Earning Trust by Respecting Our Fear of Engaging with Mental Health Care

After a very damaging healthcare experience (that I don't see myself recovering from for quite some time), I wrote a couple recent blog posts as a bold declaration of the kind of healthcare I require going forward, along with a (partial) explanation of why anything less will not only fail to assist me, but will be damaging and re-traumatizing.

The funny thing is the boldness of my declarations can be contrasted with the actual helplessness of my circumstances and options, since the system doesn't seem to be set up to allow for my needs.

It shouldn't really be a lot to ask. What I need is so basic. I'm not asking for access to expensive treatments. I'm just asking to be treated as an autonomous individual, worthy of consideration, dignity and respect, who gets to decide basic things, such as (1) whether to agree to a suggested treatment, (2) whether and to what extent to engage in an assessment process, and (3) the pace at which to do so. I'd also like some say in how the information about my background and needs is gathered from me (for instance, I'd like whoever provides future treatment to me to work collaboratively with the very qualified professionals who have been providing mental health assistance to me over many months, who have earned my trust and know me well.) 

I'm not asking to be given more and faster: I'm asking to have less pushed on me, and for whatever I'm offered to slow down to a pace with which I can feel safe and comfortable. As a precondition of any assessment or care, I need flexibility and I need my boundaries honoured and respected. I'm not asking for this because I'm being demanding and just want things done my way or else. It's because I know with certainty  that anything that doesn't honour those limitations of mine will not only be unhelpful, but will be deeply damaging to me (as I've recently experienced).

Yet so much mental healthcare and mental health messaging and regulation seems to be built on pressure, dictatorial "prescriptive" attitudes, dehumanization and outright coercion.

First, with respect to diagnosis: If I go in for an evaluation or treatment of my trauma, I'm not consenting to a wide-ranging invasive deep-dive examination of every aspect of my personality and psychological make-up. I'm not there because something is horribly wrong with me as a person and clueless professionals need to take apart every aspect of my personality querying--with a great sense of mystery and wonder--what it might be. I'm there for what should be very plain and obvious reasons to any compassionate and understanding professional: because of the things that have happened to me. It should be no mystery what needs to be addressed. I wouldn't go to a hospital for a broken leg and get a full-body evaluation, including of incredibly intimate parts of myself, just to see if perhaps I'm mistaken about the source of the damage. It's disrespectful, invasive and insulting. It also causes more injury (for reasons partially explained in previous posts). Me declining to participate in such a process isn't me resisting treatment. It's me protecting myself from further harm. If an examination of my broken leg included a process that involved breaking several other bones in my body first as part of the diagnostic process, you can bet I'd say no to that treatment too....

Second, with respect to establishing trust before proceeding with anything: I have respect for mental health professionals but I'm entitled to some basic dignity and privacy. I don't need to be a doctor to be confident that the power to take someone apart and tell them everything that happens to be "wrong" with them through invasive assessment measures, some of which may have arguable validity, isn't something that should be exercised over an already fragile person, suffering from obvious causes that need to be attended to, as a precondition of them getting treatment for the issue that brought them there. An already fragile person shouldn't have to surrender any more of her dignity and privacy than she's already had to through the things that have happened to her, unless truly necessary. A traumatized person shouldn't be asked a bunch of questions "Have you ever felt x, y, z," designed to find inherent problems with her "mood" or "personality" with no regard for the traumatic experiences that caused her to experience "x,y,z" on past occasions. Moreover, no one, especially a traumatized person, should be asked to surrender such private aspects of themselves before the time has been taken to build trust, comfort and safety. Diagnostic questionnaires should not be handed out in a waiting room with impossible-to-answer questions that don't allow for explanation ("yes, I felt x before, but only as a direct result of trauma") before a traumatized person has ever even met with the professional in question, let alone established a sense of trust and safety with them. No steps should be taken until the person is ready for them and consenting to them. Because doing so to someone who has already had their boundaries violated is itself a source of further harm. If a professional doesn't understand this, then the whole process is questionable from the start, and no one should wonder why some of us will resist that.

