A Clinical Social Worker’s Bane


I woke up to a grey Saturday, the sky a pane of dullish ashen, the sound of planes going towards LaGuardia or Kennedy, descending below the cloud line as they approach their destinations. The street is quiet from the dining room table at which I write, the constant “hum” from highway 297, a block away, only heard from the other side of the apartment. In the house, all sleep and I get up to complete some notes, an unending and infernal part of my job, the clichéd yet so apropos “bane of my existence.”

I am a clinical social worker at a hospital’s mental health clinic situated in Brooklyn, a non-profit, still somewhat independent; a unique institution with no formal affiliation. This makes little difference, I know, for I speak to other clinicians who practice at other hospitals, private, public and city run. It matters little. We have all become assembly line workers in the factory of mental health.

I completed these short three notes, from a week before, lest they “lock.” When they lock, it sets in process an obligatory reminder email from one of the managers, “cc’d” to at least five other people, all supposedly important, all laden with titles full of acronyms whose meanings are unknown to all but the proprietor, yet add gravitas to a name and a role in the factory. As I was writing, after a well-rested night, with the day full of promises ahead of me, I realized that the content, the depth and the writing were unlike that of most other blurbs that provide a summary of a person’s mental status. No hasty, badly composed sentences, repeated ad nauseam, a sort of rubber stamp to ensure that the hospital is reimbursed for a patient’s visit.

As a clinical social worker, I spend 30 or 45 minutes with individuals and using various methodologies I attempt to bring solace, clarification or just provide some company to the many troubled souls that struggle to rid themselves of daemons, bad choices and bad marriages, mean children and mean parents, poverty, and racial, gender and legal oppression. I am humbled to be the trustee of horror stories and strive to lighten the load of trauma and misery. Each individual a universe, unique and rich in diversity and exceptionality, each encounter a rich tapestry of interwoven tales, brought to life by their words, at times almost poetic and lyrical, most often devoid of joy, devoid of life. I put much effort into comprehending and grasping the fullness of the person’s potential as well as their possibilities. I toil to fulfill the other responsibilities, the bureaucratic drudgery, the clicking of endless buttons on a form, the phone calls, the emails, the forms.

I am a unionized clinical social worker, paid to work 35 hours a week, with two 15-minute breaks and a one-hour lunch. That’s the hypothetical, the agreement between my union and the hospital. Yet I take no such small breaks, eat a harried and hurried lunch when I eat at all, and carry a load of on average 100 people, for whose lives I am partially responsible. I see them at my clinic but inevitably bring work home. At the facility, I put in at least 50 hours and live with a constant dread of not having clicked a button, of not having made another phone call, of overlooking the sadness in someone’s eyes, of not fully paying attention, of not having been totally and completely present and mindful. I write rushed notes, just the obligatory, no depth, no conveyance of the interaction that just transpired. My mental health and that of many of my colleagues becomes compromised, the risk of burnout or empathy fatigue is high, yet the machine hums along. Every day, every hour, I strive to provide the best clinical and empathic care. And yet, I am always behind on paperwork, risking disciplinary actions. No one speaks of the quality of the work, as it’s all about quantity. I am privileged to work with a mostly exceptional group of professionals, and I love what I do. I have also been witness to shoddy and rushed work, clients who deserve better but don’t know what to expect.

The turnover rate in psychiatry is very high, where constancy is most needed. We appear surprised when sequential Wars on Drugs and on Depression and on Obesity are wars lost. We do not invest in prevention and we run the workers into the ground. Mental health work is not valued in this city, it is not valued in this country. Yet, this is a profoundly unwell society and the signs abound. Mental health cannot be run on Fordism, with increased production, in less time and with less resources. There are plenty of resources, but they are all going to the pharmaceutical companies who charge 10 times as much for the same medications in this country as they charge in the European Union and other parts of the world. We have vice presidents of vice presidents, subdirectors of subdirectors. We have more bean counters than we have beans. We are overseen by so many agencies that most clinicians do not know who does what, when, and how. Those, too, are profligate with acronyms.

