Authoethnographic Approach and Mental Health Praxis

Autoethnographic research refers to a research method/orientation used alongside traditional research methods in which the author/s have included their personal experiences to inform and explore topics in the research, offer reflections and interpretations, and call attention to knowledge gaps, critical intersections and nuances in socio-cultural-political domains and experiences (Adams & Herrmann, 2020). In this case, authoethographic insights are taken from reports regarding the author (with all involved complainants, colleagues, psychiatrists, and treating practitioners anonymized here), email correspondence with AHPRA officers (also anonymised), and from the author's diary entries and notes during the years a fitness-to-practice investigation by the Australian Health Practitioner Regulation Agency (AHPRA) occurred. The author created a timeline from these reports, correspondence and notes, and separated out key information for inclusion into the article. The author has situated this research writing within the medical model, in order to demonstrate that within medical-legal language and framework, substantial contradictions and inequities exist within policies regarding clinician "impairment" – which perpetuate cultures of ableism, stigma, discrimination, as well as heightening suicide risk for student trainees and clinicians.

The Use of Lived Experience Knowledge in Mental Health

Lived Experience expertise has been increasingly recognised and utilised as valuable, and critical, in informing the design, implementation and delivery of mental health clinical care, research, and education (Barbic et al., 2019; Bridson, Jenkins, Allen, & McDermott, 2021; Trivedi, 2014). Mental health clinicians and medical practitioners are increasingly incorporating their knowledge borne of lived experience, survivorship, healing and recovery of mental health concerns, traumas, and service-use as a therapeutic tool to inform their treatment approaches, connect with service-users, and to advocate for changes within mental health service culture and interventions (King & Russon, 2023; Jenna Richards, Sue Holttum, & Neil Springham, 2016; Weinstein, 2018). As a result, practitioners with Lived Experience of mental health challenges, healing, post-traumatic growth, and service-use have been able to integrate their professional identities with their Lived Experience wisdom as: clinicians with Lived Experience (CLE), "prosumers" (providers and consumers of mental health services), and "wounded healers" (Adame, Morsey, Bassman, & Yates, 2017; Cvetovac & Adame, 2017; Fisher, 2023; Holttum, 2017; Lea, Holttum, Cooke, & Riley, 2016; Oates, Drey, & Jones, 2017; Vierthaler & Elliott, 2022). The British Psychological Society highlighted the value of clinicians with Lived Experience, stating "When lived experience is actively valued in aspiring, trainee and qualified clinical psychologists, it can help to enrich practice and improve service provision" (The British Psychological Society, 2020).

The culture of mental health practice has increasingly been evolving into strengths-based, recovery-oriented care, with shared-decision making between service-users and clinicians, and incorporation of Lived Experience knowledge and peer work (Byrne, Roennfeldt, O'Shea, & Macdonald, 2018; Martin, Stevens, & Arbour, 2017; Neil & Glenn, 2015). Despite this shift, however, there have been significant barriers in the widespread adoption of authentic shared-decision making in clinical practice, the endorsement of service user-led recovery, the support of peer work engagement, and the uptake of Lived Experience collaborative research in multiple mental health and medical fields (Green et al., 2023; Grim et al., 2022; Haywood et al., 2023; Musić et al., 2022; Okoroji et al., 2023; Vandewalle et al., 2016).

In addition, CLE, including those with experience of service-use, may be unwilling to disclose or integrate Lived Experience expertise within their professional role due to stigma (internalized and external), concern for being perceived as being "impaired" or likely to experience "impairment" by default, concern for perceived undermined credibility, and facing negative career impacts (Huss, 2020; King, Brophy, Fortune, & Byrne, 2020; López-Aybar, 2022; Richards, Holttum, & Springham, 2016). CLE face complex issues regarding their use of Lived Experience knowledge in clinical work, including weighing the decision of whether or not to disclose Lived Experience, when disclosure may be helpful, as well as the potential impacts of disclosure (Byrne et al., 2022; Dunlop et al., 2022; Richards et al., 2016; Zerubavel & Wright, 2012). Students and clinicians experiencing burnout or mental health distress may similarly be reluctant to disclose their need for support, due to concerns regarding stigma and discrimination, fear of breaches of confidentiality or negative career consequences associated with their credentialing or regulatory body investigations (Biggar et al., 2023; Gundersen, 2022; McNaught, 2013; Reavley, Jorm, & Morgan, 2017; van Ekert, 2018).

Situating Disability and Impairment

Psychiatry and psychology as scientific fields traditionally situate mental illness, psychosocial disability and "impairment" through the biomedical model, which regards ill mental health as being symptomatic of "brain diseases" and "disorders" (Huda, 2020). Biological processes are conceptualised as the underlying causes of psychiatric "disorder" (Huda, 2020). Psychological and social problems that an individual may experience (i.e., aberrance) arise through biological mechanisms (Huda, 2020). Consequently, the biomedical model has been revised toward a "biopsychosocial" model which acknowledges contributing biological and psychosocial factors to mental ill health (Engel, 1977; Hogan, 2019). Compared to the biomedical model, use of the biopsychosocial model in the mental health field has been suggested to provide a less pathologising and biologically reductive alternative (Gask, 2018). However, it has also been argued that it lacks holistic recognition of critical social determinant factors such as socio-political power structures that contribute to disability (Hunt, 2022). The biomedical model conceptualisations of mental ill health and impairment inform and conflict with socio-legal definitions of disability and impairment, particularly as it pertains to stigma, discrimination, human rights, equity and accommodation (Russo & Wooley, 2020). The social model of disability understands disability within a confluence of one's social milieu, power asymmetrics, social policy and disabling environments (Hunt, 2022; Thompson, 2016). Rather than stemming from psychological or bodily malfunctions, disability is defined as a socially occurring phenomenon imposed by a disabling society that fails to accept, value, understand and adapt to diverse individuals and differences (Petasis, 2019; Thompson, 2016).

The AHPRA as a regulatory authority utilises the biopsychosocial and socio-legal models to understand and apply mental illness and disability in the context of trainee and clinician "impairment" (AHPRA, 2010, 2020a, 2020b). In the context of real-world practice, the application of these models to trainee/clinician mental illness and impairment fails to adequately recognise the stigma, discrimination and barriers to accessing academic landscapes and mental health treatment faced by trainees and clinicians (Biggar et al., 2023; Hunt, 2023a; Hunt 2023b; Hunt, 2023c). By using these models of disability to investigate "impairment" within the psychological profession, the Psychology Board of Australia and the AHPRA may perpetuate stigma and discrimination within the discipline.

In Australia, impairment is defined as "a physical or mental impairment, disability, condition or disorder that detrimentally affects or is likely to detrimentally affect the person's capacity to practice the profession" under the Australian Health Practitioner Regulation National Law (Health Practitioner Regulation National Law Act, 2009). The Australian National Regulation Law (2010) requires health practitioners, employers and education providers to report "notifiable conduct" by health practitioners to the appropriate National Health Practitioner Board through the AHPRA (AHPRA, 2010, 2020a, 2020b; Bismark, Spittal, Morris, & Studdert, 2016). The AHPRA manages health practitioner registration processes across Australia in partnership with practitioner boards that oversee each of the regulated health professions (Spittal, Bismark, & Studdert, 2019). AHPRA receives "notifications" (otherwise referred to as complaints) regarding the health, performance, and conduct of registered practitioners and trainees in four of the six Australian states and both territories, and the notification is then referred to the appropriate practitioner board for adjudication (such as the Psychology Board of Australia).

