Discussion: Reflections from the clinical trenches

This paper involves a series of personal reflections on the deleterious impact of excessive bureaucracy and other institutional forces on the psychosocial treatment of the chronically mentally ill. The writer appeals to three groups of mental-health practitioners—behavior analysts, practicing clinicians, and academic clinicians—to promote cultural change by advocating a restructuring of large-scale bureaucracies with the concurrent establishment of multiple community-based associations.