Our mental health system is very ill, and the people who most suffer are those who most need it. We are not just individual agents of change but if we are to be effective in any way, we must get out in our communities and be social agents of change. It is our responsibility to challenge those special interests with the armaments we have. Systems knowledge and systematic challenge to the powers that be must be part of our tool set. Moral courage and outrage are required as is the capacity to flex our mental and physical muscles. It is possible and not quixotic.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. The “mental health” system is working.
    But if you actually want to help people you need to look for another job I’m afraid.

    I’m finally getting my life together slowly. Learning to build a social network. Lose 200+ pounds. (Down 40 so far.) Rebuilding my shattered body, mourn my broken dreams and accept responsibility for my bad choices.

    Hard to “adult” in your mid forties. If I hadn’t fled the crazy making system it would be impossible. It exists to keep people helpless and dependent.

    Chronically ill from years on prescription drugs. Never gainfully employed. Never had a relationship. I owe it to the boon of modern psychiatry.

    My life stinks. But I wouldn’t trade places with you Manuela.

    It must be horrible to honestly want to help people who only get worse in every way possible. 🙁

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  2. As a former LISW, I saw this from the time when there was a possibility of hope to this and worse. I also have been so called gifted with being in the system in all if forms.
    Thanks for this but.
    You are not helping. Truly. It might seems as if you r but what I and friends would discuss is sometimes those helpful sessions were triggering and some of us came out of the building totally zombified. And when in a trtraumatized state and especially if you are labeled SMI the power differential is unequal.
    My mother was a MSW and worked with pregnant women who had to climb up 7 flights of stairs to get to her office. It wasn’t until she herself had been through pregnancy that she realized what SHE had done to those women and she never did that again. And she was for the 1950’s and early 1960’s fairly awoke for a white woman of those times.
    I have experienced the same OMG, WTF type of reaction after my own time in the solitary room in inpatient so called treatment.
    I saw what you have seen but there is so much more.
    I am glad you wrote this but do something. I have had bad experiences so I don’t have the freedom to do what you could do.
    1) Read up on the Pdych survivor momvement and Disability Studies. The powers that be divide and conquer so well in this area. They put each group of folk with different disabilities into little boxes and make them feel that it is a zero sum game.
    2)Ask five folks that you work work to tell them to tell you the truth of being in system.
    3) Do a trauma history with their permission and have a plan about who what where and how you can help them.
    Have you read the literature of trauma? Both professional and survivor and IHO the best are those that gave both backgrounds and are woke. There are some that have both but are not woke. Don’t dismiss them but read between the lines in everything and everyone.
    4) Make a plan to leave and get out. It is not going to get better right now. What you described is a catatonic, divisive, top down agency. It will hurt and harm you.
    Dialogue with us.Learn and maybe you can be part of the change .

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  3. and legal oppression… Yet, this is a profoundly unwell society and the signs abound.

    Its pretty bad more government money and paperworks, the solutions always offered won’t fix it.

    I remember in treatment when I was still bugged out in that state where I notice things to much and I noticed the staff spent all their time faces buried in the computer screens. Three counselors they would rotate doing groups and spend a little time with each client then all the rest of the time you look through the window they are on the computer typing typing typing.

    The nurse the same thing all day long face planted in the computer then their was 8-10 more people in other offices the same thing stuck to computer screens all day. I started thinking maybe the only way to get any attention at this place would be to dress up as a computer.

    I started thinking how in the 1930s the first diesel tractors came out and how prior to that MOST of the population was in farming but now or As of 2008, less than 2 percent of the population is directly employed in agriculture. 2% !! Modern tractors and farm equipment changed everything.

    Well in the 1980s the personal computer came out, then windows and the internet e-mail fax machines.

    An action that used to involve digging through a file cabinet, an envelope and mailman and a phone call now is just a few keystrokes and mouse clicks. A few people with the modern internet can do the office work it took dozens of people to do 40 years ago.

    So why is it with the invention of modern farm equipment now only 2% of the population farms but with the same radical improvements in the efficiency of office and communication technology why do we have more people doing paperwork then ever before ????

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    • Because office work is done without the workers realizing what’s actually going on, not having studied things like Parkinson’s Law (work expands to fill the time allotted for its completion), or the Peter Principle (employees rise to their level of incompetence, which encourages the creation of incompetent organizations).

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  4. Dear Manuela,

    I wouldn’t fancy your job.

