Trust and Mental Health Treatment (Part 1): Why Do Doctors Assume I’m Going to Answer a Mental Health Screener for Strangers?

Medical professionals have started asking me questions as they take my vitals like, “How often do you feel bad about yourself – or that you are a failure or have let yourself or your family down?” This whole blog is about how often I feel like a failure, and how I’d like to feel like that less often. The answer is, more likely than not, “more than half the days” in the past two weeks. These screeners still generate anxiety, even though I expect them now. I was at my GP the first time, about a potential sinus infection, and it was shocking and scary to be asked deeply personal mental health questions by a disinterested nurse, whose name I never learned. After the visit, I looked up the questions. Doctors are being encouraged to give community mental health screens during all routine medical appointments. Apparently, they received the advice to give them, but no training in trauma sensitivity alongside that advice. Why do people think I’m going to answer anything that personal honestly under those conditions? Are they really that uninformed about trauma responses?

I get that we live in a time of oversharing. I get that if you were raised lucky enough to just know – always – with evidence and kind words, that mental illnesses are no more shameful than physical ones, you probably are fine with sharing your mental health history, under your real name, as soon as you meet someone. I am not fine with it. If you are one of those individuals with mental health concerns who has always felt safe asking for help, you are probably someone who has already asked for help. These screeners are meant to identify individuals who also need help, but who likely haven’t asked out of fear or shame. I write under a pseudonym because being labeled without consent is a reminder of a painful chapter of my history. I still worry sometimes about sharing as much as I do on this blog. I need to really, really trust someone to attach my history to my real name.

Being asked those questions without warning is very triggering. When I don’t get a chance to prepare, or think through the consequences, or even just know the name of the random nurse asking the questions, PTSD views it as a threat. As a result, I lie on screeners, even though my therapist knows full well that my diagnoses overlap enough with depression that my score shouldn’t be zero.

I share symptoms with depression, and I identify with the personal stories of individuals with primary diagnoses of Major Depressive Disorder. I still struggle, but I’m not currently in crisis. Trauma symptoms, and their overlap with Major Depressive Disorder, aren’t something I’m ready to discuss with any old doctor at any old walk-in clinic. I am deeply afraid of having others know my story without my consent. I accepted years ago that, to get the referral to my psychiatrist and therapist, I had to tell my GP just enough. I did – and I don’t regret it –  but since then I only talk to mental health specialists about my mental health. Even then, I decide when and how I am ready to talk about personal things, not some nurse taking my vitals. I’ve come far enough to no longer automatically fear mental health labels as I did I before, but talking to medical strangers about depression? That brings up fears of doctors overreacting, and of them taking away my rights to advocate for myself. It brings up fears of my story being shared indiscriminately. It brings up fears of losing a job in which I’m trying my best to angle for a promotion, over a misunderstanding of what depression is, what my diagnoses are, and what that all means for the company’s bottom line. At its worst, it brings up psychiatric hospitals and involuntary admissions. It brings to mind doctors dictating who I am and adding labels based on assumptions. It brings to mind, in short, trauma and emotional abuse.

I am not suicidal; I do not self-harm. I feel nothing but compassion for those who are/do. I would take away the shame and fear that drives those behaviors (and that society imposes on those who experience them) as surely as I would my own nightmares if I could. I hope any readers experiencing such concerns feel they have someone safe with whom to share, and that everyone else tries to be that someone for them. Those urges are no more shameful than the PTSD fight/flight/or freeze response, but they aren’t my expressions of fear. Admitting to experiencing even symptoms common to multiple mental health diagnoses, which could lead to mistaken additional assumptions that I am suicidal or self-harming, is – given my history – terrifying. I need to consent to, and be an active partner in, my treatment. I need the ability to be believed about my own mind and body, in all medical arenas, but especially in mental health ones. I haven’t always been offered that right to my own beliefs, feelings, and experiences, and I am viscerally terrified of being sent back to any position of powerlessness. Depressive symptoms, described imprecisely and hastily during a routine checkup, terrify me that a medical professional will leap too far, assume I have intent to harm myself, and dictate all future treatment without my consent, in a way that would seriously set back my actual mental health progress and treatment.

Rationally, I know I am an intelligent woman who can speak for herself and, hopefully, protect and advocate for herself. Rationally, I believe I can handle those screeners, but trauma responses aren’t rational. They are visceral. It doesn’t matter that I know my own mind, or that I know that I have a good education and can string a few sentences together with purpose, when I also know how mental health labels make doctors much more likely to dismiss patients. So, I smile and answer “no” to questions about whether I am restless, unsettled, down, ashamed, or sleeping poorly. The random nurses never ask how I can have ADHD, anxiety and PTSD written on my records and say no to those questions.

I know doctors themselves are often overworked and struggling with mental health concerns, especially the frontline GPs, and they aren’t allowed in their own professions the time to dig as deep as patients really need. So, I know that nurse will write “no depression,” the doctor will glance only at that section of my chart for thirty seconds, then will stick to the routine – determining if Lavender’s stuffy nose needs an antibiotic or is just a virus. My psychiatrist, rheumatologist, allergist, neurologist, and gastroenterologist – who all like to give me depression screeners – don’t talk to each other, or cross-check. Mostly when it comes to depression screenings or other sensitive topics, I’m pragmatically grateful. I wish, in practice, though, that they’d instead build the culture of trust that would let those people (like me not too many years ago) who aren’t ready to admit they could use some help feel safe answering mental health screeners honestly.

I believe that we should make mental health a routine part of medical care. Doing that the right way would reduce stigma, and it would help reach the many undiagnosed Americans who could benefit. However, it isn’t enough just to give a depression screener. Patients – especially ones as skittish as me – will only be open if shown genuine concern, given an explanation of how the information they provide will be incorporated into their care, and offered a brief warning when some of the questions may be upsetting. When trauma-informed medical care is practiced by all doctors regularly alongside depression screenings, I will wholeheartedly support universal screening. Until then, I hope medical professionals will read this blog and understand why so many of their patients with real mental health needs don’t yet feel safe admitting them on waiting room screeners. I hope they understand that when fearful or ashamed patients don’t feel safe, then doctors not only haven’t helped, but they may have unintentionally made things worse for very vulnerable individuals by insensitively administering them.

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