Notifiable conduct includes "placing the public at risk of substantial harm due to an impairment" (AHPRA, 2010, 2020a, 2020b). This legislation has been criticised as having an ambiguous threshold for what constitutes impairment, in addition to the fact that mental health conditions and traumas are manageable, respond well to treatment, and are not static (Australian Medical Association, 2014; Beran, 2014; Goiran, Nash, & Haysom, 2014; Komesaroff, 2014). "Reasonable belief" of impairment requires evidence from a reliable source, or direct knowledge or observation of the patient-practitioner placing the public at harm. However, this threshold is rarely met before a mandatory report is submitted (Australian Medical Association, 2014; Bismark, Spittal, Plueckhahn, & Studdert, 2014). The Medical Board of Australia's "Guidelines for mandatory notifications" also extends to student trainees. As a consequence, tertiary education institutions are legally required to follow these guidelines and provide a notification in circumstances of significant concern: "…. if the provider reasonably believes: a) a student enrolled with the provider has an impairment that, in the course of the student undertaking clinical training, may place the public at substantial risk of harm" (Medical Board of Australia, 2011, p. 5). While the definition of impairment is akin to legislation in other jurisdictions, problems that arise with professional competence and misconduct must be differentiated from "impairment" in relation to disability, as these two issues are often conflated (McAuliffe, Boddy, McLennan, & Stewart, 2012; McNaught, 2013). For example, in a survey of academic unit leaders asked about indicators of impaired counselling students who were subjected to remediation and termination, there was no distinction between questions regarding conduct – misrepresenting one's skill level, sexual harassment of clients or other students, instances of academic dishonesty versus mental health distress/diagnoses – displaying psychotic symptoms, suicidal attempts/ideation or demonstrates a personality disorder (Li, Lampe, Trusty, & Lin, 2009). Some U.S. state laws define "impairment" as "the presence of the diseases of alcoholism, drug abuse, or mental illness" (Arkansas State Medical Board, 2017). The American Medical Association (AMA), defines clinician impairment as "physical, mental, or behavioral disorder[s]," (American Medical Association, 2009) and mandates reporting of clinicians suspected to be impaired, as well as their referral to physician health programs [PHPs] (American Medical Association, 2017). Despite this, there is very limited evidence to suggest that mental disorders in clinicians are meaningfully associated or a direct cause of harm (Banja, 2014; Lawson & Boyd, 2018). Signs of potential physician impairment described by PHPs may also be very broad and substantially overapplied, increasing susceptibility of physicians as being labelled as impaired and subjected to unwarranted medical inquires and evaluations (Lawson & Boyd, 2018).

The AHPRA guidelines for making a notification for trainee/clinician impairment describe both health impairment due to disability as well as conduct and performance: "A mandatory notification about a student/practitioner can only be triggered by concerns about impairment. The National Law defines "impairment" as "a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect the student/practitioner's capacity to carry out clinical training/practice the profession" (AHPRA, 2020c). AHPRA guidelines specify that not all impairments need to be reported, such that "a student may carry out clinical training with a mental health condition, physical health condition or physical illness, but that is not enough to trigger a mandatory notification. Similarly, if the student's impairment affects their capacity to carry out clinical training but does not place the public at substantial risk of harm, you do not need to make a mandatory notification. You should only make a notification if you believe there is a substantial risk of harm. A substantial risk of harm is a very high threshold for reporting risk of harm to the public" (AHPRA, 2020b, p. 7). Likewise, they state that if "a practitioner-patient has a mental health condition, which is stable, because the practitioner-patient is engaged in and complying with treatment, there is no substantial risk of harm to the public. This would not trigger a mandatory notification" (AHPRA, 2020a, p. 11).

The term "impairment" in the context of identifying issues with professional competence is problematic in that this term has a specific legal meaning regarding disabilities established by the United Nations in 2023: people with long-term physical, mental, intellectual or sensory impairments which interact with various barriers that may hinder their full and effective participation in society on an equal basis with others. Disabled people have the legal right to protection from discrimination, and the right to accommodations in education and employment (Australian Government, 1992, 2005, 2009; Australian Human Rights Commission, 2016; United Nations, 2023), however these protections may be effectively limited due to broad legal definitions (Allen, 2018). In academic, training and workplace settings, education providers and employers must be aware of the legal implications of using the word "impairment" when specifying problems with competency as it overlaps with disability rights (Elman & Forrest, 2007, 2008). Further, the social model of disability has provided a conceptual framework that understands disability and impairment through embodiment and a materialist socio-spatial phenomenon (Hall & Wilton, 2017). The social model recognises the oppressive social experience of disability (both ontologically and politically) as separate from unique functional challenges and capacities that arise from impairment (Hall & Wilton, 2017). Therefore, it is critical to identify whether or not a student or clinician with Lived Experience has an actual issue of competency, an impairment, and/or is operating in a disabling and impairing education or work environment – that is, a setting that is inequitable, stigmatising and/or discriminatory (Dollinger, Ajjawi, Finneran, & O'Shea, 2023; Grimes, Southgate, Scevak, & Buchanan, 2020; Lindsay & Fuentes, 2022; Milner et al., 2019; Saltes, 2022). Competency issues with other origins must be managed differently by regulatory authorities in comparison to disability-related impairment (Nicholson Perry, Donovan, Knight, & Shires, 2017).

The Royal Australasian College of Surgeons stated "the application of mandatory notification requirement must not… deter clinicians in need of help from seeking it" (Royal Australasian College of Surgeons, 2013). However, the Royal Australasian College of Physicians has issued a position statement recognizing that "mandatory reporting of impaired doctors can act as a deterrent to seeking help… [those] experiencing a health problem that could compromise their ability to practise safely may avoid approaching a colleague or supervisor for advice or support for fear of having a notification made against them" (Royal Australasian College of Physicians, 2013).

Mandatory Reporting and its Associated Harms

Fear of mandatory reporting and experiencing a complaint has been found to increase risks for functional impairment, and suicide (Biggar et al., 2023; Hawton, 2015; Rowe, 2019; Spittal, Studdert, Paterson, & Bismark, 2016). Furthermore, clinicians who have concerns and fears about litigation, or who witness a colleague being the subject of a complaint (but whom do not experience a complaint themselves) may also change their behaviour and practice, including increases in defensive practice (Fardell, 2019; Nash et al., 2010; Renkema et al., 2019; van Ekert, 2018). In addition to these criticisms, it has been highlighted that AHPRA does not flag notifications that are found to be vexatious (Schultz, 2018; Thomas & Bismark, 2017) or serving the complainants' own agenda (Swannell, 2019), and does not provide adequate support for clinicians/trainees involved in the regulatory complaints process (Rowe, 2019; Schultz, 2018; Swannell, 2019). There is no process for assessing and differentiating complaints according to risk assessment (i.e., low risk, higher risk), and creating alternative pathways to manage low or higher risk in accordance with risk assessment which may address vexatious complaints, and differing risk levels. Instead, clinicians and trainees investigated in the regulatory complaints process are subjected to prolonged, stressful processes that may fail to account for the level of risk involved in the complaint, and place the clinician/trainee at significant risk as a result.

The distribution of complaints among Australian clinicians has also been found to be highly skewed among professions, gender and age (Austin et al., 2021; Spittal et al., 2019; Veness et al., 2019; Walton et al., 2020). Male practitioners' complaint likelihood is one and a half times to twice as likely that of female practitioners, and practitioners in older age groups have been found to have one and a half to three-fold higher likelihood, which increases with age (Austin et al., 2021; Spittal et al., 2019; Veness et al., 2019; Walton et al., 2020). Complaints are also more common among surgeons, GPs, and dentists in comparison to other physicians (Austin et al., 2021; Spittal et al., 2019; Tibble et al., 2018; Walton et al., 2020), and a study of health practitioner complaints in Australia found mental health practitioners (psychiatrists and psychologists) were more likely to receive a complaint compared to physicians (Veness et al., 2019). The Australian Medical Association (AMA) highlighted the harms of mandatory reporting, and that these reports often backfire (Australian Medical Association, 2014, 2018, 2019). Mandatory reporting laws were introduced to protect the public, however it has been found that they are likely to have the opposite effect; practitioners may keep their problems hidden to avoid mandatory reporting, thereby increasing risk of harm to clients due to inadequate support and management (Australian Medical Association, 2014, 2018, 2019).