    I thought I had left Psychiatry in Ireland in 1984, but unbeknowns to me the GP I was seeing in London had reinvented Severe Mental Illness for me in 2002, (but without telling me – while I worked on Building Sites): –

    He had included my name on a Severe Mental Illness Register (to make a few quid) and was recording the non reappearance of psychotic symptoms that I had never even suffered from (to begin with), and keeping my actual circumstances off the records.

    But Dr Dominique Dock was to suffer a psychosis himself eventually, and was asked to leave the (Central London) Medical Centre:-


    There was a medication prescribed Seroquel, at 25mg per day:- but unbeknown to Dr Dock this had no Psychiatric effect whatsoever and was only suitable for off label use.


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    • An unusually large number of psychiatrists kill themselves each year. Could they be suffering from”untreated mental illnesses”? *Gasp!*

      More likely they can’t bear the torments of their guilty consciences over all the people they lied to and damaged. Like Shakespeare’s Lady MacBeth. Or the commandant depicted in Schindler’s List. (In real life he did lose it. Emotional pain is behind break downs. And guilt can be quite painful.)

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  5. Many people go into the field of social services with the intention to help individuals and families overcome trauma, oppression, and other adversities. They are compassionate people who want a career and life that facilitates healing and systemic change. Many of these MSW programs are geared heavily towards education around social justice. The shocking reality for a lot of people once they graduate from these programs and start working in the field is the discovery that the mental health system is actually an institution or manifestation of oppression. They learn that it is a textbook example of structural violence. I’ve seen professionals go into denial over this, in part because it is a very real trauma for them to be living in a culture where this is the reality, and that they have in a sense been tricked into contributing to this. A field where social justice concepts and ideas such as “trauma informed care” have been coopted, and mixed with this mentalism–this pseudoscientific propaganda, such as bogus, victim blaming, profit motivated DSM “diagnoses” and the subsequent psychiatric psychoactive drug “treatments”. Professionals in this field have essentially been force-fed the misinformation, thus becoming oppressors themselves—the very thing they unequivically oppose.

    To me, what you are describing in your article are the symptoms of this bigger picture phenomenon.

    I would encourage anyone who works in the system to use it as an opportunity to work as a change agent or just quit because both you and your clients deserve better and it is a shame that your compassion and good intentions have been taken advantage of:


    As a psychiatric survivor, I can tell you first hand that what I experienced was extremely traumatic, violent, and haunts me to this day. I know I am only beginning to scratch the surface, but here is an extremely illuminating article for anyone ready to dive deep and start educating themselves on this painful reality:


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    • “The shocking reality for a lot of people once they graduate from these programs and start working in the field is the discovery that the mental health system is actually an institution or manifestation of oppression. They learn that it is a textbook example of structural violence.”

      This is perfectly said and exactly my awakening. It even took a few times being hit over the head with this truth at a few different agencies, and it finally sunk in how systemic this was, the norm. Thanks for this powerful and clear articulation.

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      • Thank you Alex! I really appreciate that! I get a lot out of your comments. You and the other commenters have unknowingly helped facilitate a level of healing, empowerment and personal growth that I didn’t know was possible.

        As it stands, mainstream Psychiatry is one of the most insidiously psychologically abusive, fraudulent, misguided, violent, oppressive, dehumanizing, and tormenting ways a person can be victimized. The experience is extremely traumatic, and not limited to just the “clients”. Glad to hear you made it out and good luck to you!

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        • Yep, it is just that, and I think the notion of “healing from psychiatry” is the new ground we’re on here. And it is indeed empowering to put it all into perspective and have it validated by the experiences of so many others, following all of that gaslighting, denial, and projecting. They (psychiatry, et al) do make our minds spin and spin and spin, don’t they?

          “Insidious” is the word I use all the time to describe this, because that’s exactly what it is. I’m so glad to know that you have felt uplifted in this regard by what you have read here. We are so much more powerful than what that particular community would want us to believe. And they go to great lengths to make sure we are not accessing it!

          Most mh clincians I’ve met (starting in graduate school, when they were my colleagues and professors) are extremely insecure and fear-based, so they need the support of an intimidating and bullying system or they, themselves, feel powerless. It’s rather an interesting transference, I think, but still, it is toxic for clients–and society–as we know all too well.

