Legislated stigma

infographic of scales of justice

Stigma can be found in many places, even places where we might like to think it shouldn’t be.  One such place where I have found it is in government legislation, hence the title of this post, “legislated stigma”.

As a registered nurse, my professional license is through the College of Registered Nurses of my Canadian province, which is covered by the provincial Health Professions Act.  This legislation applies to many different health professions, and addresses multiple aspects of professional practice, including health professionals whose ability to practice is impaired.  Health professionals are required to report to the appropriate regulatory college if they have reason to believe another health professional poses a risk to the public related to impairment due to any sort of health condition.  A provision along these lines is typical for health professions legislation in many jurisdictions.

My province decides to take things a step further with its legislation by including a provision that doesn’t exist in any form in any other province in Canada.  If a health professional is admitted to hospital for psychiatric reasons or substance abuse, the hospital is required by law to inform the patient’s regulatory college, and the regulatory college is to treat this as a complain about the individual’s fitness to practice.  Full stop.  No assessment of risk, just mandatory reporting based on diagnosis.

I initially found out about this during my first hospitalization in 2007.  My mom was regularly checking my mail, and brought me in an envelope that had come from the College of Nurses.  The enclosed letter stated they had “received a complaint about [my] fitness to practice”, and I was given the non-choice of voluntary giving up my professional license or having it taken away.  I was gobsmacked.  Who had complained and how could I possibly be a risk to anyone but myself?  It’s not like I could have wandered away from my involuntary hospitalization and  somehow found some patients to start providing care to.  Oh yeah, these aren’t hospital PJ’s, they’re nurse’s scrubs, and the hospital socks are just because they’re comfortable!?!?   I was frantically asking different hospital staff, trying to find out who had been low enough to do this behind my back.  Eventually I found out it was the nurse manager of the unit, and her explanation for why I hadn’t been informed was that it had happened shortly before I was being transferred to the psych ICU.  Great.  Thanks a lot.

When I (and my community psychiatrist) eventually managed to convince the College of Nurses that I was no longer crazy, they slapped a bunch of conditions on my license. One of these was that I share those same conditions with my employer.  Even though the conditions didn’t spell out details of my mental illness, the condition that I had to see a mental health team and get regular reports submitted by my psychiatrist blew any chance of privacy I might have hoped for straight out of the water.  And those quarterly reports the College required my psychiatrist to submit meant that I ended up lying through my teeth to him.  When I decided to go off meds, I didn’t say a word about it and kept picking them up from the pharmacy at regular intervals to back up my lie, because I didn’t want the College of Nurses or my employer to know what I was doing in terms of my own health.  I’m not sure how that situation helps anyone…

My next two hospitalizations were at a different hospital, where either they didn’t know about or chose to overlook the mandatory reporting requirement.  During my fourth hospitalization, I was again reported to the College and given the non-choice of giving up my license or having taken it away.  The doctor who initially reported me didn’t have the cojones or consideration to actually tell me; I had to find out about it later from someone else.

So, privacy is all fine and dandy right up until the government decides it isn’t.  It’s worth mentioning that at no point did anyone treating me ever express concerns that I was posing a risk to anyone besides myself.  If I was hospitalized for a neurological condition like brain cancer or epilepsy, there would be no requirement to report me, but because my brain condition happens to be psychiatric, all of a sudden I am deemed to present a risk to the public, full stop.   No professional judgment allowed on the part of treatment providers; if I am hospitalized for depression then that is more than enough to determine that I am dangerous and people need to know about it.

Add this to the rest of the negative experiences I’ve had in hospital and I’ve come to a few conclusions.  One, I will never voluntary admit myself to hospital.  And two, I will never knowingly say anything to a doctor that is likely to get me committed to hospital.  That means I never disclose to doctors when I’m having thoughts of suicide.  Again, not sure how that situation helps anyone.

When I was a little younger and a little less jaded, I tried to campaign to change the legislation.  I was in grad school at the time and one of my courses touched on policy briefs, so I wrote a policy brief citing legislation from other jurisdictions and relevant case law.  I sent it to anyone that I thought might be willing to read it.  My provincial nurses union and professional advocacy association didn’t even have the courtesy to respond with an acknowledgement.  A couple of organizations expressed an interest and did take the issue to the government, but didn’t get anywhere.  I don’t know what else is in my power to do.

The fact remains, though, that this is discrimination specifically against people with mental illness that is enshrined in provincial legislation.  And no one seems to care.  For all the talk by government-mandated organizations like the Mental Health Commission of Canada about addressing stigma, I’m living in a province where, because I struggle with depression, I am considered a second-class nurse who doesn’t deserve the right to have my private medical information stay private.  There is something really fundamentally wrong with that, and it means that indirectly the government is putting my health at risk.  And that should never be ok.


Image credit: johnhain on Pixabay

Profiles in Tremendousness

screen shot - the Daily Show with Trevor Noah

Profiles in Tremendousness is a segment on the Daily Show with Trevor Noah that pokes fun at the competency (and lack thereof) of various characters in the Trump White House.  I’m going to borrow that idea to take a look at the less than stellar characters I’ve come across in my mental health journey.

