Is Public Psychiatry Responding to the Mental Health Crisis or Just “Treating the Chart?”

“It seemed to me that all language is an excess of language”
—Samuel Beckett

As an urban community mental health therapist, part of my job is meeting with new intakes and completing their comprehensive assessment—their first step in getting connected to a primary therapist and psychiatrist, and a document they’ll need if they apply for any special programs. The role always gives me anxiety, because I never know what I’ll get—except, of course, paperwork. Recently, I had an intake come in with the records from all his previous psychiatry treatment—a thick stack, easily 300 pages. He seemed to think it would help him get cash assistance, but this was just a therapy intake. He was confused, not fully out of the psychotic episode that had landed him in the hospital weeks before.

His confusion was warranted. What sense did it make that he had been through hundreds of pages of notes worth of treatment (multiple other “comprehensive” assessments and progress notes written by assorted behavioral health staff, in addition to legal language justifying his involuntary admission, the use of neuroleptic medications, and the safety of his discharge to outpatient care) and yet was still essentially un-helped? After he left our hour-long meeting, I spent another hour writing, adding on to his stack of papers.

I couldn’t help but reflect that my interview with him could have been more helpful in at least one concrete sense—that I could have paid closer attention to the emotional dimension of his predicament—had I not had the completion of this unwieldy document in mind. This scenario in public psychiatry settings is, unfortunately, a familiar one.

The topic of mental health is on the public’s mind, whether it’s the popularizing of therapy speak, the increased attention paid to severe mental illness and homelessness, or pop psychology advice on TikTok. It is clear that the federal and state governments, while they have made efforts to address what has been called a crisis—the new 988 suicide hotline, for example—have put little more than a dent in the problem. Thomas Insel points to this issue in his book Healing: Our Path from Mental Illness to Mental Health, remarking that the problem with the mental health care system in the US is that there isn’t actually a system in the first place. It’s a piecemeal, parcelized collection of public institutions, non-profits, and private agencies, funded by an equally complicated system of public and private money managed by insurance companies.

This “system,” however, is an elaborate bureaucracy with voluminous policies, as well as reams of data, assessments, and progress notes on people using care. To look at the records it produces, you would believe the result was comprehensive, thorough treatment. (I calculated that, if my clinic printed its notes, they would equal to a half ton of paper in one year!). Yet it’s a “system” that leads to the all-too-common scenario of my intake patient and his records.

Admittedly, paperwork in bureaucratic settings is an easy target, but there is something disingenuous going on when there is such a gap between the amount of writing and bureaucratic labor and actual health outcomes. Public psychiatry’s documentation creates an elaborate fiction about what treatment addresses and looks like, a fiction that under scrutiny ends up exposing the system’s many flaws, contradictions, and inefficiencies. And though a fiction, it has a real impact, interfering with the actual work of treatment: clinicians and patients are implicated in it, embedded within its rigid terms, often so thoroughly that they cannot get beyond it.

As clinicians, the terms we are given to describe our work inevitably shape the work itself, even if we don’t agree with them, and the patient is even more powerless is this configuration. The language performs a simplification and literalization of treatment, and since public psychiatry only improves itself within it own terms, it cannot see beyond this serious limitation. I believe that there is a crisis going on in our culture that mental health care does end up addressing, but where treatment is effective, it is certainly not because of the quantity or quality of the records it produces. Indeed, these records and the bureaucracy they reflect are patronizing and absurd in the face of the magnitude of human suffering psychiatry faces.

Perhaps the most apparent issue with our documentation is the material cost: a lot of public psychiatry’s already-limited resources goes to its maintenance, from the labor cost of actually producing it, to having high-paid dedicated staff whose main function is assuring documentation “compliance,” to the hiring of expensive third-party “consultants” to further address things like demonstrating medical necessity for insurance companies, HIPAA regulations, or liability/risk assessment. Further, new therapists and clinicians have to be trained in how to document “correctly,” a burdensome take for administrators because few believe this will make any difference for the patients.