A survey of 12,252 Australian clinicians found that a third would be reluctant to seek help for mental health concerns because of fears surrounding the implications for their registration and right to practise; over half cited lack of confidentiality and privacy as a barrier, and more than a quarter expressed concern it might damage their registration and career prospects (Australian Medical Association, 2014, 2018; Beyond Blue, 2014). Reports of suicidal ideation, psychological distress, and stigma were highly prevalent, particularly for young clinicians and women (Beyond Blue, 2014), which suggests intersecting vulnerability factors for students and practitioners who may face intersecting stigma (i.e., ableism and sexism). In addition, the psychological impact of experiencing the regulatory complaints process for clinicians can include: delayed treatment-seeking, tension, frustration, anger, distress, helplessness, guilt, shame, sleeplessness, adverse financial and vocational impacts, early resignation or retirement, substance use, symptom relapse, depression, and suicidal ideation, suicide attempts and death by suicide (Biggar et al., 2023; Bradfield, Jenkins, Spittal, & Bismark, 2023; Horsfall, 2014; Nash, Tennant, & Walton, 2004; Nash et al., 2007; Schultz, 2018; van Ekert, 2018). For some clinicians, the stress of the regulatory complaints process created a sense of betrayal, moral injury, and constituted a "major life trauma" (Emmons, 2019; Freiberg, 2023; Nash et al., 2004). Lack of transparency, lack of perceived impartiality and delays are a significant source of stress (Biggar, Lobigs, & Fletcher, 2020). Similar to these findings, increased suicide risk has been found to occurs for clinicians in the UK subjected to investigations processes, with the most stress occurring in relation to investigations that: lacked support, were delayed, accusatory, lacked transparency, were biased toward complainants, provided no means of dealing with vexatious complaints, and lacked compassion and recognition of underlying health concerns (Bourne et al., 2017; Bourne et al., 2016; Bourne et al., 2015; Brooks et al., 2014; Casey & Choong, 2016; Horsfall, 2014; Maben et al., 2021).

Based on these concerns, the AMA has had a long-standing objection to the inclusion of treating medical practitioners within mandatory reporting requirements, stating that "It is critical that health practitioners are not deterred, for any reason, from seeking early treatment for health conditions" (Australian Medical Association, 2014). Mr Martin Fletcher, CEO of AHPRA, echoed these concerns, emphasizing that the fears and unintended consequences of mandatory reporting are the biggest challenges faced regarding health practitioners seeking care (Health Communities Disability Services and Domestic and Family Violence Prevention Committee, 2019, p.10). A recent qualitative study was conducted by health practitioners and members of AHPRA of Australian health practitioners involved in a regulatory complaints process (Biggar et al., 2023). Data from interviews and serious incident analysis found practitioner distress was exacerbated by aspects of the regulatory complaints process, including poor communication, extended time to close the investigation, and the management of health-related concerns (Biggar et al., 2023). Practitioners were at heightened risk of severe distress at key stressor points in the investigation, including the initial letter or telephone call informing them of the complaint, a decision to suspend, receiving results of an independent health assessment, and a decision to refer to a tribunal (Biggar et al., 2023). In each of these key stressor situations, cases were found where practitioners had attempted or died by suicide shortly after the key stressor point in the investigation (Biggar et al., 2023). Greater risk was elevated by external personal circumstances and pre-existing conditions, while strong personal and professional support networks mitigated distress risk (Biggar et al., 2023). The authors concluded that improved partnerships were needed between regulators and key stakeholders (i.e., legal defence organisations, indemnity providers, employers, and those with lived experience of complaints processes), in order to improve support for practitioners involved in regulatory complaints processes and to address stigma, shame, fear, and suicide risk (Biggar et al., 2023).

Collectively, the above issues have led to widespread calls for review into mandatory reporting legislation (Australian Medical Association, 2014, 2018, 2019; Biggar et al., 2023; Bradfield et al., 2023; Goiran et al., 2014; Henderson, 2015; Komesaroff, 2014; Schultz, 2018; Simpkins, 2023). AHPRA and state and territory boards should continue to improve their regulatory complaints processes in order to increase support for those involved, and to ensure fair, timely, and transparent processes that minimise risk of harm (Haysom, 2016). Recommendations have included the involvement of peer support for student and practising clinicians subjected to regulatory complaints processes (Schultz, 2018; Simpkins, 2023). The author supports these recommendations and is of the position that CLE can be employed as peer support workers by AHPRA to support clinicians and students under fitness-to-practice investigation for impairment, to improve the ethics of this process and limit harm.

The mandatory reporting system and regulatory complaints process is harmful where there is an entrenched culture of stigma and ableism within the health profession, and language of "impairment" is ambiguous and/or used to uphold systems of inequity. Despite the AHPRA guidelines, neither of the notifications made against me as a student (detailed below) met the thresholds of substantial risk of harm to the public. I was not client-facing at the time of the first notification, I was engaged in weekly treatment with well-managed mental health conditions and was consistently rated by my lecturers as high-performing in all assessments. The second notification made against me was an obvious vexatious complaint. Designated Lived Experience roles in tertiary settings, workplaces, and the regulatory complaints process may shift cultures of stigma (Byrne et al., 2022; Schultz, 2018; Wang, Byrne, Bartram, & Chapman, 2023) and support use of the AHPRA guidelines while also providing support to students and clinicians who may be subjected to the distress of health notifications and complaints processes.

A Culture of Stigma and Inequity

The mental health burden and suicide risk of health care workers and students in Australia has been found to be alarmingly high compared to those in other professions (Beyond Blue, 2019; Huss, 2020). Lived Experience of previous mental health problems may be a common motivator for beginning study among psychology students (Woof, Hames, Speer, & Cohen, 2021), however clinical psychology training programs and academic settings may have a key role in perpetuating stigmatising and ableist attitudes, particularly against those within the profession (Brown & Leigh, 2018; Huss, 2020). Clinical psychology trainees with Lived Experience have reported that clinical training programs were a "breeding ground for stigma" and ableism, psychological distress, and negative feelings related to field (Brown & Leigh, 2018; Huss, 2020). Students with Lived Experience, however, may face unique challenges in psychology programs, including high levels of enacted and anticipated stigma, commonly witnessing discrimination, incongruity between taught material and their experiential knowledge, and concerns arising from delivery of taught course content (Huss, 2020; Woof et al., 2021). Furthermore, internalised stigma is also reported as being common (Huss, 2020), and significantly, internalised stigma is linked to lower help-seeking behaviours in students and clinicians (Choi & Miller, 2018; Crowe, Mullen, & Spargo, 2020).

Inadequate attention toward self-care for professionals in the mental health field has led to calls for systemic changes around incorporating self-care and wellbeing for trainees and mental health professionals as routine (Colman et al., 2016; Dorociak, Rupert, & Zahniser, 2017; Mulvogueet al., 2023; Wise & Reuman, 2019), including calls for a focus on trainee and clinician wellbeing and attendance in personal therapy (Swords & Ellis, 2017; Ziede & Norcross, 2020). Self-care is considered to be an ethical imperative for clinical practice (Johnson et al., 2012; Norcross & VandenBos, 2018; Pope & Vasquez, 2016), yet clinicians face a number of barriers to seeking and accessing their own mental health care; including stigma, confidentiality concerns, and fear of being reported for impairment (Edwards & Crisp, 2017; Gundersen, 2022; Simpkins, 2023).

