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"Good morning, Vietnam!"
The recap takes us straight into the episode, thrusting Sam into the after effects of his sacrifice in "Repo Man." He is running, plagued by his hallucinations of Lucifer, and has not slept in days. Those he encounters are unsympathetic and chase him away. As he stumbles, Sam bumps into a man, and that man shouts after him, "Hey! Dick!" He eventually encounters a drug dealer who offers some sedatives that will allow him to sleep, but they fail to produce the results he desires.
A hunk of metal is thrust through the windshield on the side of the car Sam has crashed in, and he jumps out in a panic, running away after he realizes that it was in his head. Not paying attention to his surroundings, Sam is then struck and tossed by a car. It injures his ribs, and he ends up in the hospital. Unfortunately, because of his mental state, they also lock him away in the psychiatric ward.
Dean is beside himself with worry over his mentally fractured brother. He will not and cannot accept that Sam will die this time, and in a reflection of "Faith," he starts to put out feelers to find another faith healer. Sam doesn't have much confidence, certain that it will only be a matter of time before he dies. He says to Dean, "We know better than most. It's all snake oil. Last faith healer we hooked up with had a reaper on a leash. Remember?"
Finding another one to heal him without consequences is next to nil. And yet, Dean must try and do everything in his power---just as Sam had so long ago when he had originally found Roy.
Dean burns through numerous contacts that he knows through Bobby. All of them but one reject his pleas. It would seem that Dean is also not alone in his search---another hint that Bobby is somehow without them emerges just when the elder Winchester needs it most. The contacts book falls on the floor and out falls a business card for Mackey. At the end of his rope and with nothing left to lose, Dean leaves him a message. Mackey gives him a call back and tells him about a healer he found in Colorado, a faith healer that goes by the name of Emmanuel---translated into meaning "God is with us." Mackey informs Dean that the man seems legitimate and passes all the tests. He is no demon, no magic user, no pagan god. Dean, in his desperation, goes to seek him out, only to find demons waiting at the door. When he finally looks behind him, he spots the last person he thought he'd ever see again: Castiel.
Meanwhile, Sam is taking his licks from Lucifer. There is the endless noise, taunting, and visions. Lucifer brings out all his bags of tricks, from putting maggots into Sam's food to blaring at him with a megaphone or shooting off fireworks. He blares "Wake up little Susie," and endlessly keeps Sam awake despite all the sedatives and medications concocted to knock him out. If the taunts and noise Lucifer inflicts isn't enough, the sheer exhaustion is also taking its toll. He is wavering on tired feet, yawning extensively, and looks about ready to pass out into oblivion---if only he could. Lucifer's worst tortures aren't making Sam see or hear things. It is his refusing to let Sam rest.
And yet, Sam isn't totally shutdown. Despite his extreme sleep deprivation, he manages to help another patient there because of her own supernatural problem. Marin is hearing her brother's voice"”and has ever since he passed away a year earlier. At first it had started off as comforting, but over time as her brother became an angry spirit he became more and more violent. He burned their house down around her and forced her to make an attempt on her life. She is scared and desperately needs help. Her mental state is not medical---and mirroring Sam, no medication will cure her of the voice. No psychological treatment will cure Marin of this haunting. Stuck in the institution now "Five weeks and counting. Going for the record," Marin just wants it to be over and to end.
With all of his issues, Sam takes the time to listen to her story and her reason for why she is in the ward. It doesn't take long for him to put all the clues together and realize that she is being haunted. He starts going into hunter mode. On one hand, it is an attempt to outrun and outgun Lucifer---even while trapped in a psych ward room with no escape---something that Lucifer points ot with glee. "Is it just me, or is this just like the Cage?" On the other, it is a testament to Sam's inner character and strength to put others first and want to help.
Once he has all of the clues together and the necessary tools to put Marin's brother to rest, he puts together a salt circle and takes the bracelet from her---the thing that is keeping her brother here and tying him to her. Unfortunately, Lucifer is nonplussed about being ignored and makes it seem to Sam that he's blowing the salt circle apart. He has to instruct Marin on what to do until he regains enough of his wits to manage lighting it on fire.
Afterward, he forces her to flee. Before she leaves, she expresses her gratitude for Sam's help with a soft, "Thank you." It is a small gesture, one that Sam needed to hear. In its utterance is the hope that Sam must somehow cling to as time ticks down on how long his physical body can last without sleep. Resigned at this point that he most likely will not survive, Sam made a difference in another's life, and that is all the gratitude he needed.
Soon after the hospital staff puts Sam on tie down to prevent him from using a banned item. If this isn't bad enough, the staff he's been placed in the care of does not have his or anyone's best interests at heart. It would seem that Crowley has grown impatient and has sent his horde back after the Winchesters---right when their chips are down. A demon proves as much to Dean when he says, "Please. What have you done for him lately? Roman's head on a plate? No? Whatever Emmanuel is, Crowley's gonna want him "“ a lot more than he wants you these days."
It is a race against the clock, and while Dean has found the least likely person to be Sam's healer in a mysteriously resurrected Cas, it is the only option on the table. That, too, comes with it's own problems---namely in the form of Meg. The only demon to have been on the brother's tails since season 1, she once again inserts herself into their situation, all because of Castiel. She is still trying to unseat Crowley as the King of Hell, and as any good demon knows, make the best of any opportunity. Castiel is being pursued by Crowley---all because of his healing.
The other problem? Castiel has no idea who he is---or what he is. He has all of his angelic abilities as before, but no memory. In mirror to his vessel, Jimmy Novak, Castiel has married a woman named Daphne. Much like Jimmy, Cas will have to make the heartbreaking decision to leave her behind and resume his angelic role. They arrive at the hospital, just as Sam is being "medicated" via electro-shock at the hands of a demon doctor. Castiel, uncertain and yet the same as he was before the deal with Crowley, manages to regain his memory by smiting the demons waiting outside the hospital.
He is remorseful and heartbroken at his actions---and tries to walk away. He says, "Because of me. Everything. All these people. I shouldn't be here." Dean chases after him, and says, "If you remember, then you know you did the best you could at the time." Castiel retorts back, "I deserved to die. Now, I can't possibly fix it... So why did I even walk out of that river?" Dean replies, "Maybe to fix it. Wait." To complete the gesture, he takes out the trenchcoat he's been toting from vehicle to vehicle, returning it to its rightful owner. It is a gesture of forgiveness and acceptance that the past is best left in the past. There is too much at stake---mostly Sam---to remain angry over it any longer.
Just as Sam can't take anymore, the angel smites the demon---but it is too late. Sam is too far gone, too far beyond Castiel's limited angelic help. All he sees is Lucifer. All he hears is Lucifer. He confirms as much when he rasps out, "You're not real," to Castiel. The remorseful angel tries to heal him anyways, only to find what was left of the wall is gone. He informs Dean that he can't fix it "Because it crumbled. The pieces got crushed to dust by whatever's happening inside his head right now."