These issues emerge from the conflicting interests in public health and the resulting bureaucracy, but also from the peculiar status of the discipline of psychiatry itself: where physical medicine can be described unambiguously (at least, relatively), and we can be certain of a concrete reality to which the language refers (not to mention that a physical trace might be left on the patient), psychiatry deals with something inherently subjective. And yet it’s required to document itself as if it weren’t any different, and this language, as with all of health care, become the basis for billing, proving policy compliance, and legal protection. This is a big responsibility to put on the language—it must ignore any ambiguity inherent to the enterprise of psychiatry, while also respond to external and inflexible demands. Yet, when these terms enter the medical records, they take on the status of facts.  This creates a problem in terms of the writing: it hardly flows from the nature of what its described. On the one hand, it’s experienced as a time-consuming but superfluous nuisance to be rushed through that bears only a tenuous relationship to treatment; on the other hand, there are real consequences if it’s not done correctly.

The example of the intake I did with my confused patient is illustrative. Even without any added writing, the template and its drop-down menus add up to 5 pages. I was required to go over  with him everything from the expected psychiatric history, to social history, religious affiliation, leisure activities, the minutiae of the patient’s tobacco habits, and beyond. I was supposed to use the Columbia Suicide Severity Rating Scale, a 27-item questionnaire supposedly measuring the intensity of suicidality that, if done verbatim, reads more like something an interrogator would use to ascertain guilt than a questionnaire that is meant to be helpful.

All of this is potentially clinically relevant, but it was compressed into an hour-long session, and my patient was not psychologically organized enough to truly speak about most of these items. And where he was coherent, I still felt intrusive, given that I would not even necessarily be his therapist, and certain themes had the potential to re-traumatize him. I wrote up the document as best as I could, translating his rambling discourse into the kind of concrete information the form wants. There’s something uncomfortable about this operation, giving subjective information more appropriate for the medium of poetry the weight of “facts” in a permanent medical record. And as always, I felt the absurdity of how ineffective his treatment would most likely be in comparison to the treatment ideal implied by the exhaustiveness of my assessment.

And I also couldn’t help but conclude, as I regularly conclude when I meet intake patients, is that all that really counted was that I demonstrated adherence to policy. I am a writer: I could easily enough have written an account of my interview with the intake patient that would give an accurate impression of what he was like and what might be his problems, but this document would not likely comply with the regulations. Instead I wrote a document that was largely vacuous (and certainly rushed and sloppy), yet nonetheless one of the most important documents in his cumulative records, the birth certificate of sorts of his treatment. The best I could hope for was that, tucked away somewhere between all of my box-ticking and performative language, was a paragraph or two with some genuinely useful information for another clinician to read.

The culprits of the policies that result in such unwieldy documentation are a combination of regulatory agencies (state, federal), insurance companies and their demands for demonstrating medical necessity, and internal policies that defend against liability for poor outcomes. The whole intake form, for example, is essentially a rubber stamp.

As such, I’ve come to consider our documentation as little more than internal political legitimation rhetoric, essentially covering up for our system’s stark inadequacy while pleasing regulatory agencies, whose motives are political and financial. Publicly funded psychiatry, now more than ever, is going through a legitimation crisis. It knows it doesn’t have the means to address the problem of public mental health. For one, it’s not even clear that what it’s dealing with is always pure and simple “mental health”—it is more accurate to say it is dealing with a range of social ills (poverty, anomie, the pernicious effects of social media, political division…and so on) which often present as a psychiatric illness, but which are not reducible to this category.

Further, the state of psychiatric science simply has limitations; it has not found any “cures” for the most severe forms of mental illness (it is not even decided on what should count as a mental illness in the first place). What care really takes is a robust, comprehensive system of psychiatric treatment mixed with social programs and social assistance (the likes of which Insel notes exists in Portugal)—the sort of system which our care’s rhetoric seems to imply could or should exist, but which doesn’t. There are simply not enough resources for such a system nor a willingness to invest in it.

