The 2 North Milieu

When you visit 2 North at Westchester, you might find 20 teenagers hanging out in a spacious sunlit living room. There’s a big group crowded noisily around a card table as they play Egyptian Ratscrew, slapping their hands in as fast as they can and laughing raucously as cards fly everywhere. Kids are lounging on comfy couches, some conversing quietly with each other, others idly doodling on folders, others next to them read well-worn paperbacks. One sits at a bay window looking out onto the lush lawns and groves of upstate New York. They’re all clad in pajamas and sweats and slippers, all without makeup, all without pretense. There’s not a cellphone in sight. The place looks so placidly idyllic that you might wonder why a place like this exists in a modern world like ours. Well…

NYP Westchester is a dedicated psychiatric hospital, and 2 North is the adolescent unit. Almost all of kids there are admitted for depression and suicidal ideation.

Hmm. Perhaps if we look closer at the scene, we can uncover clues about this most curious place. All around 2 North, the door handles are stainless steel levers that are shaped to be so smooth that the patient’s can’t hurt themselves. The doors are all locked. There’s a window looking into a nurse’s station, where one kid is waiting to receive his medications. In the living room, the furniture is all wooden, the windows only open 6 inches, the TV is encased behind a plastic barrier. The standard issue “safety pens” are small implements with flexible casings so they can’t be used for self-harm. All strings — shoelaces, sweatpant ties, headphones — were removed as a precaution when they were admitted, hence the dress code.

You can observe the kids themselves more closely too. There’s a boy who rolls up only his right sleeve, always taking care to keep his left forearm covered. There’s another who only wears blue hospital scrubs because he has no family who can bring him his own clothes. The girl with fractured arm after her jump needs constant overnight observation because her sling has a strap of fabric. One girl eats all her meals in the hallway so they can make sure she eats enough. And there are the few kids still in the deepest depths of their depression who just… look depressed. They mope slowly and quietly and thoughtlessly around the unit with expressionless faces, avoiding conversation and mumbling their replies while staring at their socks.

Most of these patients are here recovering from the darkest moments of their lives, and it’s a remarkably high-risk population. Think about it; doctors decided they needed to be admitted to an acute inpatient psychiatric ward for a week or two. Thus, the environment of 2 North is carefully crafted to support these kids as they get better. It’s called “milieu therapy.” They make the place as safe as possible — it’s meticulously regulated to be physically harmless; the kids are asked to be amiable but private; they know that there is always staff available to help them whenever they feel “unsafe.”

Of course, the staff (wearing our red lanyards with our keys) are all actively enacting the other aspects of treatment. Every morning, the psychiatrists examine each kid, tweaking medications and evaluating the treatment plan. There’s a teacher who runs “school” in the mornings, therapists who lead group and individual sessions throughout the day, and nurses and mental health workers that support the kids in every way possible throughout the days and nights. The MVPs are the social workers who talk with parents to instruct them how to support their kids through their illness and make their households safe, contact new outpatient therapists and psychiatrists for follow-up therapy, and coordinate with school counselors and teachers to make accommodations.

2 North is designed to be a haven, a place where the kids can feel safe and comfortable — but not too comfortable. After all, it’s a small hospital wing in high demand (in the NYP Cornell ER yesterday the doctors were like “dang it, this 15-year-old needs to be admitted to Westchester but there are no beds!”) and the goal is to get them on track to safely work through the rest at home. Inevitably, there comes the moment in morning rounds when we reveal to the patient “well, ready to be discharged home today?” They only have a few moments before their parents come to take them home to begin outpatient therapy and resume wading through the troubles adolescence. Before they leave 2 North, they bid brief farewells to their new friends/fellow patients, but they’re asked not to keep in touch on the outside.

After spending a short week on 2 North as an observing medical student, I find it an amazing place. The kids leave in a better state, equipped with an armamentarium of coping skills and a new broad support network. Almost all the patients are admitted for depression (a minority are hiding from debilitating anxiety, coming off manic episodes, or cooling off after violent outbreaks), yet it’s not a sad place. In fact, the striking normalcy of the 2 North milieu is somewhat troubling.

Imagine walking into any classroom in any high school. Imagine finding a group of kids noisily playing cards, bantering, reading to themselves, looking quietly out the window. There’s a boy wearing a cardigan in the heat of late spring, a girl staring at a barely-eaten banana on her desk, a boy who slips a pencil sharpener into his pocket. How many of them may be hiding a brewing depression? Without the extreme protection of a place like 2 North, how many might do something unsafe in a moment of utter hopelessness?