The madhouse. Loony bin. Asylum. Psychiatric wards are called many things, but what is it really like inside one?

Freudian Script continues to give writers an up-close-and-personal view of mental health services in the UK and this week’s post concentrates on the inside of mental health unit.

History of the psychiatric ward
The first “psychiatric wards” were the asylums of the 18th century. These were private houses where your relatives could send you because…well, because they felt like it, really. There was no regulation and the owners didn’t ask many questions, provided you could pay. The first mental health legislation in the UK – The Madhouses Act 1774, for the legal nerds – was to regulate these houses, license and inspect them. In many ways, mental health services have moved on from this point – and in some ways they haven’t.

Who is admitted to a psychiatric ward?
So, why do people come to a psychiatric ward? In the old days of asylums and institutionalisation, you came to a psychiatric ward when you displayed any sign of mental health problems. The default treatment was containment. As treatments for mental health problems got better and people realised locking folks up for an indefinite period was bad for them (which took a shockingly long time), more emphasis was placed on care in the community.

Which is a long-winded way of saying that the threshold is quite high for hospital admission. It mostly comes down to risk. Psychiatrists and mental health professionals are in the business of risk – apparently, doctors make good stock brokers because of our risk assessment skills. Admission to a psychiatric ward happens when it is the only safe place for that person at that time, usually because they are a danger to themselves (e.g. feeling suicidal), to others (e.g. experiencing delusions that their family are trying to kill them) or at risk from the illness (e.g. too depressed to wash or feed themselves).

Some people only stay one night – referred to as a “crisis admission”. Some people stay for weeks and months. Some hospitals have specific assessment units, where people only stay a few days and, if they need further treatment, they are moved on to longer-stay wards.

What if you don’t want to come in?
If you are a danger to yourself or others and those risks can’t be addressed safely in the community, that’s where the Mental Health Act comes in. I won’t go over the law again here but, suffice it to say, you can be admitted to hospital against your will if specific criteria are met.

What does a psychiatric ward look like?
First, a caveat – all psychiatric wards are different. Obviously, things like building age, local variations, etc. play a part. I have worked in a handful of them, so this is from my experience. Also, I’m not commenting on the private sector – I’m sure you can take a tour of The Priory, if you wish.

The dining room of a psychiatric ward in North Wales

These are not your ordinary hospital wards. Forget your six-bed rooms, your nurses’ uniforms, gaggles of doctors doing daily ward rounds. Most psychiatric wards have individual rooms, though there are a few dormitories remaining, and these are often en suite – think university halls. These can be locked – sometimes patients have their own keys, sometimes not. They are typically divided into male and female corridors. There are communal areas, like a dining room, lounge/TV room and an occupational therapy room/games room. And there’s an outside space, which is also where people smoke, though more and more hospitals are going smoke-free.

Typical day on a psychiatric ward
For the staff, the day begins with a handover of information. For patients, it begins with breakfast – and, sadly, psychiatric wards are not exempt from the “hospital food is crap” stereotype. During the day, the consultant (i.e. head doctor) will see some of the patients for a review.

People are typically reviewed once a week, sometimes more in ward with high turnovers. Unlike general hospital ward rounds, the psychiatrist sits in a room and the patient comes to her. Other people in the room might include a junior doctor, a nurse and a pharmacist from the staff side. If the person is already under mental health services, they might have a designated person who is responsible for them – called a key worker or care coordinator, who also attends – especially when planning discharge. Members of the patient’s family and independent advocates may also attend. Some people bring their lawyers.

The rest of the day is taken up with meals, a few scheduled activities (typically in the afternoon), and visits from family, advocates or the chaplain. I’ll be frank – psychiatric wards are not renowned for being a stimulating environment, and people frequently take up smoking out of boredom and to socialise. Smoking rates are obscenely high in people with mental health problems. Aside from the scheduled reviews, the patient might see a doctor for physical health problems as they would usually see their GP.

Psychiatric Intensive Care
Like a general hospital, intensive care is for most unwell patients. However, psychiatric intensive care units (aka PICU, pronounced pick-you or pee-cue) don’t involved tubes and machines. It’s a very low stimulus environment, to reduce agitation levels, and there’s a high staff: patient ratio.

One thing to note here: no padded cells, no strait jackets. Some rooms are stripped down with weighted furniture, but an actual padded cell is very rare. PICU can be very calm and controlled – until it’s not.

Psychiatric emergencies
This is not like a crash call on Holby City (though, of course, psychiatric wards have medical emergencies too – they just mostly involved dialling 999 and waiting for the ambulance).


Imagine, for a moment, that you woke up this morning and thought the NSA were spying on you – not a difficult leap. Your phone has been bugged, your laptop monitored, and the car parked across the street has two of their spies. You confide in your best friend, but instead of helping you escape, he takes you to a hospital. Where they lock you up, suggest you take medication and call you crazy. Meanwhile, anyone could be a spy for the NSA in here and they ask so many intrusive questions. You’ve had enough – you’re getting out of there.

You try the door, but you’re locked in. So you try to kick it down. When that fails, you grab a mug and smash it against the sink, so you at least have a weapon when they come for you. Suddenly, they’re all surrounding you, trying to get you to take more pills. You have to GET OUT!

This is a psychiatric emergency. First this is de-escalation – basically, talking someone down. If that doesn’t work, a thing called Rapid Tranquillisation comes into play. It’s medication to sedate someone, plain and simple, and it’s a last resort when something is an acute danger to themselves or others – i.e. an emergency. Tablets are always offered first, but if they are refused – or often thrown – the next step is injectable medication, into the muscle under restraint.

These situations are terrifying – for the person at the centre and for staff in fear of their safety. Sometimes, sadly, there are no good solutions – only the lesser of many evils at that time.

Do you have experience of a psychiatric ward? What notable books/TV/films get it right – or very wrong? How can you use an accurate depiction of a psychiatric ward in your project?


  • Emma Sawyer

    I found this a very good explanation on how a mental health unit works/runs. I work in mental health rehab in leicestershire and it is like this but more low key. patients are more stable at this point.

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