Further, psychology trainees often receive messages about the need to be authentic as therapists, to model self-acceptance and authenticity, and are trained in humanistic theory (Yang et al., 2023). Exposure to these messages and theories, however, may directly conflict with the power dynamics within Masters and Doctoral programs that often are hierarchical, demand adherence to strict instructions/authority, and require evaluation and letters of recommendation (Yang et al., 2023). These program structures may actively discourage authentic student expression (Swaby, 2020; Yang et al., 2023), particularly those from marginalised backgrounds (Yang et al., 2023), including disabled students (Hunt, 2023a). The culture of stigma and silence within clinical training and academic settings may interact with expectations that trainees engage in self-care and personal therapy, which may maintain and compound stigma (Tay, Alcock, & Scior, 2018; Vally, 2019). This intersection may lead to trainees experiencing fears of being perceived as "failing" to maintain self-care (i.e., being perceived as incompetent due to perceived impairment) and fear of mandatory reporting if disclosing mental health challenges in personal therapy. Stigma and discrimination within the mental health field equates to a heightened risk for CLE facing serious negative impacts from disclosing, and this risk may be even more elevated for trainees, who may also face additional barriers to help-seeking such as uncertainty where to get help, and financial limitations (Edwards & Crisp, 2017; Zerubavel & Wright, 2012). Further, students with invisible disabilities including mental health conditions commonly face barriers to equitable postsecondary education, such as accessing information on academic support and any available adaptations and accommodations to the academic environment (Bunbury, 2020; Grimes, Scevak, Southgate, & Buchanan, 2017; Venville et al., 2016). Further access barriers to learning accommodations arise due to enacted and anticipated stigma and discrimination and social and structural inequity in the academic landscape (Hunt, 2023a; Lindsay, Cagliostro, & Carafa, 2018; Lund, Wilbur, & Kuemmel, 2020). Students who report a lack of support and feelings of institutional betrayal also indicate higher rates of depression and lower self-esteem (Lett, Tamaian, & Klest, 2020).

Fear of being reported for impairment or being stigmatised for having been the subject of a complaint leads to clinicians continuing to attend work when unwell or distressed (presenteeism; Simpson et al., 2019; Thun & Løvseth, 2016; van Ekert, 2018); resulting in detrimental impacts on practice (i.e., inattention, problems in decision-making, empathetic distress and compassion fatigue, vicarious trauma, and burnout; Etling, 2017; Leiberg, Klimecki, & Singer, 2011; Naylor et al., 2017). Studies have revealed that psychologists frequently withhold important clinical information (e.g. feelings of suicidality) from their therapist (Pope & Tabachnick, 1994) and withhold such information from colleagues through nondisclosure in supervision (Hendin et al., 2000; Sweeney & Creaner, 2014). Peer supervision settings are an important professional support that can facilitate a balanced healthy professional identity, learning and development (Walkman & Williston, 2015). An emotionally-safe environment must be established for effective peer supervision, as without this condition, trainees and clinicians with Lived Experience may feel unable to disclose due to experiencing stigmatising reception of disclosed mental health distress in peer supervision groups, and/or concerns about career impacts (Karbouniaris et al., 2023). Psychiatrists with Lived Experience reported that prior peer supervision groups they had been involved in had negatively responded to their personal disclosures of mental distress (Karbouniaris et al., 2023). Lived Experience disclosures were perceived as transgressive and as violating professional codes of conduct (Karbouniaris et al., 2023). One participant described it in this way: "Previous peer supervision groups felt unsafe and the topics discussed remained very superficial. My personal disclosures were looked at as "acting out". But in this [current peer supervision] group, I can really be myself, as a whole with all my issues and I don't feel alienated anymore" (Karbouniaris et al., 2023, p. 7). These findings highlighted the importance of establishing strengths-based values and a safe environment that are inclusive of Lived Experience knowledge to facilitate disclosure in peer supervision (Karbouniaris et al., 2023). Greater efforts are needed to dismantle stigma and ableism in clinical and academic settings, and to provide support for trainees, such as: creating a safe and strengths-based culture of learning that recognises and values diversity (including Lived Experience); and access to peer support, accommodations, remediation plans, and peer supervision grounded in a recovery-oriented and disability-affirmative framework (Karbouniaris et al., 2023; Price, Salzer, O'Shea, & Kerschbaum, 2017).

In an Insight+ poll completed by over 2800 clinicians, 59% of clinicians believed they could not disclose mental health concerns to their doctor and seek treatment without endangering their career (Rowe, 2019). These findings are deeply concerning and correspond to research findings of stigma for clinicians experiencing mental health concerns (Beyondblue, 2013; Toland, 2017), leading to treatment avoidance (Edwards & Crisp, 2017), and heightened suicide risk (American Psychological Association, 2010; Schultz, 2018). Barriers to seeking mental health care can foster a culture of secrecy and shame as opposed to pre-emptive conversations and actions to provide support, self-care plans and strategies (Carter & Barnett, 2014; Sapienza & Bugental, 2000). Ingrained stigma within healthcare professions may also be related to epistemic injustice and an "us and them" dichotomy that serves to maintain power hierarchies. This division ascribes legitimacy to expertise by qualification, delegitimises expertise by experience (i.e., Lived Experience professionals such as peer support workers), and marginalises mental health service users. A person can hold and belong to multiple intersecting identities such as a service user identity, a professional identity as a mental health practitioner, an activist researcher identity (Gupta et al., 2023). CLE sharing of Lived Experience can promote stigma reduction and help-seeking within the health profession and break down the perceived "us and them" divisions that maintain power imbalance in mental health services.

Autoenthnographic Insight of Disclosure: The Choice to Disclose

At the beginning of my postgraduate study of a Master of Professional Psychology, while applying for my provisional psychology registration, I was met with the choice of whether or not to declare that I had a condition that could potentially impact my ability to provide psychological service. I had concerns about the potential impacts of disclosure, however I chose to declare my diagnoses in accordance with my values based on the following; (1) my belief in the value of Lived Experience in mental health work including clinical practice; (2) my belief that mental health concerns and traumas are manageable and should not exclude an individual from engagement in mental health work; (3) my confidence in my understanding of my own personal strengths and sensitivities, development of personal coping strategies to support my wellbeing, and the support provided by my treating GP and psychologist; (4) having worked with my psychologist to plan for self-care and future scenarios (such as if I would need to take a break from engaging in clinical work); (5) a naïve or misguided belief that disclosing these diagnoses to the regulatory body AHPRA would be met with understanding rather than stigma; (6) a naïve or misguided belief that AHPRA processes were relatively transparent.

After disclosing my diagnoses, I was notified that the AHPRA was concerned about my potential risk of harm to the public, based on my disclosure of a past diagnosis of schizoaffective disorder (in remission). No concern was expressed regarding my disclosure of diagnoses of anorexia nervosa, major depression, anxiety disorders, and of suicide attempt survival. This was an example of the significant stigma regarding voice-hearing and unusual perceptual experiences, thoughts and beliefs (UPTB) (otherwise referred to clinically as psychosis) in comparison to other diagnoses. My history of UPTB/psychosis has been contested by differing mental health practitioners as being trauma-based, and has been well-managed for many years and was in remission following therapeutic treatment for adverse experiences and trauma survival – a known aetiological factor for UPTB/psychosis (Alameda et al., 2020; Chase et al., 2019; Coughlan et al., 2020; Higgs, 2020; Reilly & Gunnar, 2019). I regarded my anorexia nervosa and depression as more likely to recur under stress and as more likely to potentially impact my study and later practice, as these were more current mental health concerns that I was managing in therapy. These diagnoses, however, were not met with the level of apprehension that drew AHPRA's justification for ongoing monitoring. At the time of disclosure to AHPRA, I was engaged in long-term therapy, managing my mental health and wellbeing, and beginning my Master's course.