          You have a really powerful voice, Kid3019, and I encourage you to keep using it. You know truth, no doubt about that, and you speak it with precision and light. Thank you again for that. Spread the awakening!

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          • Alex, re: “Most mh clincians I’ve met.. are extremely insecure and fear-based, so they need the support of an intimidating and bullying system or they, themselves, feel powerless.”

            Exactly!! It is their own fears and issues with self-image, insecurities and a desperate need to feel superior, powerful and important. This explains why they can never allow themselves to admit to making a mistake or a misdiagnosis, no matter how much the evidence proves them wrong.

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        • Alex and Kld3019, thanks for your insightful comments. This website and the blogs are very informative and helpful but I also learnt so much from Alex and other commenters including yourself KLd (and Steve McCrea, Rachel777, KindredSpirit, Oldhead etc). It has been healing and empowering for me too to read the comments of others.

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          • Thank you Alex and Rosalee! I really admire your courage for speaking out and continuing to chip away at this highly sophisticated, insidious institutional gas lighting—this brain washing on an international scale. Being exposed to such a terrifying and destructive cultural norm on a daily basis makes unweaving the complex web of my own victimization quite challenging and your powerful voices help me cut through that web. I am grateful to you both as well as to the other commenters, bloggers and this platform as a whole.

            The DSM is essentially a book of 1,000 mentalist slurs, purporting pseudoscience, hate speech and overall bigotry as “therapeutic”. It is a way our culture suppresses and dangerously oversimplifies the spectrum of human emotion, behavior, suffering and experience. The abuse I suffered was outside of me, and largely at the hands of psychiatry. I would not be able to effectively process the resulting trauma if I were conned into believing it was a permanent medical issue as opposed to a human being’s natural response to an unjust society and subsequent abuse.

            The fight or flight response tells us there is danger. It is a survival instinct, (and I would argue a form of intuition) not a “brain disease”. Suppressing these responses would be detrimental to the survival of our species. In this context, the danger here is the continued institutional oppression/violence of the mental health system. Part of processing trauma for some, could be channeling the fight or flight responses and intuitions into constructive and concrete actions. When I listen to my instincts and intuitions, whether tied to my traumatic experiences or not, one thing I am told loud and clear is that I want to fight this and other forms of injustice. I am also told to take care of myself physically, emotionally, and spiritually; work on personal development; educate myself; love others; and continuing processing my trauma—not suppressing it and none of this in a “psychiatrized” way. Everyone has a different path or beliefs, which I respect. This is just a snapshot of mine and what works for me. A work in progress if you will.

            Thank you both again for your powerful voices and helping to amplify my own healthy intuition and instincts.

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          • Same for me re you both and the many on here whose voices are refreshingly honest and unique. I’ve been influenced deeply by the many examples of clear, direct, and heartfelt truth-speaking, and the courage and trust to be persistent in these vital endeavors, despite the repeated frustrations. As long as more and more clarity comes to light, we are making progress.

            Thank you, Rosalee and Kid3019, and many others, for the enormous inspiration, and encouragement. To me, THAT is “the movement” which brings the most rippling and expansive change, from the core outward. It is real and true and from the heart. How lovely were that to become the new normal!

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  6. Thank you for offering your insider perspective from the professional point of view. This is what doesn’t at all surprise me the most about what you write above, and yet it is still what would alarm me the most–

    “I have also been witness to shoddy and rushed work, clients who deserve better but don’t know what to expect.”

    I shudder to think what one would find were one to follow the thread of that slip-shod “work.” I would call clients who do not know what to expect “unsuspecting.” That’s like being told “sit here and wait for the next bus” not even imagining that there might an avalanche about to crush you from behind because of someone’s clerical or error-in-judgment “oops!” And yet, it is commonplace. Rushed client work can lead to all kinds of tragedy, including suicide from blatant neglect, for one thing.

    The system, itself, is burned out, and I think it’s because all the pretense and misguidedness of it is catching up with it. When a system holds no truth or light, it is a house of cards. I don’t see how it can be replenished when at least practically everyone (if not absolutely everyone) in it is burned out, and, more than likely, quite discouraged. That means they are burning out their clients.

