Reflective Statement Ms. KW is a 32-year-old woman that was admitted to WPIC through the DEC because of suicidal concerns.

She had a long history of struggles with social anxiety and alcohol abuse. Her struggles were not only affecting her to the point of thinking about ending her life, but also affecting her family, friends and current boyfriend. One of the precipitating factors for her decline was a traumatic experience nobody deserves; she had been raped two years ago while working at a daycare. Her family, overwhelmed by her excessive drinking after her sexual assault, tried the strategy of being hard on her and it only led her to move out in with her boyfriend. She took it as if her family was not supportive after her assault. This trauma, along with many from the past, broke her heart and her sense of self. She did not trust anyone, not even herself. Her boyfriend initially took good care of her, but with time began to be physically abusive and careless to the point where KW was afraid for her life. It was extremely hard for her to be in this situation, the man that she saw as her support was now threatening her life. She was devastated and did not had desire to continue living. It was then, that she knew she needed help and decided to come to WPIC. This is how I met KW. I was just a 3rd year medical student with only 3 weeks of experience in the floor. I was completely overwhelmed and pitiful for her, just from reading the DEC summary. In the beginning I did not realize completely how much guidance and help I could do for her. I was scared and worried about KW life. Nonetheless, I made the decision to work with her, as I learned about motivational interviewing and psychiatric care. This is a clear example of how sexual assault in society harms not only one person, but also harms society as a whole, breaks up families and creates an atmosphere of hate and resentment. During morning rounds, when the time came for me to interview her, I knocked on KWs door to receive no answer. I opened the door and saw her lying in bed shaking. It was shocking; I had never seen somebody feeling this way. I asked her to come with me to the rounding room. She sat down on the rounding table, and I began my session introducing the team and explaining how treatment worked in our floor. I might have sounded as an expert to her, but I was as nervous to carry on with my session as I could. Our team was relatively large, having 3 residents, 3 medical students and a psychologist. As I continued to engage her in conversation, I was not getting anywhere. After five minutes of reflecting and eliciting information, I realized how terrible her pain was. I had to do something. The significant alcohol withdrawal had her struggling to even talk. I quickly ended my session and reassured her symptoms will be taken care by medications. I felt terrible for not being aware of her alcohol withdrawal situation earlier, at the same time I was just beginning to learn about it. After reading more about her history, I met with her during the afternoon for a oneon-one session. She was in significant pain so I interviewed her in her room. I wanted to be brief to avoid discomfort, but KW wanted to talk about her struggles. She was in desperate need for help. I explored part of her struggles, as uncomfortable and sad as they where. Just thinking about all the traumas she has

had in her life, made me value life to a greater extent. After talking for only one hour, KW had given me a snapshot of her life, her traumas, and the struggles she was currently going through. She thought this was the end of her life and said to me I want to be able to get my life back on track, have a family, kids but I dont think that is possible. It was sad to hear, how she had been in this vicious cycle, which had led her to the point of thinking about ending her life. The next day, when I asked KW to come to the rounding room, she fell to tears. She refused to go into the room because of the big team. She was extremely anxious and described how during her life, she had always had trouble with situations where she was the center of attention. During this moment I felt terrible, confused, without knowing what to do. On one hand, I had to bring the patient to the rounding room and interview her in front of the team as it was the standard procedure, and at the same time, I felt the pain she was going through to just even consider going into the room. After explaining the reason behind the large group, and emphasizing her own decision to seek treatment, she agreed to come into the room. She was crying and shaking throughout the interview, it was emotionally draining and difficult to handle. Even though she was feeling extremely anxious, she worked through her emotions because she could not continue living the way she was. Afterwards she realized it was important for her to start opening up in front of the big group in order to diminish her anxiety in the future. After this, KW was more open during the afternoon sessions. She shared with me her struggles and her traumas. After half a week of working with her, I felt she began to trust me. This trust allowed her to open up and share what she called her deepest secrets. Continuing to build on her own ideas using MI, she began to form goals. She decided to have her mother come for a family meeting. Furthermore, she formed a plan of things she thought were important to achieve her goals. It was amazing to see how using MI, I was able to guide her to formulate a treatment plan that would allow her to change her behaviors of alcohol abuse and reformulate her anxiety. It was incredible to see how, the ideas, feelings and decisions came from her, I was just a facilitator and interpreter of what she was going through. Occasionally I provided suggestions about therapy when asked for. Overall, she was the one who made the decisions and did the work. KW was looking forward to her mother coming for a session, at the same time she know it was going to be extremely hard for her to open up in front of the big group. She was in a situation that in the past she hadnt been able to handle and she told me, I got to do it. She did it; she came into the room and talked to her mother about her feelings and about her struggles. The session was emotionally charged, but they were able to start rebuilding their communication. Here I saw the beauty and importance of communication. On one hand the mother had done so many things for her daughter because she thought they were the best for KW, and on the other hand, KW saw things from a different perspective, interpreting her mother as not supportive and intrusive. After that session, KW was much relieved and felt that she was now able to move on in her life and rebuild her trust relationship with her

mother. Even as her mother didnt want KW to continue living with her current boyfriend, she understood the message and allowed KW to decide on her own. It was devastating for me to see how KW did not wanted the life she was living with her boyfriend, at the same time she was too afraid to end the relationship and move on. It was here when I found myself struggling to maintain equipoise. She provided me with things she was looking for in a relationship, at the same time she identified that her current relationship was the complete opposite. Her ambivalence about her relationship had not been resolved, yet she knew that one of her greatest triggers to alcohol use was her troubled and abusive relationship. She realized how her current boyfriend was physically abusing her and that most likely things were not going to change. Even with days of change talk and identifying that he was not what she was looking for, she decided to go back and live with him because of being afraid. It was here when I had the hardest time during my rotation. I wanted to jump in and tell her, what are you doing?, he is clearly not valuing you nor the relationship. It is the righting reflex we all got as training physicians. At the same time I knew it was not appropriate and will not lead her to any change, therefore I remained silent about my opinion. One thing I did do was sharing my concern for her safety. Was it me that did not work hard enough with my KW to guide her to realize that the relationship was affecting her life, or was she not ready to move on? This has been a question that I have been carrying since. At the same time, after reflecting and speaking with my attending and residents, I came to the understanding through first hand experience, that we are in this field to guide our patients but at the end of the day, its entirely up to them to make their decisions. It is also important to maintain equipoise, respect their autonomy and dont take sides. I know I tried my best and even though she did not ended the relationship that had cause her so much harm, I planted the seed for change and her perspective about life has changed. Overall my rotation allowed me to learn about a whole different way to practice medicine. By learning how to do Motivational Interviewing, I acquired skills that I can apply to my future daily clinical practice and hopefully help guide patients to achieve the change they want to make. Besides learning about psychiatry, after this rotation I am always going to see patient care from a different perspective. Looking back to the first two years of medical school and reflecting, I have come to the realization that emphasizing patient autonomy and working towards their own goals is the way to practice medicine. Looking forward, the MI skills I learned during this rotation will be invaluable for my career and the challenge lies in maintaining perspective and continuing to integrate MI to whatever field I eventually chose as my specialty. I have clearly seen how the answer to patients struggles lies within them and is our job as physicians to facilitate that process. Furthermore, this was the first time I was given the autonomy and responsibility to work with a patient in all the aspects of their care. Through my rotation I was able to work with two individuals who had fallen from their path in life, but through the guidance I was able to provide, they were able to identify the behaviors that led them to fall off track, how to approach

their recovery and are now feeling better on their way to get their lives back on track. This is the reason why I chose to enter the field of medicine. I will carry these two patients through the rest of my career.