The AHPRA then began an investigation and withheld my provisional psychologist registration. I was ordered by the AHPRA to release my entire psychiatric case file to the Psychology Board, which was extremely difficult to obtain, and an invasive, distressing breach of my right to privacy, since this information stretched back to my treatment as an adolescent patient, and contained details about my treatment as an adult, young adult, adolescent, as well as some details of my prior mental health treatment in child and youth services. It should only have been necessary to provide information about my current wellbeing, for which my treating practitioners had provided recent reports, and I had provided documentation from the previous 12 months of medical or psychological treatment. Despite repeated appeals to the AHPRA regarding the unnecessary invasion of privacy and the distress it was causing, I was informed that the investigation would not progress without my release of my entire psychiatric case file to the Board, and if I did not, my provisional registration and place in my Master's course would be terminated. The AHPRA would not accept limited release of further documentation (such as further documentation of my treatment within the previous year, or documentation that only pertained to when I was first diagnosed).

I was additionally ordered by AHPRA to undergo a medical evaluation by a Board-appointed psychiatrist at a cost of $2000 AUD – without this assessment I would not be able to obtain provisional registration and would therefore be forced to forfeit enrolment in my Master's degree. Due to the extended length of time AHPRA took arranging an appointment for the medical evaluation and reviewing the report by the Board-appointed psychiatrist, the deadline to obtain provisional registration for my university course lapsed, and I had to be unenrolled for the semester. AHPRA's decisions regarding investigations are discussed at Board meetings which occur every three months, leading to process delays. My case was not discussed during the first two scheduled Board meetings following the completion of the report by the Board-appointed psychiatrist, resulting in a delay in scheduling my medical evaluation, which further pushed back the timeline for my review. The delays by AHPRA caused me to incur both academic and financial losses through the loss of university courses which had been paid for and partially completed. Due to the extenuating circumstances, the university was willing to hold my place in the Master's Program; however I would have to re-enrol and re-start the courses the following semester or year, and repeat assessments and exams I had already completed if I was able to gain registration with AHPRA.

The independent Board-appointed psychiatrist concluded that I did not present a "risk of harm" to the public, and could continue with my Master's Program. Unfortunately, due to AHPRA's delays in processing this report, I had already been unenrolled for the semester. My treating practitioners had also submitted reports that they believed me to be fit for study and employment as a competent peer support worker and future psychologist, and that I was engaged and committed to my personal treatment. Despite these reports however, AHPRA placed conditions on my provisional registration and postgraduate study. These conditions amounted to a community treatment order. In addition, when searching my name as a provisional psychologist on the public register, it stated that my registration held conditions for practice. I was concerned about the negative associations that this carried, the negative assumptions that could be made, and potential impacts to my career.

My provisional registration and therefore, enrolment in my Master's program were dependent on the following conditions: I must (1) engage in treatment with a psychologist and psychiatrist; (2) provide the contact details of the treating practitioners to AHPRA with their acknowledgement of the conditions on my registration; the treating practitioners must provide three monthly reports to AHPRA about my wellbeing or when otherwise requested; (3) provide confirmation from my treating practitioners that they have seen a copy of conditions on my registration and are aware of their need to report to AHPRA as well as confirmation that my supervisors have been informed of the imposition of the conditions; (4) All costs associated with compliance of the conditions on my registration were to be at my own expense.

These requirements resulted in a continuing loss of confidentiality, presented a severe barrier to therapeutic engagement (due to fears surrounding the repercussions of disclosure in therapy), and incurred significant financial distress due to the cost of the frequent mandated mental health appointments with both a psychiatrist and psychologist, particularly while studying as a disabled student. When my treating practitioners were late submitting their reports, I would receive more correspondence from AHPRA compliance officers, demanding that I follow up with my practitioners and chase up the reports. This led to further anxiety and stress, and a continuous fear that I would "fail" to meet the conditions and lose my registration. Forced relinquishment of my entire psychiatric file to AHPRA was a grievous invasion of privacy; I could not stop thinking about strangers having access my case file that contained years of my health information without my consent or trust. I felt betrayed, coerced, dehumanised and re-traumatised by AHPRA throughout this process, despite my attempts at transparency. I continued to worry about the impacts on my career, and how I would be able to engage in therapy safely without being able to maintain confidentiality.

Autoenthnographic Insight: Report for Impairment

In October 2017 (when I was halfway through my Master's Program), I was reported to APHRA for "impairment" by an education provider. At this point in time, I was not engaged in clinical work with clients as a provisional psychologist, nor would I be engaged in supervised clinical practice for another year. This mandatory report, therefore, did not meet the threshold of "notifiable conduct" for observation that I was placing the public "at risk of substantial harm due to an impairment" (Bismark, Spittal, et al. 2016; AHPRA Australian Health Practitioner Regulation Agency 2010). The report concerned an incident of approximately twenty minutes. The context of my attendance to class was relevant to the incident, and I provided this information to AHPRA after they received the notification. Students enrolled in the Master's course were required to have a one hundred percent attendance record for all classes, facing academic penalties and make-up work if they failed to do so. As a disabled student, I had a disability support plan, and had made multiple requests to the university's Disability Support Service for accommodations if I was unwell or unable to attend a class (i.e., lectures being recorded, exemption from penalties). I was informed that that the university refused to record the Master's coursework, and that there was "no possible way" to make accommodations. On the date in question, while travelling to class on the bus, I had responded to a threat to personal safety from a traveller. As a result, I experienced a resurgence of trauma symptoms, and on arrival to class was withdrawn and minimally communicative. A student noticed that I was withdrawn and grabbed my shoulder. I jumped at the contact and began to cry. Knowing that I worked as a peer support worker (i.e., awareness that I have mental health diagnoses), the student began to yell "She's having an episode!" and went to get the class lecturer (and later, complainant). The teacher-complainant took hold of my shoulders and began to push me down the hallway, into the office of another lecturer. Their sustained physical contact (which was sudden and unwelcome) maintained my fear and confusion. The teacher-complainant left, and I spoke to the second lecturer, who supervised while I managed my distress, before returning to class, with the agreement of both lecturers that I was well enough to do so.

The teacher-complainant acknowledged that this incident was brief and quickly resolved, however little context was provided in their complaint. They described the incident as a psychotic episode and did not accurately describe their own interactions with me, nor the behaviour of the other student. The report was stigmatising, biased and quoted me inaccurately. The complainant did not inform me that they would be making a health notification; otherwise, I could have informed them that prior to this report, I had already discussed the incident with my treating psychologist, and they had included it in their mandatory report to AHPRA as per the conditions on my provisional registration. My treating psychologist had expressed no concern about the incident and had understood it in the context of my trauma history and the context I had provided. As a result of the complainant making the health impairment notification, however, I was subjected to a fitness-to-practice investigation.

In addition to the conditions already enforced on my registration, AHPRA added a new condition to my provisional registration, which required that my Master's Program supervising course co-ordinators submit monthly reports on my class performance and observed mental health and wellbeing. This added further stigma, inequity, invasion of privacy and barriers to my ability to study safely at university. In addition, I was prohibited from engaging in direct or indirect client contact for three months. AHPRA's summary report detailing the reason for the Board's decision contained multiple redacted points – because of this lack of transparency, I could not understand or answer to the decisions that were made which critically impacted my study and career. My personal private health information had been breached, yet I was not permitted to understand the full justification behind the decisions of the Board. The imbalance in the process was stressful and disempowering. The AHPRA's requests for follow up regarding my supervisors and treating practitioners' late reports failed to appreciate the difficulty of the situation I was in – I was already scared of the negative evaluation I might be subjected to from my supervisors both in their reports to AHPRA and in my coursework (particularly as they now perceived me to be impaired), and I was now expected to demand they submit their reports in a timely fashion to AHPRA, and chase them up when they failed to do so, heightening my fears of potential negative assessments.