My first hospitalization was a sh*tstorm of incompetence all around as far as I was concerned, and years later I found out a little tidbit that gave at least some objective confirmation of that.  One of my discharge diagnoses was borderline personality traits.  There’s nothing wrong with that diagnosis if it’s accurate, but unfortunately sometimes it says more about a practitioner’s stigmatized views than anything else, and is applied as a euphemism for “difficult patient”.  Any competent psychiatrist would know that a diagnosis of personality traits/disorder can’t be made cross-sectionally (i.e. just looking at a specific point in time), particularly when someone is acutely ill; it needs to be made based on patterns that are relatively consistent throughout the person’s life.  The hospital psychiatrist seemed to  have skipped this lecture in med school, and instead decided to ignore taking any sort of social history or gathering any collateral information and instead just slap a label on because I fought the treatment team tooth and nail while I was in hospital.  Not only does this leave me with a diagnosis that doesn’t accurately reflect my experience, but it minimizes the significance of the challenges that people with BPD often face every single day.

I used to go to a medical clinic associated with the local university’s medical school, and I would get seen by whatever medical resident happened to be on for that day.  The discharge summary and who knows what else from my first hospitalization were in my chart at the clinic, and I think a lot of the residents were scared because I was the crazy girl who had tried to kill herself and they didn’t know how to deal with that.  When I went in for pap tests, they would always insist on doing a PHQ-9 (a depression screening test).  One day I went in asking for a lab requisition to get routine blood sugar and cholesterol  checks.  I was stuck there for an hour because, even though my illness was in full remission at the time and I had a psychiatrist who I was seeing regularly, the resident had a very hard time believing I wasn’t going to jump in front of a bus the moment I left the clinic.

The first time I tried therapy was okay but not particularly productive.  I decided to try again when I became depressed a few years later, and made an appointment through my Employee Assistance Program.  I wasn’t thrilled with the therapist’s interviewing style, but the real treat came as we were wrapping up the session.  Her advice was that I would feel better if I started dating.  Seriously?  That was the end of that.  And to top it off, when I emailed her to say that I wouldn’t be seeing her again and explained the reason, she thought it was peculiar that I would have chosen to fixate on that particular statement.  Um, perhaps because it represents incompetence?

That theme came up again more than once.  I clearly remember a nurse in hospital who observed that I must be depressed because I was single, and that must have been why I attempted suicide.  Between her and the nurse who was convinced that I must have attempted suicide because I was angry about something, it was a sad state of affairs.  But the stellar lack of competence didn’t end there.

freudThe hospital psychiatrist who initially treated me on the inpatient unit knew I didn’t like him (I guess the screaming and swearing was a pretty strong hint), so he decided to transfer my care to a different doctor.  This character was very much of the psychoanalytic/psychodynamic therapy persuasion, and as far as I could tell he was even more of a nutbar than I was.  My first meeting with him was all very Freudian, with a focus on sex and early childhood.  How old was I when I lost my virginity?  Did I like sex?  Did I remember how I felt when my brother was born when I was 3 years old?  He told me that the ONLY way for me to get better was to get psychoanalytic therapy, and I should only be on meds for a couple of months and then come off them.  Wowza.  But I wanted to get discharged, so I said the things he wanted to hear.  Later, my community psychiatrist commented that he wasn’t sure who that discharge summary was written about, but it definitely didn’t sound like me.

A couple of years ago, things started falling apart.  A very close friend died unexpectedly. I was bullied at work and ended up quitting because of it.  I was worried about getting sick, but I held it together.  And then I found out that my ex-manager was doing his best to destroy my career (in very much a reality-based sense, not a cognitive distortion sense), and the sh*t really hit the fan.  When I went in to see my psychiatrist, I was so slowed down that I moved from the waiting room to his office at a snail’s pace, and had a hard time even stringing a sentence together.  He knew about all the other stuff I’d made it through, but the best he could come up with was that I needed therapy to learn better coping skills so I wouldn’t get depressed when things like this happened.  I’m not sure why he thought that was the appropriate response and the appropriate time, but that was the last time I ever saw him.  Once trust is broken, I’m done.  So I decided to go see my new GP, who didn’t know me from a hole in the ground.  And what did she have to say after I told her the reason I’d decided to stop seeing my psychiatrist?  “Don’t you think you do need better coping  skills?”  Are we passing around stupid pills?

Don’t get me wrong, there are some great mental health professionals out there; I know because I’ve worked with some of them.  Unfortunately there are also some real duds, and in the next edition of Profiles in Tremendousness I’ll cover some of the specimens that I’ve worked with.  It would be nice if this wasn’t an issue we faced when trying to access mental health care, but sadly it’s far too often the reality.

What have been some of your worst experiences?


Image credits:

The Daily Show with Trevor Noah

Skeeze on Pixabay