Trust is Expected without being Earned, but its Absence Labels us Pathological
[Content Warning: Mention of sexual abuse by a mental health professional, psychiatric abuse]
A common theme I have experienced within mental health services is the diagnosing, formulating, labelling and/or conceptualising of patients as having “pathological” trust issues, when the extraordinary amount of trust expected by mental health staff from patients isn’t immediately forthcoming.
It seems likely that given the extremely high numbers of trauma survivors accessing services, many people will indeed (quite understandably) have difficulties with trust - but I don’t think this is the issue. The trust expected from us as patients towards services and the staff within is extreme in nature. It’s a one-sided trust; a trust which will never be reciprocated; a trust rarely, if ever, acknowledged in its presence, but immediately called out in its absence. It is a trust which is automatically expected and forever demanded, despite never having been earned. A trust we are supposed to maintain even when it gets broken over and over. Honestly, I consider such an ask to not only be unrealistic, but, frankly, unhealthy. In what other area of life are people expected to offer up and sustain such trust while all available information suggests we are wrong to do so? I wonder how many clinicians have stopped before decreeing their patient has trust issues and considered that perhaps they have no right to expect trust, that perhaps it is they or their service that, in fact, has trustworthiness issues.
My own mental health notes describe a “pathological distrust of men” apparently observed by my psychiatrist when, after discovering he had lied to me, I explained to him I no longer trusted him. The arrogance in such a statement is mind-blowing. That the trust he expected from me was perceived as so basic, so assured, that when it didn’t materialise, it seemingly reflected on my relationship with all men. It couldn’t possibly be that by deceiving me for eight months, he was no longer trustworthy: the problem had to have been located in me.
One of the foundations of medicine is the trust between patient and clinician. Despite it being vital to the patient-clinician relationship, this trust is unilateral. The patient is the one who trusts the clinician with their body/mind, their health, their secrets, their safety, their embarrassment, their dignity, in some cases, their life. As patients we trust that clinicians will be honest with us; will ensure our interests, not theirs, lie at the heart of consultations; will not abuse their immense societal and role power; will keep our secrets, our minds, and our bodies safe; will believe us; will help us. We approach the relationship from a position of relative powerlessness, both as the party seeking someone with knowledge and/or access to resources we don’t have, and as the party who must reveal their vulnerability. As mental health patients, we are in an enhanced position of powerlessness in comparison to all other areas of medicine, as the Mental Health Act allows for capacitous adults to be detained and treated against their will. We also face an immense wall of societal and clinical stigma, which automatically brings our judgement, honesty, and insight into question, no matter our presentation.
In ordinary relationships, one manner in which trust is built is through the mutual divulgence of personal information. One person shares, the other reciprocates. However, in medicine, clinicians are not required to reciprocate on any level. From the word go, patients are considered untrustworthy; perceived as either lacking insight, lacking medical knowledge, or as deliberately deceitful (or all of the above...). Clinicians are not expected to trust our experiences, our perceptions, or our opinions. On no level do we occupy the same space as them. In no other area of my life have I been called manipulative, attention-seeking, or delusional. In no other area of my life do I share information about myself for it to be treated with immediate and automatic scepticism. In no other area of my life have I been explicitly told I am not allowed to know anything about the life of the person I am sharing my own with.