    That’s what I would call a really bad ripple into the collective and quite toxic to society, like nuclear waste. It really does need to stop, if it can only create burnout to anyone who gets near it. I can’t see it any other way.

    With all due respect and with compassion for your position, I do think that trying to fix the system is, indeed, quixotic. Less so is the idea that society can not only survive without it, it can actually thrive and evolve. I think that is a way more realistic possibility than the idea that the system can ever be anything but a drain on society and its humanity, as it only has been forever since its inception (whenever that was) really, to my mind.

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      • That’s certainly how I found my solution to all this, totally outside the system. The system is chaos and sabotage, whether it means to be or not. Healing has absolutely nothing to do with “the system.” I’d think this would be most obvious by now.

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          • In the UK if someone makes longterm recovery from a “Severe Diagnosis” “they” don’t acknowledge this Recovery and attempt to learn from the process:-

            “They” put the Recovered Persons name on a Severe Mental Illness Register thus (generically) pulling them straight back into the System.

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        • First off thank you Manuela for your honest and courageous writing of this necessary post. I personally appreciate the simplicity of clarity throughout. I am, however, a little torn on the issue of unionization in a mental health profession. As a lifelong union supporter-originally from Detroit, there’s something troubling about it’s reach to the profession of mental health. More troubling than I care to unpack here. Unionization for the purpose of job securities is good thing, me thinks. But unionization that bleeds into praxis or informs formative or operational processes, not so much. And who holds firm that Chinese wall?

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  7. Manuela, you are doing very important and vital work in a system that doesn’t support you, but that wants reports which get turned into more reports and stats for some government agency to report on. And mental illness is a true and valid reflection of the shattered, battered world we now inhabit…..

    I’ve never been in the system (I’m in the UK), but my dad and younger brother – both deceased – were. They found it helpful, but then things were better funded (mid 70s and early 2000s respectively). But, I’ve had psychotic episodes, and chose to avoid GPs and hospitals, because I found meaning in the psychosis. It was difficult for my husband and son though, I can see that now. (I found Open Dialogue therapy which pieced me back together again, thank God!)

    Perhaps a group of you could get together and plan a better system. Nothing changes without a small community. Look into Open Dialogue too – far more holistic, open and polyphonic. All the voices are important and resonant. Sending you warm wishes for the work you do. And Portugal is a wonderful country – your harm reduction strategy is so much wiser…..

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  8. Dear Manuela
    I will try to keep this short. Thank you for the courage to post your comment. At least you are young and have the hope and energy to change our broken US Mental Health Care System.

    As a 66 year old Biopsychologist I have much to say but will leave it up to the nearly 500 psychiatrically hospitalized individuals from the recent survey done by Mad In America (MIA). SEE BELOW.

    Manuela and others please see all their comments. They are relevant because they also relate to other aspects of our US Mental Health Care System.


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  9. so sorry. i really am. it appears that just as I entered the world of Mental Health, Inc. thinking they could “help” and that they did “important work…”

    so did you. My personal advice, which only echoes that of several other posters, would be to get out. You’re intelligent, you’re compassionate, you’re well-eduated, and you’re driven. Speaking as a “patient” doing what I can to make a quiet, unnoticed exit from The System, I -do- appreciate your efforts to provide real human kindness to those in need. Having said that…

    at the end of this novel I read way back when…I think it was The Women’s Room…a character says something like “the institutions get you in the end.”

    get out while you still can. 🙂

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  10. The Mental Health System certainly is B-R-O-K-E-N. I could write an entire book on the subject having been misdiagnosed & over drugged for thirty-five years, and then went on to heavily research Psychiatry, Mental Health field, and psychiatric drugs collecting over 800+ pages of documentation proving just how dangerous & deadly the drugs are.

    Mental Health has no problem loading us up on drugs more addicting than heroin and then proceed to inform us it’s just fine to abruptly stop taking them sending our brains into the world of suicide & homicidal ideations, complete psychosis when that’s not what we signed up for. A psychosis so terrifying many commit suicide to escape it’s clutches. I was one them many times over. I only survived by the grace of God.

    Our 10 minute psychiatrist appointment consisted of holding our hands out, touching our index finger to our nose, and sticking our tongue out. He just wanted to make sure we’re still alive so they can prescribe more neurotoxin’s for us. I will never again walk into a Psychiatrist office, a mental health clinic or even a General Practitioner’s office when suffering ANY kind of mental distress unless I desired to have what few years I do have left in utter suffering. No thanks. This girl has had enough. I’m lucky to be alive as it is.

