Change versus bureaucracy in mental health

Why things don’t change

If you’ve been alive long enough you may be getting an uneasy feeling in the last few years that modern civilization is not working too well. Where the turning point came is somewhat hard to determine but the gears seem to be grinding to a halt as more and more problems go unrecognized and unaddressed. My observation is that this is true in virtually all sectors of society but, since my experience of things is in the mental health and public health fields, I notice this phenomenon more in these spheres.

For practitioners in the mental health field who want to practice effectively the bureaucratic red tape and redundancy is fairly overwhelming. It is discouraging for seasoned professionals and new practitioners alike to face these roadblocks limiting our effectiveness especially if you keep in mind the original reason why many of us went into the field in the first place – to help people.

What is the bureaucratic brick wall?

Simply put, it is the red tape that we must struggle through every day to serve our clients. This includes all kinds of documentation requirements that are handed down from the federal, state, and local levels. The intentions are good. This paperwork is meant to help us understand the client, provide the appropriate treatment and maintain safety for the client. It often works at cross purposes, however, since all the questions and answers often place the client in a diagnostic box which, frankly speaking, the client is unlikely to be allowed to emerge from.

Because documentation requirements are overwhelming, many clinicians tend to not have the time to assess the client without depending on the old paperwork. Documentation supports a diagnosis which follows the client everywhere. Documentation makes a “case” for a diagnosis. It’s ironic that to “get better” a client needs to escape the past in fundamental ways but this proves to be virtually impossible when they carry the weight of a diagnosis and a mountain of paperwork to support it on their shoulders.

Solution anyone?

How can we do a better job of assisting clients without putting them in an impossible bind? From my experience here are a few things that might help.

For administrators

*Standardize and simplify required assessment forms across settings.

*Involve clients and direct service professionals in the development and roll out of any new clinical paperwork requirements.

*Require that every new piece of documentation replace a pre-existing from or be incorporated into a pre-existing form.

For direct service professionals

*Invite the client to be a partner in the assessment and diagnostic process.

*Assess the client without prior documentation or diagnostic information initially. If necessary review prior documentation after the face-to-face assessment.

*Provide the client with a copy of the documentation for review and possible amendment before finalization.

For the client

*Be proactive about wanting full participation in the process with access to the resulting documentation.

*Ask to review the factors involved in diagnosis if this is not clear.

*Challenge any inaccuracies in the assessment or the previous documentation.

Many of these recommendations are in place now, in my experience, but are poorly implemented in many settings. This is primarily due to time constraints and staffing levels. Improving things would require better funding to lengthen the assessment process. More time and money spent on the front end would result in better outcomes on the back-end as the focus would be on current problems and possible solutions. After all, wouldn’t this be a start to help clients emerge from the diagnostic stranglehold? How can people change when the bureaucratic tangle weighs them down?

Chronic illness AND a social life?

When you are initially diagnosed with an illness that later becomes chronic it is not likely that you are thinking about how this may affect your social life. Naturally, you are focused on how to cope with the illness itself. As difficult as the illness can be, however, it can be just as difficult to see your social circle dwindle as your illness progresses.

Here are a few of the stages that people I know who have a chronic illness have experienced. I hope it helps to know you are not alone in this and you CAN have a social life AND a chronic illness.


When you are initially diagnosed family, co-workers and friends are usually very supportive. They cover your workload, accompany you to doctor’s visits, help with household tasks and call frequently to see how you are. The practicalities of the illness act as a strong link between you and them.


When an illness is prolonged, however, things begin to change. If you are no longer able to work your work colleagues are the first tier of your social circle that begins to go. This is a natural evolution and does not necessarily reflect badly upon your former workmates. They are moving on with their lives. You no longer have as much in common. Your experience is with the new world of your illness and not the old world of your career.

When the going gets tough

This is the true test of friendship. Be prepared for some friends to slowly disappear. Also be prepared for old friends who you have not seen regularly to come back into your life. Who sticks around, who leaves and who reappears is not always who you would expect it to be. Prepare to be surprised.

Social circle reinvention

There is no doubt that chronic illness limits your ability to be social but at some point in the illness you may have enough energy to want to start making new friends. Things will be different; what was important to you before will not be important now. When you are out of the work world you have the gift of having time to determine who and what makes you happy.

You may have a lot in common with others who have the same or similar illnesses. You may resume or take up hobbies that you used to be interested in. You may volunteer for a cause that you believe in. You can make new and solid friendships through being involved in activities you are committed to and enjoy.

And, hopefully, those tried and true old friends are still around to remind you of what you were and who you have become….