One of the areas I was required to assess with the same intake patient was his Social Determinants of Health. The presence of this screening in healthcare settings is relatively new, and an example of an initiative aimed at improving services. Indeed, it would seem to be a step forward that clinics would introduce this more holistic perspective on health, except that they aren’t doing anything differently other than adding to the sum total of paperwork and bureaucracy—another box to tick, one more thing for auditors to verify. We can’t actually address the social determinants of health any more than we already do. And in the case of my patient, it was simply redundant—I hardly needed an intrusive, 40-plus item inventory to know that social issues were part of his “presenting problems.” This tendency to “screen” for different conditions and problems is endemic to all of healthcare, and incredibly wrong-headed, given that adding more assessment to treatment without adding more time and resources is not going to change outcomes and arguably might make things worse, given that providers are less able to focus on what they can do within their limitations.

What makes the inclusion of this kind of assessment all the more patronizing to all involved is that it is at odds with other policy currents. It acknowledges, rightly, that health problems are related to, or even in some sense are, social problems; however, there is equal pressure from the insurance companies to demonstrate the objective “medical” nature of psychiatric issues, as if they were no different than a knee injury or a bacterial infection.  Our system’s risk management policies and overall strategy of defensive documentation is another counter-current: we document that our efforts at care (or lack of) can’t be blamed for failures. Put in other terms: our documentation is near-utopian in its scope and what it thinks treatment could address; but at the same time, it has an artificially narrow medical perspective; and finally, it rigorously, with airtight legal jargon and defensive language, obviates any responsibility for its all-too-common and frankly inevitable failures.

All of this documentation adds up to a significant psychological toll on the writer—how could it not? We are pulled in different, opposing directions, and rather than become therapists, we’ve become propaganda producers, painting a picture of our work that is supposed to legitimize it, but somehow collapses in on itself in its contradictions, and certainly does not capture what it’s like to do therapy.  We’ve done nothing more than produce flat, perfunctory, meaningless language—small black shapes on a screen taking up space that are still the only acceptable basis for demonstrating that we did our job. It’s no wonder community mental health therapists often quit and move to private practice, where they can choose not to accept insurance and document their work in the way they choose.

At times when I write my notes, I start to wonder if me, my actions and my patients have any meaningful existence at all other than in the documentation language. From an institutional-regulatory perspective all that counts, anyway, is that the correct words are there to demonstrate policy adherence; what they mean or refer to is unimportant. Sometimes the distance between the language and its supposed referent is so great that it’s as if the documentation is hermetically sealed off from any reality at all, and it’s tempting to consider that we would be better off if there were no patients in the first place. Certainly, it would free us up to do a better job with our documentation.

Take for example my intake patient from above. We did have one psychotherapy session a month later, when he was added to my caseload. In the intervening weeks he had stopped taking medication. He no longer believed he had a mental health issue or diagnosis or even cared about getting benefits. Rather he wanted to talk about a scheme against him involving implants in his brain, espionage, and attempts at mind control. Per health insurance policy I’d already written a treatment plan on him, despite only having met him once, a month ago. It was required to have “measurable” objectives (e.g. “patient will sleep at least six hours a night”) tied to his diagnosis, and also per policy the patient had to agree to it. I didn’t share my plan with him; nothing could be more absurd given that he didn’t see his problems as being psychiatric or even that what we were doing was therapy—he just wanted to talk to someone. That’s what we did. I let him tell the story of what was happening. It can actually be quite fascinating to speak with someone in the throes of psychosis—in the alleged madness, there are often glimmers of enlightenment. But this is crudely attenuated by time constraints and the fore-knowledge of the note that will be written.

In this case I wrote an account of the session that made it sound like I performed a procedure on him, offering things like “cognitive restructuring” or “reality testing” and somehow demonstrating medical necessity but without invoking the idea of psychiatric illness, given that that this would be patronizing to the patient, and he would have access to the note. I also had to document that he agreed to his treatment plan, and that he posed no danger to self or others. In effect, very little of what I wrote bore any meaningful relationship to what took place between us, and the specter of an imaginary auditor, threatening to deny payment or, worse, hold me liable for the patient’s misfortune, hung over me.