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  11. Actually if one works in a government entity one is in the government union. Supervisors are part of the bargaining unit and so forth. It gets very mess when there is a strike. Some workers stay inside in order not to break the lines.
    In Community Mental Health Clinics despite popular myth they are not government entities. In fact, they were supposed to get monies from the Fed but the monies never materialized and county taxes were used to shore up the system since each center was separate and unique. In some states funding was divided with labels such as DD levies versus DDand MH levies.
    So unions were helpful to staff it they were alliwed. Unlike government agencies there were no Pensions or PERS.
    It then made agencies created in this mode to use public and private insurance. Then even government agencies were feeling the elevator drop in financial support and they went into gaining access to government insurance. The state government did not like their Medicaid monies going to agencies do a cat and mouse Hell was created with states using every opp to deny billing monies to agencies based on progress note VOCABULARY. This approach was further developed along Case Management and Therapy lines. Administrators would cull ever note written and probably still do to ensure proper wording was in place. In the last agency I worked at a well known Jewish agency staff were using copies from progress note workbooks to ensure their notes were not censured and kept their jobs. It wasn’t never, at that point what you did, it was solely what you wrote.
    Clients needs and concerns were st the bottom of the cess pool.
    I walked away after nearly being fired. This was based on vocabulary in my progress notes. They knew I was good just not profitable. The folks I worked with ALWAYS or mostly AlWAYS liked me. I was not perfect or totally awoke but I tried to honor and respect them and learn from them.
    So their clients were retraumatized once again by having me leave. Stupid , stupid, and more stupid.
    There are folks who have a knack for supporting others through trying times. Our society puts all of us in the shredder and doesn’t care one iota how we or us or we who have tried to gain access to so called help and or support end up. Once agencies assumed CEO and CFO officials we and the system were goners ruined and abused goners.

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    • er, The labor relations board in the United States does NOT allow supervisors to join unions AND when government workers go on strike, they get fired. Government workers are NOT ALLOWED TO LEGALLY STRIKE!!! I don’t agree with that the government won’t let them strike, nevertheless that is their policy. ……Managers and supervisors are also not protected by the NLRA, and cannot join unions or be part of the bargaining unit. … from this link… https://www.nolo.com/legal-encyclopedia/free-books/employee-rights-book/chapter15-2.html and also…. Who Is Covered
      With the few exceptions mentioned below, the NLRA applies to all employers involved in interstate commerce, which generally means almost every company.

      Who Is Excluded
      Certain groups of employees are not covered by the NLRA. They include:

      confidential employees such as company accountants
      the families of employers
      government workers

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  12. Actually, Manuela, your desired system of care would be INCREDIBLY productive. You hit the ice pick on the head, when you said, “We have more bean counters than we have beans.”. There would be PLENTY of time and resources, if we only trimmed the fat of #FAKESCIENCE . That racket is rife with fraud and force. And, those are guaranteed wastes, no matter the context.

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  13. Reading this at last.

    The problem of course is that there is no way to solve the inevitable results of capitalism, which include the disconnect between what one spends most of his or her life doing and what one finds personally meaningful or fulfilling, which is often regarded as an irresponsible and selfish preoccupation. So creating a “department” to deal with the basic reality that the system is not set up to meet people’s needs, nor considering this a priority for the future, is by definition futile.

    Attempts to fit any of this into a framework of so-called “mental health” at this point is about as relevant as the flat-earth theory is to climate change. If the “mental health” system ISN’T broken it should be by now.

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  14. A union for social workers won’t help prisoners of psychiatry. … Actually a union of social workers WILL help. Unions are about CLASS STRUGGLE the WORKING CLASS fighting against the FOR PROFIT MEDICAL SYSTEM , that it is FOR PROFIT is why there are PRISONERS!!!! Solidarity can and will be formed between the patients and the workers WHO ARE IN THE SAME CLASS AND HAVE A COMMON ENEMY, EACH OTHER’S STRUGGLE IS ONE AND THE SAME!!!! Together they fight and work towards a socialist medical system!

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