After the three months prohibiting me from engaging in client contact were over, AHPRA did not remove the conditions from my registration. These conditions remained in place indefinitely, even though I had met the conditions and attended the mandated treatment, which my psychologist and psychiatrist had attested to in their reports. Despite my repeated requests to AHPRA enquiring about what was required in order to have the conditions removed, I received no clear answer: it appeared that I would never be able to meet the Board requirements, as no transparent answer was ever given.

Dominant understandings of psychosis and "madness" have been challenged in other autoethnographic research, particularly in connection to trauma, agency, and psychiatric discourse (Franco & Nicholls, 2023; Johnston, 2020; Johnston, Sanscartier, & Steckle, 2023). It's important to underscore that while I was judged to be "impaired" during this period largely based on a historical diagnosis and an incident of 20 minutes of distress, I had demonstrated consistent ability to maintain high performance and professionalism in all areas of coursework, was a class-elected representative as a student Ambassador for Psychology, maintained a high standard in my work as a peer support worker, and had continued to engage in my treatment — none of these factors indicated "impairment" or potential risk to the public. Rather, I was demonstrating consistent agency, ability, but nevertheless was being subjected to stigma, surveillance, discriminatory treatment and stress and pressure that placed me at risk.

The investigatory proceedings themselves were invasive, drawn-out and harmful. Thrice my case was not discussed during the tri-monthly Board meetings, leading to delays for reviews on the conditions on my registration. Every time I received a new email or call from AHPRA, I felt a sense of dread and would have a panic attack. As a result of the further loss of confidentiality and sense of safety in therapy and at university, my health deteriorated significantly. The stress of this experience led to daily panic attacks, relapse in my anorexia nervosa, four relapses of self-harm, and ongoing suicidality. With the prolonged stress and subsequent relapse of my anorexia nervosa, my weight fell to a dangerous BMI (body mass index) of 12. I feared returning to hospital would further compromise my registration and felt unable to seek emergency medical and mental health treatment, as I had further concern that this would lead to being unable to complete my Master's program, and would lead to further privacy violations of my medical information. At a breaking point, I attempted suicide and was hospitalised for medical and emotional stabilisation in 2017.

The condition prohibiting me from engaging in client work was eventually lifted by AHPRA so that I could complete my supervised Master's course placement, however the other conditions remained in place for three years. This occurred despite multiple submissions to the Psychology Board where I explained the context of the original incident of the complaint and provided details about my current wellbeing in addition to supportive reports and letters from my GP, psychologist and psychiatrist. Ongoing reports from placement supervisors and teaching staff that were mandated from the remaining conditions on my registration also consistently advised the Board that I was fit to practice. Furthermore, the AHPRA case officers were repeatedly changed over the course of the three years. This made the process more stressful, as I would have to keep re-explaining my situation to new case officers. This also created a continuing loss of privacy, as my psychiatric case file could be accessed by each newly appointed case officer – leading to more stress, anxiety, depression, and a sense of powerlessness.

At the time of the initial report, I had had no client contact, had not harmed any member of the public, and was not at risk of harming as I was not client-facing, however despite the continuing harm I experienced, I received no personal support. I was informed by AHPRA compliance officers that the conditions on my registration did not represent punitive action for mental health concerns and having health conditions; rather that they were measures intended to "support my ability to practice while safeguarding against potential risk for harm to the public". These measures, however, in no way supported my ability to practice. By removing my confidentiality in therapy, by forcing treatment I could not afford which also lacked confidentiality, by removing my confidentiality in my Master's course and creating stress, stigma, and isolation (i.e., being subject to reports about my mental health and functioning by my teachers, and creating distancing from peers who feared repercussions by association with me), and subjecting me to coercion through threat of losing my career, I experienced harm. With the sustained stress and lack of confidentiality in therapy, forced disclosure of private medical case files, lack of privacy at university, my mental and physical health continued to deteriorate, greatly impacting my life and future. I was hospitalised twice for medical and emotional stabilisation and nutritional re-feeding near the end of 2019. I submitted my final Master's portfolio from a medical ward while on 24/7 medical monitoring and nasogastric re-feeding. While in hospital I was unable to truly engage in treatment – continuing to fear that receiving inpatient treatment would be perceived "proof of impairment". I became more depressed and suicidal, and discharged myself against medical advice in both admissions after 1 week and after 2 weeks, fearing longer admissions would result in the termination of my registration and the end of my career.

Autoenthnographic Insight: Vexatious Complaint

In April 2020, my second formal application for review of my conditions was processed. At this time, I had secured a one-year internship as part of the 5+1 program in order to gain full registration as a psychologist. AHPRA then notified me that there had been another complaint made against me in December 2019, of which AHPRA had not notified me when it had first been made. Like the first complaint, this second complaint had also been made when I had not been working as a psychologist and was working as a peer support worker only. The complaint had been made by a fellow student and provisional psychologist who had studied in my Master's program, and had also worked alongside me at the hospital where I worked as a peer support worker. It was this complainant's standpoint that a person with Lived Experience of mental health concerns should not become a psychologist. They had made the complaint after learning that I had secured an internship, as a pre-emptive (defensive) health notification on the grounds that they believed that once I began my internship, I would harm patients due to my Lived Experience. This complaint also did not meet the threshold of "notifiable conduct" for direct observation that I was harming the public or placing the public "at risk of substantial harm due to an impairment" (AHPRA, 2010, 2020b; Bismark, 2016; Bismark et al., 2014).

This complainant had been made by a former student peer and now colleague. They had now graduated from the Master's course, however I was still completing the course due to the lengthy AHPRA investigation, (i.e., the delays resulting in unenrolment and re-enrolment, and interruptions due to impacts on my health). This person was aware of the former complaint that had been made against me by our lecturer. While we had both been studying together, this person had engaged in unsettling behaviour toward me, such as taking photographs of me during class and during lunch breaks. I had not felt able to discuss it with my lecturers due to having been reported to AHPRA; I felt I would be misperceived as being "paranoid" and was afraid that my lecturers may write that I was paranoid in their reports about my performance and competency to AHPRA if I mentioned the behaviour of this student toward me. This further demonstrates issues with this reporting process – the lack of support for student trainees, particularly disabled individuals, and the problems that can occur in stigmatising and unsupportive workplace and educational environments that others may take advantage of to engage in bullying and/or discriminatory behaviour. At the time of their complaint, this former student peer and now colleague had been a casual "friend" on a social media account of mine. Unbeknownst to me, they had been engaging in months of their own surveillance behaviour of me, both in the workplace and of my social media posts. This surveillance included writing detailed lists about what I did or didn't eat or drink while at work, my interactions with hospital patients and colleagues, and screenshots of online posts of mine (social media posts which aimed to create awareness about mental health concerns and dismantle stigma) and screenshots of my social media profile photos. They had amassed these pictures into a file, along with handwritten notes about my body weight, eating habits, and perceived "impairment", which they had been sending to the Psychology Board as "proof" that I was "impaired" and should not be allowed to practice as a psychologist. The complainant had also made multiple phone calls to the Board. In their report, they acknowledged that after their first phone call to AHPRA to complain about me, beginning in February 2019, they had offered to provide the Board with the "evidence" they had collated from my social media posts as "proof" of my impairment. They also acknowledged that the Board had not contacted them further to request the social media posts, so they had self-elected to provide their collected documentation of my social media posts and photos to the Board irrespective of the Board's lack of follow-up and lack of interest in this material. The complainant had then spent months tracking my social media posts under the guise of being a "friend", and repeatedly sent photos and correspondence about me to support their original complaint. At this time I was working as a peer support worker and not as a psychologist or provisional psychologist. However like the first complaint, this complaint suggested I would be unfit to become a psychologist. In their report, the complainant acknowledged that the photos of my social media posts that they had included were (quote) "[social media] posts from the past that do not directly relate to the current notification, however provide evidence of long-term issues with mental illness". This statement on its own provided evidence of their bias, and the vexatious nature of the complaint.