After this session—sensing I wasn’t going to helpful, I can only assume—my patient didn’t attend his next appointments with me or his psychiatrist. However, because he had been deemed “high risk” due to his previous psychotic behavior, I had to call him multiple times, his family members, and even a Mobile Crisis team that tried unsuccessfully to visit him. At some point he was hospitalized again in another facility and, determining that because of a previously undisclosed drug problem we could not treat him after discharge, I had to carefully document this reasoning and my conversations with his inpatient psychiatrist and social worker (throughout this time, I had no actual contact with the patient). I thus added another few pages to his chart. It was as if I was writing about a fictitious character, whose actual existence was unimportant compared to my linguistic presentation of him, a presentation which had to carefully show how good a job I was doing while also scrupulously protecting myself and my institution against any liability—as if somehow, from the confines of my office, I had some power over this patient’s life, if only he would just comply—and because he just wouldn’t comply, there was no one to blame for his misfortune other than himself.

This state of affairs is what is meant by the cynical expression “treating the chart.” It’s a common expression that has deep implications: we don’t do real work, we perform a linguistic representation of work.

Naturally none of this is good for treatment. Aside from the material cost of the writing, there’s the psychological risk that we begin to internalize the documentation: there’s no longer a separation from the real business of treating patients and the essentially false way have to document it. Patients become bureaucratic subjects, their status as real people diminishes, and since they inevitably fail as bureaucratic subjects, we feel that we’ve failed too, our efforts are futile. Why can’t they just be helped the way our charts and rules and regulations suggest they’re supposed to be?

This not to say that people aren’t helped in public settings and that I and my hard-working colleagues (including the administration’s whose unfortunate burden it is to enforce bureaucracy) are not doing meaningful work. But this work more than likely has little representation in in the record. For example, I once helped organize a picnic for a group of patients with severe mental illness, and this was one of the more meaningful things I’ve done in my career. Yet it was written up as a “health education” event about hand-washing to prevent the spread of covid-19. Likewise, the documentation of the subtleties of building trusting, understanding relationships with therapy patients is essentially irrelevant to questions of “medical necessity” and “measurable progress” in treatment. Often, it is as if we help patients in spite of what the rhetoric says we’re supposed to be doing.

It is, of course, not surprising that a big, underfunded bureaucratic system such as the one that regulates public mental health treatment would be ineffective. That flows from the condition of late-stage capitalism. But what I am getting at here is something more than just pointing out the policies’ many problems and contradictions. Specifically with psychiatry, there is something inherently problematic about using language as the basis for regulation and administration, because something that is tenuous and ambiguous has to behave as if it’s concrete. On the most basic level, I do not want how I describe my work as a therapist to be held to this standard. And how is my language or a clinic’s language in its charts reliable as a source on which to evaluate the quality of its services? The only way that our notes could truly be used as a way to evaluate our work would be if there were few constraints on how and what we write: then, though it would be highly subjective, our choices as writers might reveal something about the treatment.

Similarly, there is no way that from the documentation we can assess whether new polices are helpful. In fact, it seems that there is a perverse logic in which, from a regulatory standpoint, policies that are documented are good because they have been documented, and they are documented because they must be good. It’s a closed system, beside which you have a different reality taking place between clinicians and patients, patients who have no true voice, and whose deviance from the treatment fiction described in the documentation is, with more of the same rhetoric, explained away.

To address this unwieldy problem of documentation in public psychiatry would take a willingness to bar interference from outside pressures—namely, insurance companies and economic/business interest—from shaping policy and enforcing regulations. Simply put, notes should be written with the sole aim of clinical utility in mind, and perhaps they should not even be made available to any other party other than healthcare providers. Policy makers need to devise ways to assess quality of care and outcomes that actually consider the experiences of clinicians and their patients and patients’ families, and not just audits. Policies and initiatives need to be commensurate with the real capacities of institutions, otherwise they are little more than empty rhetoric that is nonetheless labor-intensive to maintain and ultimately detracts from what can be done.

I don’t believe our system in its current state is in any way meaningfully responding to the surge in need for more mental health care. The simple fact that insurance reimbursements for behavioral health are stagnant is proof enough that the new initiatives side-step a fundamental problem, that the system is underfunded and neglected. I do believe we are able to help people, in spite of all our flaws—but I doubt that anyone who has had a positive experience with community mental health care will get much of a clue as to why they were helped by looking at the massive digital paper trail their treatment created. And for anyone who has been helped, there are just as many like my intake patient, who could rightly say all he got out of treatment was 300 pages of nonsense.