PLACEMENT REPORT

MODULE 6203

PRACTICE PLACEMENT

JG JAYALATH

2015/MCP/08

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TABLE OF CONTENTS

1 INTRODUCTION TO THE PLACEMENT SITE(s)…………………………..3

2. HOW REFERRALS ARE MADE…………………………………………………..5

3. HISTORY AND BACKGROUND ISSUES………………………………………6

4. THEORETICAL AND METHODOLOGICAL APPROACHES ……………8

5. ETHICAL AND LEGAL CONSIDERATIONS………………………………….9

6. REFLECTIONS…………………………………………………………………………10

REFERENCES………………………………………………………………………12

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1. INTRODUCTION TO THE PLACEMENT SITE(s)

My placement is initially divided into two placement sites due to the reasons of the
distance from the work place and to carry out psychosocial work easily as the one placement
site is combined with a rehabilitation center. However, it has been extended further to another
placement site since I have been granted permission to work with mental health patients at the
Sri Lanka Air Force where I am working. Following are brief introduction of the placement sites.

DISTRICT GENERAL HOSPITAL – POLONNARUWA

This hospital is located in the Polonnaruwa city and providing health care for the general
public with wide range of medical facilities. This was brought under the Ministry of Health in
July 2010 and comprising of 22 clinical wards and 46 different units.

There are two mental health wards (female/male) including a mental health clinic.
These clinics are held on Monday to Friday and special child clinic is held on Saturdays.
Peripheral clinics are held in scheduled days at Sevagama Rehabilitation center for disabled,
Kandakadu for drug addicts and at Hingurakkgoda rehabilitation center. In addition to these
clinics, there are programs to educate mental health professionals such as medical officers,
nurses and social workers who are working with the hospital and special programs have been
designed to provide psycho education to patients, families of patients, general public, school
children and military personnel in the area.

The mental health wards are under the responsibility of one consultant psychiatrist Dr
Nayana Edirisinghe and four medical officers along with two social workers. These medical
officers are not from the medical field and they have been trained to provide clinical care by the
psychiatric consultant and two of them intendeds to specialize the psychiatry. There is
counseling room at the main clinic and this room has been occupied by the two-three MOs to
provide basic diagnosis for the patients after registration is done at the clinic. Both wards have
one counseling room each.

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 I have participated in ward rounds with the consultant, provide psychosocial education
for the MOs, medical students and developed my skills to identify the procedure carried out in
a mental health clinical setup. Counseling of patients at the wards also carried out and this
provide me the opportunity to learn new skills to deal with different type of patients in a single
venue. I have worked with 10-20 female inward patients and 15-25 inward male patients with
understanding their basic mental health problems and how their diagnoses are made. However,
only very limited patients were available to carry out counseling.

DISTRICT HOSPITAL HIGURAKKGODA

This hospital is smaller than the Polonnaruwa hospital and newly established clinical
ward is located at the hospital only providing clinical facilities and rehabilitation facilities for the
patients. This ward comprises of all necessary spaces for the clinical, counseling and
psychosocial work with necessary equipment. However, no inward patients were treated in this
ward. Most of my counseling interventions were carried out in this ward as it provided
conducive conditions for the counseling. The rehabilitation center was setup as day center and
a mixture of patients in all mental disorders were present at this site working together and
they were educated to make tea for themselves, making coir mats, necklaces, and other house
hold items and sold to public to find money for their bus fares etc. The patients were educated
to socially interact with each other and the results were encouraging over the period of time.
Selected caregivers formed to work as funding team for the patients and this society is looking
after monetary aspects for the patients.

SRI LANKA AIR FORCE MENTAL HEALTH CLINICS

The main clinic for the all personnel was held at Air Force Hospital Borella and the initial
clinic was at the Anuradhapura Air Force Base Hospital. At Anuradhapurra hospital I have
worked with the clinical psychologist and the at the Borella clinic I was able to work with
consultant psychiatrist. The main aims of these clinics were to identify the mental health
problems related to military personnel. Proper counseling facilities have been established in
these clinics.

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2. HOW REFERRALS ARE MADE

The referrals are made to Polonnaruwa Hospital mainly by the MOs of other district
hospitals. Meanwhile, there are referrals from other medical wards of the Polonnaruwa
hospital itself to get an opinion of the mental health status of the patient. Also there are
referrals from the legal bodies such as the police and magistrate courts. In addition, some
patients seek clinic services on their own initiation, though this is a small number compared to
the referrals.

From this patient population the consultant will refer patients who are diagnosed as to
need counseling intervention directed to me to work with them. However, most of the time I
was watching the consultant treating the patient and she stooped at important moments to
educate me the theoretical and practical aspects of the issue. At this time MOs also called in to
the clinic room to discuss issues relating to the patient and then proceed with the case.