AHPRA had not informed me of the complaint immediately in December 2019. The delayed notice of the complaint meant that the complainant was afforded the opportunity to continue their online stalking and workplace harassment without my knowledge. Despite the obvious vexatious nature of this complaint, I was still subjected to a second fitness-to-practice investigation, and was not offered support or resources, although in the email about the complaint, an AHPRA did offer a warning that the complaint material "may be distressing to read". Further, as the support of my treating practitioners was undermined by breached confidentiality due to their requirement to submit reports to AHPRA about my fitness to practice; I now had concerns about how I would be able to communicate to my practitioners about how I felt about again dealing with the regulatory complaints process. I was again subjected to the distress of having my private medical documentation openly accessible by AHPRA case investigators and the Psychology Board. It took another three months until the Board met and discussed my case in July, and then another two weeks for the Board to organise a new independent assessment by a psychiatrist, compounding my anxiety and exhaustion. This independent assessment would be used to simultaneously determine my fitness-to-practice, and to review the conditions on my registration. It would mean forced disclosure of personal information to more individuals.

The independent assessment by the Psychology Board determined that the new complaint was vexatious. It was determined that I should be able to practice and could therefore renew my registration and begin my internship. The reports and letters provided by my treating psychologist, psychiatrist, and GP that attested I was fit-to-practice and posed no risk of harm to the public; the Psychology Board-appointed psychiatrist who conducted my second independent health assessment had concluded: "It is my opinion that Ms Elwyn is safe to practice. It is my opinion that the normal supervision for a graduate entering into the profession of psychology is the appropriate monitoring for her to obtain and maintain registration. At this point in time, I do not believe that there should be any specific additional supervision placed upon her". Despite these opinions, however, the Board determined that the conditions on my registration would remain in place, indefinitely, whereby my registration would be contingent on the conditions that I engage in treatment and that my practitioners provide mandatory reports about my condition to AHPRA.

I received notification in September 2020 of the Psychology Board's decision that I could renew my registration and begin my internship, with the conditions on my registration to remain in place indefinitely. By this time, I was traumatised by the process and impact of the investigations from my self-disclosure, the first complaint, and the recent vexatious complaint. I was harmed by the stigma, removal of confidentiality in therapy and breach of privacy, forced treatment, and by the knowledge that these complaints had arisen when I had not even begun working as a psychologist. I had viewed my Lived Experiences as a source of strength and insight that would support my therapeutic skills; however these experiences were being used as a basis to accuse me of potentially harming the public in the future, despite no basis or evidence for these claims. At the time of both complaints, I had not been practicing as a psychologist, had caused no harm to the public, and there was no evidence that I would cause harm.

The circumstances surrounding both of my complaints and consequent fitness-to-practice investigations are consistent with research that the majority of health notifications are not made by a clinician-patient's treating practitioner, may be stigma-based, and grounded in pre-judgemental and superficial impressions, and/or serving a complainant's own agenda (Bismark et al., 2016). Throughout these experiences of AHPRA regulation, I had wondered if peer support would have resulted in a kinder, more compassionate process, and my distress and suicide risk would have been reduced. The current regulatory investigation and mandatory reporting processes endanger the health and wellbeing of clinicians and students and may marginalise and exclude students and clinicians from the profession (Biggar et al., 2023; Taylor, 2019).

A Resolution and Need for Compassion

On the 14th of September 2020, I was informed that the Board had reached a decision, and while I was granted renewal of my registration, my registration would still be contingent on conditions that I: engage in treatment with a psychologist and psychiatrist; provide the contact details of the treating practitioners to AHPRA with their acknowledgement of the conditions on my registration; my treating practitioners were to provide three monthly reports to AHPRA about my wellbeing, provide AHPRA with the contact details of my supervisor at my place of practice and an acknowledgement that AHPRA would contact them and that all costs associated with compliance of the conditions on my registration were to be at my own expense. The review period of these conditions would be one year (the length of my internship).

The conditions on my registration had not been lifted after over three years, despite the conclusions of AHRPA's own Board-appointed psychiatrists and my treating team that I did not pose a danger to the public and that both notifications had failed to meet the high threshold for risk to the public. No clear outline had ever been provided by AHPRA as to what I could do to demonstrate sufficient evidence for these conditions to be lifted. The most recent report submitted by AHPRA's independent psychiatrist had explicitly stated that these conditions were not required. Despite the fact that I had never harmed anyone, was well engaged in treatment and always had been, no time limit was apparently "enough" to demonstrate to the Board that the conditions on my registration could be removed.

Following the second complaint and decision of the Board to request another health assessment, I briefly hired a lawyer experienced in medico-legal cases with practitioners. However, at this point, I was again, stressed, exhausted, and my health was continuing to suffer. According to AHPRA's own guidelines for mandatory reporting for impairment, I did not meet the high threshold for reporting (i.e., I was engaged with treatment, had direct supervision, and had well-managed conditions prior to the reports). I had also been assessed by two Board appointed psychiatrists who concluded that I was not a risk to the public and was able to practice as a provisional psychologist.

After the Board's decision not to remove conditions on my registration, and in the context of the uncertainty of the COVID-19 pandemic, I felt I could not continue to risk my health and finances to fight the conditions on my registration. I had to try to regain my health, and first and foremost, I needed to regain my sense of safety and confidentiality in therapy if I was going to be safe. I notified AHPRA that I was relinquishing my registration. My clinical psychology career was over; systemic stigma had ended it before it could truly begin.

After relinquishing my registration, the AHPRA investigation officer told me that "the Board did want to express their sympathy for what I'd experienced; and acknowledged that I'd experienced prolonged distress during the investigation of the complaints, which ultimately led to the surrender of my registration for the sake of my health, at a time when I had been at the very beginning of my career". The officer said the Board "wanted to express their support and regards if I did choose to return to the clinical profession, and their support and regards for my future career in any other areas and endeavours if I did not, and for my health and wellbeing". The officer said they realised these systems and processes were flawed, but they were "all we have at the moment", and that they hoped that for me, "it's over now", and that I could "move forward, have closure, and put it behind me". The AHPRA officer extended the Board's congratulations to me on my acceptance into my PhD program and asked me about my research project. We talked a little about the Lived Experience work I was involved in, and about the increased valuing of Lived Experience knowledge in the mental health field, which showed hope for the future against the harm of stigma within the profession. The officer informed me that if I did choose to return to clinical work (within the 2-year time limit required for registration in order not to have to repeat my degree), the complaints would have no impact on my registration. I cried after the phone call, both for what I'd experienced and for having finally heard an acknowledgement from within AHPRA as an organisation of the damage this process had caused to my health and career, and the need for improvements to be made in the future.

On the 15th of February 2021 I received an email and follow-up call from an AHPRA investigation officer, informing me that the Board had formally resolved the matter of the second complaint against me following the medical investigation, and had determined no further action was required. AHPRA had determined no investigation was warranted into my social media posts (the basis of the complaint), and that the complaint had been determined by the Board to be vexatious and "personal in nature" and did not indicate "impairment". AHPRA also formally acknowledged my withdrawal of registration.

If there had been more transparency and compassion throughout the regulatory complaints process, perhaps the impacts might not have been as devastating. This article is an attempt to join others, including AHPRA themselves, to call for transformation, to protect the health and lives of students and clinicians who face these investigations and need greater support.