Third, with respect to understanding power dynamics: our mental health system allows for an incredible amount of power to be exercised over those who are suffering. Mental health professionals should know and expect that many of us will therefore be terrified and perhaps justifiably unwilling to engage with them, especially if we've already been damaged and had "worst case scenarios" of betrayal and abuse of power happen via trauma. We can be hospitalized against our will and any number of invasive potentially permanently damaging and profoundly traumatizing "treatment" procedures forced on us if we encounter the wrong professional who mistakenly feels the threshold for doing so has been reached. I've been assured this is very unlikely to happen to me, as I'm nowhere near that threshold, but that doesn't stop me from being terrified of it. All it takes is one risk-averse professional who misinterprets something I say. Instead of dismissing these fears, the basis for them should be reduced by truly protecting people against the prospect of them ever being used and slowly building trust with people before engaging with them if that's what they need to feel safe. Each time I encounter a professional who is careless and dismissive in how they engage with me, that fear grows because all it takes is to encounter that kind of person at the wrong moment in a vulnerable state and the results could be catastrophic. Even if professionals "know" that no such danger exists with them, they need to understand and validate our fear that it could and let us slowly build our trust with them before doing anything (not as a precondition to treatment that fearful patients hope for, but as part of the treatment process itself).

Moreover, such power can also be wielded in relation to mental health by non-medical professionals, so those who engage with mental health professionals may also fear those implications (even if they're comfortable and safe with the particular professional offering services). Professional regulators and employers may not be as understanding about mental health as they should be. Consequences can result. Family and friends may not be understanding and supportive.Social exclusion may result.

So it's a big deal to submit oneself to "assessment" and "care" by a professional and the system in general. Instead of urging, persuading and pressuring us to "reach out" anyway, professionals need to focus on their side of the equation by ensuring that as little "reaching" as possible need be involved in "reaching out" first. Slow down. Let us go at our pace. Build trust before doing anything if that's what we need, so that reaching out won't have to feel like extending our limbs over a steep cliff with no confidence in what might happen next. People are afraid for a reason. Because this is a big deal. Understand and honour that first and every step of the way and then maybe more people will feel comfortable taking that leap....Otherwise, respect our choice to maintain a distance that feels safe to us until we are ready to risk moving forward.

I have a lot more to add but I'll just arbitrarily stop there (because my coffee is done and my dogs feel entitled to a walk today....)

Overall, I'll just say this. Many of us struggling with trauma and mental health are afraid. Please stop condescendingly telling us we shouldn't be. Stop gaslighting us. And start honoring, understanding and slowly counteracting that fear at a pace that feels safe for us. I know many won't be happy with my messaging here since encouraging people's fear is seen as a barrier to them seeking treatment (which is why so much mental health messaging glibly says "Oh, hey there, don't be afraid. Reach out. It's okay. We won't hurt you...."), so maybe I might seem to be fear-mongering by describing the profoundly negative impact that such responses to me "reaching out" have had on me, especially recently. To them I say, many of us suffering are already afraid and have had that fear reinforced by experiences we've actually had. You're not going to be able to talk us out of it. We have reasons for that fear. Telling us to let it go won't make it go away. For some of us, the only safe way forward is to name, honour, and respect that fear--to give ourselves permission to feel it accordingly and refuse to engage with professionals who don't likewise understand and honour it the way we need them to. To me that's not silly or self-destructive or an indication of my unwillingness to be helped. It's health-promoting: it's self-protection and -care, which is exactly what I need. I'm proud of myself for asserting it despite the reality of how little choice I actually have right now.

Providing people with a way forward that allows them to proceed in spite of their fear, not by suggesting they're "crazy" and "wrong" to feel it, but by earning their trust slowly and assuring them that their fear will be respected at each step of the way is what will enable people like me to reach out. So I'm not sorry to be asserting that here. I'm not telling anyone that they should be afraid. I can speak only for myself. But if so many people are afraid, maybe their fear isn't the problem. Maybe it's the reaction to it that needs to change....

What I've articulated above isn't radical, or at least shouldn't be. It's basic trauma-informed care. It takes thought, caution, self-awareness and care on the part of those providing services, but it's completely possible to accommodate. So I won't apologize for insisting on it.

As always, please note that I am a lawyer, not a mental health professional of any kind. I have no expertise in trauma or mental health. Also, please note that any opinions and views expressed in this blog are solely my own and are not intended to represent the views or opinions of my employer in any way. For more information about the purpose of this blog, please see here and for a bit more information about my personal perspective on this issue, please see "my story" here

I am very grateful to have received a "Clawbie" Award for this blog (which reflects the importance of this topic): https://www.clawbies.ca/2019-clawbies-canadian-law-blog-awards/

For some of my external writing on this topic, see:  

• https://www.canadianlawyermag.com/news/opinion/a-more-inclusive-discussion-on-the-impact-of-trauma-on-lawyers-mental-health-is-needed/276166 
• https://www.cbabc.org/BarTalk/Articles/2020/February/Features/Speaking-Up-About-Trauma-and-Mental-Health    
• https://www.canadianlawyermag.com/news/opinion/changing-the-conversation/326240