Ward rounds with MOs, social workers and all mental health staff was carried out by the
consultant in every Thursdays and this was a great opportunity to learn how clinically interact
with the patients in inward set-up. At this point consultant asked me to explain theoretical
background of the mental health conditions such as severe depression to the staff and she also
explains it further. At times one or two patients assigned for me to carry out counseling
sessions with them at the ward itself after the ward round.

At the Higurakkgoda Hospital the consultant refer me the patients directly to carry out
counseling sessions as soon as a brief discussion is held with patient. However after each
session he used get the feedback of the patient and put remarks on the diagnosis card. If
necessary he fine tunes the plan and let me go ahead with it. He advised me to include
psychosocial components to the intervention plan if required.

At the SLAF clinic the patients were referred to the Anuradhapura AF hospital through
the MOs working at the nearby AF stations and within the Anuradhapura Base. For an example
a patient from the SLAF Palai was referred by the Palali MO. Further in rare instances, patients
were referred from the commanding officers and peer counseling personnel. From these

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personnel clinical counselor referred the patients to me and he was supervising me throughout
the session and gave feed back to me after the session with paraphrasing.

At the Borella clinic, I was observing the clinical psychologist and the visiting consultant
psychiatrist (Prof Hemamali Perera) working with the Air Force patients and at the end of clinic
a proper de-briefing was given by the clinical psychologist.

PSYCHOSOCIAL WORK

I actively was participating with the MOs to share psycho education with them and
carried out lectures for the visiting medical students to develop counseling skills. Psycho-
education was given to the patients and their family members when they come to visit the
inward patients.

I participated with the staff and patients to commemorate the world mental health day
with helping to organize the programme.

It was at the Higurakkgoda hospital there were more psychosocial work has been
carried out to work with patients to identify the different needs of them and how they socially
interacts.

Moreover, cleaning of the mental health rehabilitation center at Higurakkgoda and

Bosath Children’s Home where more than 50 girls are rehabilitating also carried out.

3. HISTORY AND BACKGROUND ISSUES

With regard to the counseling services offered by the Polonnaruwa Hospital, it was not
clear the patients did show any interest of it as they didn’t know what is happening for them.
Since the staff were too busy with the documentation and arranging patients for the MOs and
MOs also try to forward their patients to consultant psychiatric.

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 The small space was not enough the caregivers to provide their support for the
incoming patients at the main clinic and even the consultant’s talking to the patients was being
heard by the in line patients.

Most of the patients were administered by the drugs at the first conversation even if
they are having a mild depression. Then they were questioned the background issues and the
basic counseling aspects such as empathy, paraphrasing, unconditional positive regard or active
listening were not observed regularly and they were interrupted at several times when they
started to talk. It was very clear that some of the patients wanted to talk a longer time but they
were deprived of it and they were given advices to correct their behavior. For an example
couple came for treatment for the wife’s problem of forgetting things regularly and had some
disputes over the husband due to mistrust. She was severely advised for her behavior and drugs
were given to her to calm her down when she goes out of temper. Then they have gone out of
the consultant’s room and waited outside until they get another opportunity to meet the
consultant. Finally just before we left husband came in and asked to talk to her since she
needed to be heard carefully by somebody.

At the wards especially at the female ward the space was not enough for the patients
and their privacy is not safe guarded. They all were seen as not normal and they were not ready
for counseling at any time. However, they were referred for me at the ward round.

During the practice sessions at the Higurakkgoda a different approach was applied by
the consultant as the clinic had time, space and resources to apply all counseling skills in
practice. The patient’s turnout was comparatively low at this clinic and I had the opportunity for
systematic intervention. However, the rehabilitation center was not having the intervention
tools such as (Kessler,2002) psychological distress scale (K10) as an instrument of screening the
patients.

On the other hand there was a systematic approach was observed at the SLAF clinics
and a proper intervention for the issues and applied all the techniques for the patients. Only
issue at the clinic was that some commanding officers were interested to know what happened

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to the patients and what they have told the counselors. Special skills of handling these issues
were required to avoid sensitive information being leaked for the best interest of the patient.

4. THEORETICAL AND METHODOLOGICAL APPROACHES

I was able to use most of the theoretical and methodological approaches learned
throughout both postgraduate and master’s degrees and learned how to use in practical
sessions at all of the internship sites.

Active listening, unconditional positive regard, paraphrasing and empathy was easy to
use for the patients and I have seen how it being used when the consultants and clinical
psychologist used the skills to challenge the patients at counseling sessions. I kept eye contact
all the time when the patients were assigned to me. At times at the wards it was boring to
listen same story over and over again and the patients were not prepared for counseling
sessions as most of patients were on medication shows sleepiness. However, I managed to
build a good rapport with them to have a positive relationship with everyone dealt with.