The Western Australian Exemption

The Western Australian (WA) exemption is legislation that exempts a treating doctor from the mandatory reporting of a clinician-patient (AHPRA, 2013; Goiran et al., 2014). The majority of health notifications of practitioners for impairment are not made by their treating practitioner; rather the complainants are other health practitioners or employers (Bismark et al., 2016; Spittal et al., 2016). Mandatory reporting legislation for treating practitioners to report clinician-patients, therefore, may have little benefit to the protection of the public, and may instead increase risk for clinician impairment by creating barriers to seeking and engaging in treatment, due to clinicians' fears of the negative impacts of disclosure (Goiran et al., 2014). Critically, in a review and submission to parliament, the AMA concluded that the WA exemption for treating practitioners had not compromised the ability of the Medical Board to protect patients (Australian Medical Association, 2014), and advocated for current mandatory reporting requirements to align with the Western Australian model of exempting doctors from mandatory reporting of clinician-patients. The WA exemption also alleviates ethical dilemmas around mandatory reporting for treating practitioners who provide care to mental health clinicians (Bismark, 2016; Bismark, et al., 2016; Goiran et al., 2014; King, 2011) — this is particularly important regarding concerns for clinician disclosure of suicidality. Compared to WA, the treatment of clinicians across the majority of Australian states was highlighted as unequal and inequitable, and as negatively impacting patient safety (Australian Medical Association, 2014, 2018, 2019). Similarly, the New South Wales (NSW) complaints management process differs to that of other states (Walton et al., 2020). The classification of a complaint in NSW as "performance" related (as opposed to conduct related) typically means the complaint is not investigated; a clinician is instead assessed by peers and may be required to undergo additional education and training (Walton et al., 2020). A standard national approach to complaint regulation is needed in order reduce distress faced by clinicians involved in regulatory complaints processes and to reduce inequity across states and territories. It has been argued that as the WA exemption legislation would enhance health access for health practitioners and benefit patients, and should therefore be considered for implementation throughout Australia (Goiran et al., 2014).

Lived Experience Involvement for System Change

A more supportive and compassionate regulatory complaints process could be adopted by AHPRA through the employment of CLE that can act as peer support contact points for clinicians and students who may be undergoing fitness-to-practice investigations or are involved in complaints. In addition, CLEs may act as contact points for clinicians or students whom are concerned about a colleague/student peer and are uncertain of how to sensitively approach them for supportive intervention or remediation. Lived Experience expertise must be included as part of the bedrock of the mental health workforce to support both public and clinician/student safety, equity, and dismantling oppression and stigma. Introducing designated lived experience (LE) roles into organisations has been found to result in cultural shifts that benefit the whole workforce (Wang et al., 2023), which has implications for the role of peer support in the AHPRA regulatory complaints process. The inclusion of designated lived experience roles can result in better performance, diversity and inclusion outcomes, and the development of more healthy and inclusive organisations (Wang et al., 2023). Transformation of the regulatory complaints process may have significant flow-on effects for dismantling stigma and fear of mental ill health in healthcare settings, internalised stigma, and barriers to help-seeking. Continued efforts must be undertaken, however, to address stigma and discrimination for clinicians and trainees, such as the inclusion of peer support or Schwartz Rounds in workplace and tertiary settings (Deborah Allen et al., 2020; Behrman, Baruch, & Stegen, 2020; Carbone et al., 2022; Franke, Paton, & Gassner, 2010; Herrema et al., 2020), Lived Experience workshops and advocacy (Hogg et al., 2023), anti-stigma interventions (Kaiser et al., 2022; Tóth et al., 2023), and information about and access to health programs (Jiménez-Gómez et al., 2022).

Conclusion and Recommendations for Change

By changing workplace cultural practices and norms from risk-aversion to person-centred intervention, the wellbeing of practitioner-patients may improve significantly. This article contributes to literature on mental health stigma and discrimination in the workplace and educational settings by providing lived experience example of systems of inequity and privilege within the psychology sector (i.e., perception of diagnosis and perceived "impairment" and dangerousness to others), and real-world impacts of the regulatory complaints process on mental and physical health and wellbeing (including suicide risk), employment, and financial security/stability. This paper additionally contributes to our understandings of cultures of ableism in healthcare by demonstrating how ableism and inequity is maintained through policy (i.e., language of "impairment", perceived lack of credibility, uncertainty, lack of transparency and double standards, ongoing surveillance, loss of privacy and confidentiality, isolation) and upheld downstream (i.e., reporting for impairment without meeting thresholds, vexatious reporting, avoiding medical services out of fear of mandatory reporting, defensive practice).

In this article, a multi-pronged approach has been discussed for systems change. It is recommended that change to the regulatory complaints process in Australia include: (1) The adoption of the WA exemption legislation for other Australian states to exempt treating practitioners from the mandatory reporting of doctor-patients for impairment, in order to reduce treatment barriers within the profession; (2) A review and investigation of the current mandatory reporting system and regulatory complaints processes in Australia for clinician impairment, and their impacts on the mental health and wellbeing of mental health clinicians and students. These impacts include the expediency and transparency of the regulatory complaints process; and its relationship to the culture of mental health stigma in the health profession, defensive practice amongst clinicians, treatment barriers, risk for disability discrimination, and risk for trainee/clinician suicide; (3) Differentiation of complaints according to risk assessment (i.e., low risk, higher risk), and creating alternative pathways to manage these risks in accordance with risk assessment; (4) The widespread provision of education to trainees/clinicians in the health and mental health profession on the thresholds and requirements for mandatory reporting, including the provision of ethical decision-making models for mandatory reporting; (5) The employment of peer support workers to provide support to trainees/clinicians involved in the regulatory complaints process; (6) Integrated information or specialist services into the regulatory complaints process to provide support to trainees/clinicians; (7) Greater transparency throughout the regulatory complaints process, and the provision of information about the rights of trainees/clinicians involved in complaint or investigatory processes; (8) Use of clear, non-legalistic communication throughout the regulatory complaints process to reduce stress and a sense of punitive action or accusation; (9) Identification of stressor points throughout the regulatory process as key processes for improvement and areas where more support is needed to reduce trainee/clinician risk; (10) Development of a response process to effectively manage vexatious complaints and misuse of the complaints system.

Clinician support networks that include sharing Lived Experience of mental health concerns and service-use can foster the dismantling of workplace stigma, internalised stigma, and barriers to mental health service-use for clinicians. CLE are in a unique position to directly contribute to this cultural change through the provision of peer support for clinicians and students who have been the subject of health notifications and investigated. There is potential for CLE to act as peer support contact points for clinicians who may be experiencing suicidal thoughts and feelings, experiencing mental health distress, or in need of support in the workplace, and to provide support for clinicians who are concerned about a colleague and uncertain of how to sensitively approach them for supportive intervention. The author has provided autoethnographical insights of their personal experience of mandatory reports and investigation for impairment as a student, with the aim of critiquing the mandatory reporting legislation. The author supports suggestions that current investigatory processes of clinician impairment and fitness-to-practice should be amended to involve prosumer clinicians with Lived Experience of mental health concerns, traumas, neurodivergence, and experience of mental health service-use. This involvement can reduce risk to wellbeing for clinicians being investigated by facilitating compassionate support through Lived Experience. The Western Australian Exemption can be implemented throughout Australia in order to remove barriers to treatment-seeking within the health profession, and reduce suicide risk of Australian mental health clinicians and students. The implementation of these and other suggested changes to the current mandatory reporting system and regulatory complaints process may reduce stigma and increase support for distressed clinicians; including reduced healthcare avoidance, defensive practices that occur out of fear of mandatory reporting; misuse of and vexatious health notifications; and risk to wellbeing for clinicians and students being investigated. These issues are matters of ethics, disability justice, and discrimination, equity and equality. The regulatory complaints process within mental health education and training has been shaped by deeply embedded cultures of shame, ableism, discrimination, and fears of impairment rather than well-established systems of support, communication, transparency, and prioritising wellbeing, equity and inclusion. It is a grave injustice that the regulatory complaints process that aims to mitigate harm to the public inadvertently maintains stigma, barriers to help-seeking, and creates harm for those working in the profession, and therefore, ironically, potential risk to the public. The wellbeing of health and mental health clinicians and trainees is fundamental to their care provision and cannot be safeguarded without safe access to the services they work in, and freedom from stigma and fear from their regulatory bodies and peers.