As has been written about previously, all regulators practice some form of reactive regulation, one of the main components of which is the complaints process. When regulators receive complaints from the public, they must triage them, which includes identifying the issues and making a preliminary assessment of the seriousness of those issues. Triaging allows regulators to make a decision regarding next steps in the complaints process.
Since complainants don’t always provide clear details in their complaint, it often falls to the regulator to tease out more pertinent information, such as the identity of the licensee and the date of the incident. There is also information that only the regulator possesses which will help in the triaging, most notably the licensee’s history, which, if there is a history of repeated complaints, may increase the level of seriousness and direct the level of action taken by the regulator.
There are many key data points that a regulator requires to make an initial triage decision, particularly regarding the licensee. But another task that often falls to regulators is identifying the possibility of mental illness in a complainant and tailoring their response accordingly. Mental illness can have a serious effect on a complainant’s behavior as well as their recollection of events. Thentia’s own Cara Moroney, Senior Director at the company’s Centre for Regulatory Excellence, recalls two separate incidents in her own career as a regulator that highlight the importance of investigating mental health issues that may be present in a written complaint.
Mental health in the complaints process
The Mental Health Commission of Canada reports that one in five Canadians is affected by a mental illness or addiction issue every year. According to the U.S. National Institute of Mental Health, nearly one in five Americans lives with a mental illness issue as well. With “mental illness” describing a wide range of afflictions and conditions affecting people’s lives to various degrees, it is important for regulators to keep in mind the complexity of the issue when they face it in their day-to-day work, and to stay well-informed on mental health basics as well as trends in research and public data.
With mental illness as prevalent as it is in the general population, it follows that regulators will be forced to confront and respond to it from time to time, particularly in the complaints process, which often involves direct back-and-forth communication with aggrieved members of the public. The real-life examples that follow are not edge cases. If regulators want to effectively serve the public interest, they can work to better achieve this mandate by familiarizing themselves with potential mental health-related issues and potential responses.
There are a few key signs that regulators can look for when trying to identify signs of mental illness in a complainant’s recollection of events. Though this is in no way a definitive list, the following symptoms tend to present themselves more frequently than others:
- Incoherent storytelling
- A seemingly implausible set of facts
- An inability to appreciate simple information or instructions
- Repetitive and rambling communications with the regulator (email, voicemail, etc.)
- Disclosure of mental illness in the complaint or in evidence provided by the complainant
Some of these symptoms are present in the following real-life examples, and the facilities’ and regulators’ responses to these warning signs in each case played a crucial role in the overall outcome of the incident.
Scenario I: An unusual recollection
The first scenario involved a client going to a medical facility for a routine appointment. Moroney says the complainant’s narrative started out in ordinary fashion before descending into details of an incident that were so brazen and unprovoked as to seem implausible. Among other things, the complainant reported that the licensee held a knife to their throat and re-used equipment “from a dead man,” threatening to give the client diseases.
The details of the complaint were such that, if true, this would be a very serious matter likely destined for the discipline process. Although the facts seemed highly improbable given the other information the regulator had about the licensee, the severity and intensity of the complaint spurred regulators to investigate more thoroughly. This involved contacting the facility for records of the incident and setting up interviews with the complainant (in person) as well as the licensee and other relevant parties/witnesses. Moroney says the licensee in question was particularly co-operative with the investigation and patient with the complainant.
As the evidence was received, it became clear that while some of the basic details of the complaint were true, the client had ultimately been seen by the licensee without incident. It was a routine procedure performed in a routine manner. Regardless, even when a complaint appears to be informed or influenced by the mental illness of a complainant, regulators owe it to the public to take their claims seriously and to investigate them to a reasonable degree. Moroney says she met with the complainant and explained the evidence and the steps regulators had taken to find out what happened.
Despite this, the complainant adamantly maintained that they had been assaulted by the licensee and followed up by submitting an appeal after the regulator eventually closed the file. At this point, the situation was out of the regulator’s hands—once the complainant decides to appeal, the regulator must cooperate with the appeals process. Throughout the complaints and appeals processes, it is important for regulators to take complainants seriously and to always make a good faith effort to honor the complainant’s desire for an investigation.
Scenario II: Delusions of grandeur
The second case is one where the complainant also made serious allegations against a licensee, this time indicating they (a client) were in a sexual relationship with the licensee at the same time the professional relationship was occurring. During the triage process, evidence came forward that the client had a known history of mental illness and, moreover, some of the symptoms of the diagnosis were grandiosity and/or paranoid delusions. The client was well-known, according to the executives at the place of work, for often rambling about untrue events.
