RCPsych Wales - Psychiatry Placement Reflection

Alexandra Willis is a 5th year medical student at Cardiff University. Alexandra was recently awarded the Welsh Psychiatric Society Clinical Aptitude Award, in this blog she reflects on a recent psychiatric placement.

During a psychiatry placement, my consultant was asked to speak to a patient who was shouting and swearing loudly regarding his feelings of indignation that he had been sectioned for assessment at a psychiatric facility. The patient was French-Canadian who was studying at university. He had been sectioned after he presented with a first episode of psychosis which was associated with a short period of heavy substance misuse. He was irate and screaming that he wanted to “speak to his lawyer” and “leave this f*cking sh*thole”. This aggression escalated to violence when he began to kick and smash ward furniture. At this point, the staff began to implement de-escalation techniques.

Whilst observing the impact of sectioning on this patient, I felt a sense of trepidation and anxiety while he became increasingly more distraught. When IM medication administration was discussed, I felt uneasy due to the stereotypical media presentation of this practice. However, as the patient agreed to take PO medication, I was left feeling relieved that the situation was diffused much more quickly than I expected.

I was surprised by my mixed feelings during this clinical encounter. Whilst I experiences a lack of emotion in response to his physical violence and behaviour, I felt the patient’s distress, exasperation and lack of insight into his condition had more of an emotional impact.

As the patient became more distressed and frustrated with staff, he expressed emotions that I could personally empathise and relate to. We were of similar age and had both experienced moving far away to study at university. I was able to see through the shouting and swearing and realise that this young man had been through difficult life experiences and had developed unhealthy coping mechanisms for stress whilst far away from home and family.

The patient expressed feelings of isolation and the difficulties of moving to a new city and culture. I became very aware of how I have been privileged with a close-knit supportive family who has helped me develop strategies to manage similar experiences. Hearing about the patient’s social history deepened my understanding of how mental ill-health can affect people from all backgrounds and walks of life as well as the importance of assessing patients holistically to help further understand the cause of certain behaviours.

My emotional reaction to the patient highlighted the importance of introspection and self-awareness. As a future clinician, I can appreciate the necessity of reflecting on how my personal past experiences inform how I understand and relate to patients.

Staff members demonstrated an example of an excellent de-escalation practice. All staff involved were quick to react, clearly explained what was happening to the patient and did not use coercive measures. It was evident that nursing staff had invested time in developing a therapeutic relationship with the patient and were well informed of any personal provocations or triggering topics. This resulted in the patient agreeing to take oral medication himself for agitation and therefore more restrictive practices such as physical interventions did not have to be utilised by staff.

Observing this clinical scenario deepened my appreciation for the psychiatric nursing team who have a front-line role in preventing and managing aggression as well as having direct-care responsibilities. The violence was triggered by the patient’s responsible clinician explaining why discharge was not possible, but it was the nursing staff who had to deescalate the violent and threatening behaviour.

Aspects to reflect on include the positioning and layout of the consulting room. The patient was positioned closest to the exit which affected the escape route for the members of staff. This highlighted the importance of taking the time to appropriately arrange a consulting space to ensure the safety of service users and staff.

This encounter made me reflect on current attitudes towards patients experiencing psychosis. I feel that although there is now increased awareness of mental health conditions such as depression and anxiety, there is still a limited dialogue regarding psychotic illnesses, and I feel that these patient groups remain marginalised within our society.  

The patient detailed during this reflection made a lasting impact on myself. The patient highlighted the fine line between a person not being able to cope with the daily challenges of life and how this can easily escalate to illness without proper support systems in place.