The breathing exercises were very useful for the patients many of them even not heard
of it. In fact, the use of the tool was not a success for some patients who were at the ward.
They simply listen to it and just said that they are tired to do it in practice. My effort was to
introduce it just not worked.

Kessler K10 was used to find out the depression levels of the patients and this was new
experience for me since it was the first time that I used the tool in practically and it was difficult
for me to translate the questionnaire to suit to the patients. And it took a longer period than
expected to explain. I shared this tool with the hospital MOs and the staff.

Star chart was used to motivate the children to achieve targets. This was also new
experience for me as it was the first time I used it and consultant was also helpful me when it
was used in practice.

Despite the fact that my clients are persons in the ward or visiting patients for
the clinics, the PADHI (2009) framework of wellbeing is applicable to map their psychosocial

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needs. Even though the most urging needs of the patients may vary from a person living a
regular life, it is still important to identify the gaps in their wellbeing. The five wellbeing
domains of PADHI are as follows;
 Access physical, material, and intellectual resources
 Experience competence and self-worth
 Exercise participation
 Build social connections
 Enhance physical and psychological wellness
 Systems and institutions

This tool was extensively used at the rehabilitation center at Higurakkgoda where many of the
psychosocial work had been done at this site. For an example the schizophrenia patient who
didn’t know how to use their hands to make tea or make a coir mat was successfully thought it
using all of above domains and it was easy to map their requirements.

5. ETHICAL AND LEGAL CONSIDERATIONS

Since I was involved in actual patients in the hospital clinical settings I was abided by the
strict ethical rules of the hospital. It was clear that no information of the patients should be
shared with anybody other than the professional staff of the hospital and not to provide
financial or other gifts to patients. This was very difficult to follow at times since most of the
patients were low income earners and sometimes they didn’t have money to bear the bus fare.
Anyhow I determined not to give any sort of gifts for any patients and this was one of a heaviest
decision I have made during my internship.

When working with inward patients they were expecting their relatives to be there at
lunch and many of their expectations were not met and they were crying and asking me to give
telephone calls for their loved ones to be present. Few patients were being referred from the
legal bodies and they wanted to revenge from the authorities for they being held there and

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handling this kind of issue with patients needed peace of mind and emotional barriers had to be
made.

At the SLAF, it was found at times that some of the patients were the subordinates of
mine and then I asked my supervisor to be away from the clinical setting. However, supervisor
asked me to stay with him since they were not relatives or friends of mine. Occasionally, SLAF
patients were asking my advice to face situations in their military life and I managed to provide
advisory role after the therapeutic sessions only. Even the supervisor and I had some
discussions for the betterment of the patient to find the best course of actions when it comes
to SLAF legal issues such as absent without official leave or desertions of depressed / attempted
suicide patients.

6. REFLECTIONS

I wonder why in a hospital all the patients were given drugs at their first appearance
even though they could be treated purely in counseling. On the other hand they were just
interrogated merely to get an idea of the history and background and then they were admitted
or given another date to be appear at the clinic and no basic counseling skills were used or in
practice. Many patients were flocked at the clinic and their discussions with the practitioner
could be heard by the waiting patients too. They were abruptly interrupted at times to share
the theatrical background with me and other MOs present. I didn’t understand as to why these
routine applied in the clinic and it was later I also used to it. However I determined not to
practice it when I am practicing with my clients. Further the counseling rooms were not
designed to carry out its purpose and at sometimes no clean chairs were present at the wards.
When patient is urinated on the floor it took hours to clean and dry the place. I thought due to
less or no resources was the main reason for these issues since there are many patients to seek
help from the government hospital.

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 This condition was not there at the Higurakkgoa hospital and SLAF clinics and the ward.
The standard was excellent compared to Polonnaruwa hospital. They used all the skills and it
was better environment for the patients too.

However, at times I was disappointed with my work since the patient I worked with no
longer to be seen in next day since he or she was discharged from the ward. I discussed this
with my supervisors and they said don’t plan too much with inward patients and even to work
with many sessions was a nightmare for me.

The limitation such as discontinuation of the patient without notice, in ward patients
were not conducive to for counseling, too many patients seen in a day was really challenging at
the hospital setting. In fact when I was given a patient just after the ward round I was tired
since the whole day I was walking through the wards. I needed a break than to practice. The
consultant was not in a position to identify it. When I was assigned to teach to medical
students I was delighted and it was a completely new experience for me. I thought it would be
difficult as they would ask many questions as they were medical students. When I actually did it
, it was not so as they did not know the counseling.

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REFERENCES

Kessler, R.C., Andrews, G., Colpe, .et al (2002) Short screening scales to monitor population prevalences
and trends in non-specific psychological distress. Psychological Medicine, 32, 959-956.

PADHI. (2009) A Tool A Guide and a Framework: Introduction to a psychosocial approach to

development. Colombo: Social Policy Analysis and Research Centre.

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