“Presenting psychosis”: how is it triggered on a ward and interpreted by psychiatry and other health professionals?
Authors: Gray Benjamin Thomas , Sisto Matthew , Conley Renee , Sisto India 
Published: January 2025

Purpose
The purpose of this paper is to explore the bias of psychiatrists and other healthcare staff’s perception of “presenting psychosis”. The purpose of this paper is twofold: first, to suggest that psychosis, rather than residing in the individual, can be triggered by a hostile ward environment (e.g. very loud emergency alarms) as well as the negative attitudes of staff and friction with other service users; second, to argue that psychosis is not just in the person’s mind but interpreted and negatively labelled by psychiatrists and other healthcare professionals.

Design/methodology/approach
This paper is based on the lived experience of Ben, who was first diagnosed with schizophrenia in 2003 (when he spent two years in and out of a mental health unit). Ben had a relapse in 2013 and spent six full months in the same unit. Ben has been working as a peer worker on the same ward he was on as a patient for the last 17 months. This paper is informed by participant observation as a patient and peer worker, particularly reflecting on the general ward environment, ward reviews and punitive action faced by Ben and other service users. The title of this paper is based on occasions when Ben has been told that he cannot interact or take service users on leave off the ward, because they were “presenting psychosis”.

Findings
Ways of judging whether someone is presenting psychotic behaviour sounds straightforward enough but in fact can be quite complex. Whether someone is presenting psychotic behaviour is open to interpretation. Psychotic behaviour is perceived as latent or inherent within the individual by psychiatry. This paper makes the case that presenting psychotic behaviour is in fact a construct or interpretation by psychiatrists that works to limit people’s freedom, coerce them, take away their leave off the ward and voice, and which expresses power imbalances between staff and service users. The impact for service users of psychiatrists and staff’s decision-making can lead to service users being angry and upset, a negative ward environment and feelings of unfreedom. A good example is that service users present psychotic behaviour due to a hostile and frightening ward environment, with loud emergency alarms (like sirens) and the threat of restraint, restrictive practice and seclusion in de-escalation rooms being used as a threat.

Originality/value
People with mental illness, particularly schizophrenia like Ben, can be stereotyped as psychotic, aggressive and dangerous or a risk to themselves and others. While this can sometimes be the case the majority of people with mental illness that Ben has interacted with for over 20 years could be described as “broken” and in need of care, fixing and giving them hope in their recovery. This paper is of value because it draws on over twenty years of experience of the lived experience of Ben and his diagnosis of the harmful label of schizophrenia. It describes the added value of peer work in an in-patient mental health unit. It also introduces the new idea of “clemency”.