Searching for “normal”: A report from a first time mental health advocate

This week I had my first Mental Health Review Board hearing as a legal advocate. As tends to happen with firsts, the experience left a strong impression on me. So much about the hearing process is new to me - the only familiar feeling was my synapses firing as I mentally sketched an understanding of what takes place at a hearing - drawing lines between what is typical in hearings, and what is particular to this one.

I have a sense of the hard rules, like who are the people on the panel and what are the steps in the hearing process, but I’m trying to understand the soft ones, such as how panel members interact with the doctor as compared to me and the patient, how do I cross-examine the doctor without questioning their competence, and how can I be a strong advocate when my client says something that seems, well, crazy.

I first spoke with my client, Igor,* before knowing what diagnosis had been attached to him.  I immediately liked him. He is a 73-year-old man who presents with symptoms of bipolar disorder and depression (or so reads the opening line of the medical consultation report in his file). His thick Slavic accent, no nonsense attitude, and the slight cheekiness that sneaks into his stories remind me of my own grandfather.

Igor is involuntarily detained in a psychiatric ward. He cannot leave, has no choice about whether to take his medication and cannot decide to stop seeing his case manager, whom he dislikes intensely.

Do you think you have bipolar disorder? I ask Igor. Me? What do I know? I listen to the doctor, he responds with a two-eyed wink and a small closed-mouth smile.

At the panel, the doctor makes his case for why Igor should remain detained. The doctor reads out his symptoms: irritable, anhedonic, labile, paranoid ideas about his doctors...

I had seen it all in his file, along with detailed notes of his daily activities and thoughts, for instance one nurse diligently recorded: Igor asks ‘don’t you think my gowns are sharp?’ referring to his hospital gowns. Writer notes patient is probably making a joke. Sarcasm detected.

Granted, the nurse also records how Igor vomited his anti-psychotic medication and refused to eat and drink for a day. When Igor is down, he often refuses to eat or be treated for his mental and physical health issues. He waves away the nurses who try to engage with him and he is described as withdrawn.

Reading Igor’s medical record, I think about my own down days. At the office, the other summer students and I imagine what observations nurses might make about our condition during the law school exam period: Disheveled appearance, decreased food intake, trouble sleeping, low self-esteem, occasional panic attacks. 

I suspect that most people put under the watchful eyes of a mental health care team would be found to exhibit bizarre behaviours. This is not to trivialize mental illness, but I wonder how common the symptoms carefully tracked by the nurses are in the broader population.

When is a person’s behavior so problematic that he must remain in hospital against his will? This is what a doctor is trained to determine. But a patient’s disagreement with the doctor’s decision cannot be taken lightly. At the core of medical care is the patient’s consent, and treating a person against his will is a serious, though at times justified, interference with an individual’s liberty.

Determining whether this interference is justified is up to the panel. My job is to advocate for my client, so that the panel can make a decision based on clearly articulated positions on both the doctor and patient’s side.

At Igor’s hearing, the panel decides he still meets the requirements to be certified. I had persuaded myself the panel might interpret his irritable, anhedonic state as the personality of an old, prickly man who is tired from years of working as a barber, raising five children, losing his wife and now living alone. His paranoia about doctors is rationally rooted in the fact that they keep him in hospital and force him to take medication against his will. He doesn’t want to be poked and prodded over his physical ailments. To Igor, they are just aches and pains.

From my side of the table, the doctor had medicalized Igor’s abrasive personality and his human response to receiving treatment he doesn’t want. But to the panel these behaviours are symptoms of a mental illness.

Can my perception be attributed to a lack of experience as a new advocate? A wide-eyed summer student who listens to her patient all too earnestly?

Or perhaps it is that when we’re talking about mental health and weighing a diagnosis from a medical professional against a personal account from a patient, there is much uncertainty.

Will I become more confident in my judgments over time? Will my understanding of mental illness change?

I can only anticipate that with time my newness will wear off some, my eyes will become a little less wide and I will start to develop a sense of what is “normal” in these hearings for patients diagnosed as mentally ill.

By Leanna Katz, a student at the University of Toronto Faculty of Law who is working at CLAS as a Donner Fellow this summer. Name and some personal details have been changed to protect the client’s identity.