The licensee’s superiors at their place of work initially confirmed that they had no suspicions of an illicit relationship. Further, despite the receipt of the complaint from the client, the client proved difficult to get ahold of (although it was unclear how many attempts were made and by what method) and an initial interview was not possible. The complaint from the client was closed because it appeared there was no evidence of a relationship and that the complainant’s allegations seemed untrue and born out of their mental illness.
It was only when one of the licensee’s co-workers reported seeing strange behavior between the licensee and the client that the facility followed up with the regulator. At that point, the regulator was forced to dig a little deeper. Once a more fulsome investigation commenced, further evidence was uncovered that suggested the licensee and the client were living at the same address. Additional statements came from other witnesses that spoke to a relationship that went beyond merely a professional one, but they yielded nothing proving the existence of a sexual relationship.
Ultimately, the complainant did not participate, despite the original letter to the regulator. The regulator also could not provide the necessary proof to carry the case to discipline even though circumstantial evidence did uncover that there was likely some breach of professional boundaries. The extent and nature of the breach simply remained too unclear for the regulator to do anything but raise the concern with the licensee in a confidential process.
Moroney says the fact that this licensee had a clean record at the time of the incident may have also quelled suspicion at first and contributed to the initial delay in conducting a more thorough investigation. The allegations were very serious, but because they came from a mentally ill complainant and because the place of work was dismissive of the allegations, the regulator followed suit and dismissed the initial complaint as well. While perhaps the outcome would have been the same either way, the regulator lost both time and potentially valuable evidence as an indirect result of their dismissal of the complaint.
What can be learned?
The two cases provide different examples of how mental illness can affect the complaints process. In the first, regulators took substantial measures to determine the validity of the claim despite the complainant presenting potentially serious mental health issues. In the second, the infraction went uninvestigated at first because the allegations appeared false and only a cursory review was conducted.
The lesson that can be learned from these scenarios is that when triaging complaints to never allow a complainant presenting mental illness to get in the way of taking a legitimate look at the facts of a case. When regulators dismiss members of the public who are limited in their ability to recall events clearly and coherently, they let down the public on the whole. No matter what mental illness presents itself in a complaint, it is on regulators to look at the facts and give everybody the basic credence they deserve.
How to respond?
The fundamental lesson is to not dismiss a complaint simply because there appears to be evidence of a mental illness. To do so risks that true and serious allegations are missed and the public is not being protected. Particularly where a complaint makes serious allegations, a more robust initial review or investigation may need to take place. The second scenario shows that the work facility involved in an incident, if the regulator only speaks to high-level staff, may not have enough knowledge about what is happening day to day between their staff and clients. Speaking to other staff members may produce more evidence.
However, in situations where the complaint does prove to be inaccurate and not in the public interest to pursue further, what can a regulator do? A regulator is not in the position to offer help or therapy and resource constraints require that regulators deal with complaints in as efficient a manner as possible according to their apparent seriousness. At the same time, the regulator’s treatment of the complainant throughout the process can be seen as part of their mandate to protect the public interest and build public confidence.
One thing is clear when it comes to triaging complaints from the public: respect and responsiveness are essential. Given the prevalence of mental illness in the general population, it is important for regulators to contemplate how their complaints process treats such complainants, and to potentially make room for some adjustments that don’t overly stretch their limited resources. While this is not an exhaustive or determinative list of steps to take when triaging complaints, some suggestions for how to be better prepared for when signs of mental illnesses arise:
- Meet with the complainant, even when it isn’t in the usual course
- Review any written materials or written correspondence very carefully and ensure that plain language is used as much as possible and that any necessary regulatory terms are well defined and explained
- Ask and document how a complainant wishes to be communicated with. Document and record all interactions
- Have another staff member present during any important calls, meetings, or interviews with the complainant
- Take time to explain and be ready to re-explain the process to the complainant and ask them if they don’t understand anything. Ensure when you make calls to the complainant that you are free from distractions
- Consider specialized training for a subset of staff who may be delving deeper into investigations on how to interview and gather evidence from and how to communicate with mentally ill complainants
- Conduct generalized awareness training for all frontline staff and Board members on better understanding the signs and complexities of mental illnesses and how they can affect a complainant’s ability to participate
