The old PAAZ is at once a psychiatric ward, a setting for Emma’s experiences of mental illness, and a place whose disappearance turns memory into something physical. When Emma and Sergei return to the hospital grounds, the building has been replaced by a wide expanse of sand. The hospital and other landmarks remain, but the ward itself is gone; the loss leaves Emma unable to recover even its exact outline in her mind.

Identity and setting

The PAAZ was an old psychiatric building on the edge of the hospital grounds. Emma remembers it as small and worn, standing somewhat shamefacedly beside the rest of the site. On her later visit, the new construction stands across from the place where the old building used to be. Between them lies the sand that covers its former footprint. The contrast is striking: a large, white new building faces a space in which the earlier structure has left no visible trace.

The old PAAZ is not a setting that can be reconstructed from a detailed architectural description. Its significance comes instead from Emma’s attachment to the place and from the experiences she associates with psychiatric care. The surrounding grounds provide a few stable points of reference: the hospital, the new construction, the parking area, and a small monastery bell among the trees. Emma looks for these landmarks to orient herself. Everything is still there except the building she has come to find.

A setting for illness and care

The ward belongs to a larger history of psychiatric treatment that the book does not confine to one institution. In the author’s note, the account titled PAAZ is described as a fully anonymized, near one-to-one report of the author’s first psychiatric admission. Up, by contrast, draws on experiences across different parts of psychiatry, including diagnostic processes, day treatment, a stay in a psychotherapeutic clinic, and a second admission to a PAAZ. The author cautions that events in Up did not always take place in a PAAZ or involve the staff and clinicians depicted in the book. The old building is therefore a specific place in Emma’s story, but it should not be treated as the literal setting for every experience the narrative recounts.

Within that story, the PAAZ is associated with episodes that resist easy explanation. Emma tries to describe a change in perception as the lifting of a lifelong mist: the familiar sky and moon seem transformed when she believes she sees them as they really are. Her difficulty is not only finding words for the experience; it is finding words that will make sense to a psychiatrist. Elsewhere, a night-time check by nurses gives way to a return of painful memory. Emma tries not to feel, think, or remember, but the remembered feeling overwhelms her, and depression becomes an image of fragments of the self sinking into a depth beyond a balcony.

The ward is also where the book gives sharply different emotional states different relationships to time. Emma recalls Beatrice’s observation that depression has no time. In her account, mania contracts attention into an urgent present, while depression allows the past to swallow the future until time itself seems to lose meaning. Waiting outside Rajid’s room, Emma studies paintings hanging between the doorframes. Several are upside down, a small visual disorder that echoes her sense that her own life is inverted while what appears normal to others remains strange to her. The PAAZ is not simply a backdrop to these reflections: its rooms, routines, and objects give them a place in which to take form.

Demolition and return

Four months before Emma’s return, the small, dilapidated building still stood at the edge of the grounds. Now she sees only the sand. She says that absolutely nothing is left, and Sergei answers by pointing out the new construction. Emma looks toward the large white building, but her attention keeps sliding back to the place where the old ward stood. The physical replacement does not replace the remembered place.

A large lock joins the two halves of the gate; Sergei takes it in his hands as they stand outside the former site. The barrier marks their separation from the grounds, but the deeper obstruction is the building’s disappearance. Emma tries to summon its precise appearance and cannot. The sand, she feels, has erased not only the PAAZ’s contours from the landscape but also its contours in her mind. Its demolition makes return impossible in a literal sense and unsettles the memory through which she might have returned inwardly.

What remains

As Emma is about to turn away, she sees a large black dog waiting in the shadow of the shrubs, on the spot where the PAAZ once stood. She stiffens, then looks to Siem, who grazes peacefully by the roadside and appears to see nothing unusual. Emma recognizes the dog as something in her own mind; when she looks back, its form seems to fade. The vanished institution and the apparition briefly occupy the same ground, but the scene distinguishes between what is present and what belongs to Emma’s perception. The dog is allowed to remain in her mind without being mistaken for something real.

Siem’s warm coat and the life Emma feels in the pony offer a concrete counterpoint. She hides her face in his mane, then takes Sergei’s hand. The return does not restore the old building, nor does it make Emma’s experiences disappear. Instead, she leaves with room for both the imagined dog and the living pony, and with the possibility of making more room in herself. As Sergei laughs and the pony’s hooves clatter, Emma looks back at the sand and states that the PAAZ is gone, but she will continue. She puts an arm around Sergei and says she is home, adding her thanks to the PAAZ. The ending holds loss and gratitude together: the place is no longer accessible, yet its meaning remains part of the life Emma carries on beyond it.