Act is a serious, detailed and time-consuming process. It is never done flippantly. Stringent procedures follows strict guidelines. The assessment of the patient must be carried out by two senior doctors, who are independent of each other as well as an experienced social worker (known as an approved mental health practitioner). These professionals have to undergo rigorous training to gain in-depth knowledge of the Act. It’s not enough that the professionals want to detain the patient in order to treat them. They must prove that they believe the patient needs to stay in hospital for their own health, or their own safety or because someone else’s safety would be under threat if they were released. Indeed, there are hundreds of people with active symptoms of mental illness, who are not a danger to anybody. They survive perfectly well without their freedom being restricted. And rightly so. The professionals also must also prove that the patient would not recover without this enforced treatment, and that there isn’t a less restrictive option. 

Contrary to what many films depict, all the patients on a psychiatric ward are not there against their will. In my experience, on general adult wards around half to two-thirds of inpatients are sectioned. The others are there as a voluntary ‘informal’ admissions, which means they have the right to leave or to refuse treatment. However, in the locked secure psychiatric wards that I work in currently, all the patients have a history of violence, and therefore have to be sectioned; I talk about numerous anonymised case examples on my YouTube channel: A Psych for Sore Minds. 

As to what kind of mental illnesses tend to lead to psychiatric admission, in my experience, the majority of patients suffer from a psychosis like schizophrenia or a mood disorder such as severe depression or mania (when people with a bipolar illness are in a ‘high’ phase). However, I’ve also been involved with treating patients with more unusual psychiatric disorders such as catatonia (a severe psychosis which can render the patient completely mute and sedentary, as if paralysed), and AIDS-related early dementia.

What is life like on a psychiatric ward? Like all hospitals, psychiatric ones are places of healing. Depending on the profile and of the patients and the quality of the staff members, some wards can be peaceful and therapeutic. I’ve witnessed tremendous compassion, support, and camaraderie between the residents. Sometimes the most mentally unwell people find solace amongst those in similar positions. At times, some patients can be disturbed, and the ward can be chaotic. This is far more common within the secure wards for mentally disordered offenders that I work in now as a forensic psychiatrist.

So, what happens on psychiatric wards? People live there, and gradually recover. There usually are individual bedrooms as well as communal areas such as a lounges, with TVs, video games and a pool table. Patients live together, and some integrate well and support each other. Others may value their privacy and choose to isolate themselves. This could be related to mental illness (e.g., paranoid or negative thoughts). Equally, it could just be down to personality.

There are nurses on site, 24 hours a day. I’ve worked in places with well-motivated and caring nurses who engage patients in conversation and therapeutic activities every day. Unfortunately, I’ve also worked in places where this doesn’t happen. Every patient has a consultant psychiatrist assigned to them; the boss. They are ultimately responsible for salient decisions such as medication, leave and discharge, though a good consultant will liaise with and seek counsel from the nurses and the rest of the team. Psychiatrists have many other duties outside the ward, such as outpatient appointments and home visits. Therefore, they tend not to be on the ward on a daily basis, but instead usually have weekly ‘ward rounds’; here, each patient is invited to discuss their progress and any issues. There are also junior doctors on the ward, who review the patients regularly and feed back to their consultant psychiatrist. They themselves are usually in training to become fully-formed psychiatrists one day.

Patients are served three meals a day. Most are given medication once or twice a day, though occasionally are offered some extra sedatives if they become particularly distressed. Therapeutic activities should be offered throughout the day. At least theoretically, there should be other staff members (known collectively as the multidisciplinary team) that can contribute to various aspects of the patients’ recovery. They include psychologists who can meet them individually or in groups and use talking therapy and thinking exercises to help nurture insight and the ability to reflect on their mental illness, personality and behaviour; this might include figuring out triggers and risk factors to avoid future relapses. Occupational Therapists help provide activities including sports and art therapy. They can also help patients find work that is appropriate yet challenging, both inside the hospital, and in the long-term, after discharge. Social Workers help with a variety of issues such as communicating with family members, managing benefits and finances and finding appropriate accommodation for patients after hospital. All of this is available in an ideal world. But I’ve only ever worked in the real world, where some patients have to wait on the ward for weeks after their recovery to have their accommodation sorted, and some people never see a psychologist even though it would have been beneficial. Underfunded and under-resourced services lack necessities. This can make reintegration back into society much more of an uphill struggle for some people. 

Isn’t everybody just doped up on a psychiatric ward? Not at all. With new patients when the extent and type of illness is unknown, there tends to be a period of observation for several days or even weeks before a decision is made on what medication should be used, if at all. Ultimately these decisions are down to the treating Consultant Psychiatrist, but good practice is to start at low doses and increase gradually depending on response. The benefits and side effects of any medication varies significantly between patients, and are unpredictable. There is no right or wrong answer. Decisions are made from years of clinical experience. Treating mental illness is an art form as well as science. Over medicating patience is not a wise strategy, as the chances of the individual being compliant with tablets after discharge is low, often resulting in readmission and starting from square one. 

Is it true that people are locked up for years? Rarely. Length of admission varies significantly and depends on the situation. I’ve treated patients who have literally stayed for one night only; usually in the context of a crisis, or sometimes psychosis related to drug use, which resolves relatively quickly. Conversely, I’ve also seen patients with recalcitrant mental illnesses who lack insight or are unlucky enough to need several trials of medication before they find one that works effectively. They can have admissions that last several months, or even years. Some of the patients I worked with in Broadmoor hospital will likely never be discharged.

I discuss a whole range of mental health topics on my YouTube channel. Some videos are related to offending and violence, though others cover more common presentations.

Sohom Das, MD is a consultant forensic psychiatrist who lives and works in London. In his role, Sohom assesses and rehabilitates mentally disordered offenders in prisons, courts and in special secure psychiatric units that are reserved for the most dangerous and violent mentally ill patients.