I understand that it is not realistic or fair to expect clinicians to divulge private information about themselves to all their patients, or even that this is necessarily helpful to the therapeutic relationship. However, it seems to me that if trust can’t be built through reciprocity, services need to ensure they are extra reliable, extra safe, and extra consistent, so as not to exacerbate the already uncertain and vulnerable position of the patient… but they aren’t. Appointment times are rarely kept; phone calls are scheduled but the phone doesn’t ring; meetings are booked and cancelled without notice or are sprung on you at the last possible moment; diagnoses are given out and then changed repeatedly; promises are made and broken over and over again; staff leave and drop you; complaints are dismissed or buried; lies are told; confidences are broken; boundaries are pushed, breached and flattened; we are not listened to, not respected, not trusted, not believed, and yet, we are expected, without fail, to maintain a never ending fountain of trust. Trust in unreliable services; trust in staff who hold so much power over us; trust in a medical specialty based entirely on subjective professional opinions; trust in a “science” built on years of unethical, abusive, discriminatory, ableist, homophobic, racist, misogynistic, victim-blaming, animal-abusing, fascist-enabling practices. Despite the fact that staying in services and continuing to talk is a display of trust, when we show even the slightest signs of discomfort (because who on earth wouldn’t?) it’s turned back on us and pathologised – a symptom of “illness” or traced back to a “history of trauma”. The truth of it is that mental health patients are ordinary people being asked to display an extraordinary level of trust by a service which not only fails to earn that trust, but actively works to destroy it.
Over the 9 years I have spent under mental health services I have lost count of the number of times I have been lied to, lied about, manipulated, deceived, gaslighted, ridiculed, neglected, coerced, dehumanised, and intimidated. I have received almost no tangible support, and the harm inflicted upon me by services has actually made me more unwell than I could ever have imagined. And yet, despite this plethora of evidence as to why I should not to continue to place trust in services, I am expected to maintain it. This hasn’t been easy. To maintain this trust, I have not only been forced to lie to myself about past experiences and convince myself that ‘this time will be different’, but I have actually had to gaslight myself by repeating that my own perception is at fault because I am “mentally ill”. Something is terribly wrong with a service which puts those it is supposed to be supporting in the position of having to rid themselves of their own self-belief and perception of reality to feel safe to access support. The mental gymnastics involved in that thought process hurts my head. Think about it: despite real and valid reasons to not trust services, I am labelled pathological if I don’t trust. To “recover” from such an affliction, I must deny reality. I now inhabit a world which does not actually exist, but I am no longer pathological… It’s more than just falling down the rabbit hole, you’d need to take up permanent residence in Wonderland for this to make sense.
We are expected to give and give and give this trust, because society tells us that clinicians and health care organisations are innately trustworthy. But are they? Maybe I’m being cynical here but shouldn’t services and the individuals they employ actually make efforts to earn and maintain that trust, both on an individual and societal level?
In my area of the UK, between 1960-2000, two psychiatrists (William Kerr and Michael Haslam) sexually abused tens, possibly hundreds, of mental health patients. Over the years, at least 67 patients came forward to report them, but were dismissed, and both doctors were able to finish their careers and retire before (minimal) charges were eventually brought. The culture in mental health services allowed these predatory men to freely abuse whoever they liked, for decades, while their victims were dismissed, disbelieved, and silenced. The Kerr/Haslam public inquiry notes that this was not a mass “deliberate conspiracy” by healthcare professionals to cover up sexual abuse, rather it was due to a culture in which staff disbelieved patients and “chose to remain silent when they should have been raising their voices”. I think current day services like to believe they have changed. They haven’t. I am under one of the mental health trusts whose hospitals were used as hunting grounds by these men, and yet when I raised concerns about the safety of a male staff member, 20 years after the Kerr/Haslam public inquiry laid out the incredible failure of the NHS to take such complaints seriously, I was dismissed. In an instant. Without a moment’s hesitation. I was told my concerns were entirely unfounded and based on my history of trauma. How can I be expected to trust a service which is repeating the same mistakes over and over?
Mental health services are not infallible. Mental health professionals are not saints. Can’t we just have a reasonable expectation of trust within services, where individual staff earn their patients trust like any other person, without expecting it to be automatically present, and without pathologising its absence? Is it too much to ask for a mental health system which openly acknowledges and takes responsibility for the history of abuse and neglect it is built upon; actively works to build trust with the public; and then continues to prove itself as trustworthy? Given what is expected of us as mental health patients, I think a reason to trust services is the least we can ask for. “Trust us blindly because we are the experts” is not acceptable anymore… It should never have been acceptable.