The Therapy State: Why Pouring Billions Into NHS Mental Health Services Is Not Making Britain Well

More Money, More Services, More Misery

The statistics present a puzzle that nobody in the mental health establishment appears eager to solve. NHS England's Improving Access to Psychological Therapies programme — rebranded as NHS Talking Therapies in 2023 — has treated more than two million people annually in recent years, at a cost that has grown substantially over the past decade. The NHS Long Term Plan committed to expanding mental health spending by at least £2.3 billion per year by 2023-24, with a stated ambition to reach 380,000 additional people through community mental health services. Mental health has, by the standards of NHS funding debates, been something of a protected priority.

And yet. Rates of self-reported anxiety and depression have not fallen. Antidepressant prescriptions in England reached a record high in 2023, with NHS Business Services Authority data showing over 8.7 million people receiving at least one prescription — a figure that has roughly doubled over fifteen years. Waiting times for specialist mental health services remain long, with many patients waiting months for a first appointment. Young people, in particular, are reporting higher levels of psychological distress than any previous generation for whom comparable data exists. The suicide rate, which had declined gradually through the early 2000s, has not resumed that downward trend in any sustained way.

Spending more has not produced the outcomes the spending was supposed to produce. That is a fact, not a political argument, and it deserves to be taken seriously.

The IAPT Model and Its Limits

The dominant model of NHS psychological treatment in England is cognitive behavioural therapy delivered at scale, primarily through the Talking Therapies programme. CBT has a genuine evidence base for certain presentations — mild to moderate depression, specific anxiety disorders, panic — and the decision to expand access to it was not irrational. The programme has helped a meaningful number of people, and dismissing it entirely would be unfair.

But CBT delivered through a bureaucratic NHS pathway is not the same thing as CBT delivered by an experienced clinician in a therapeutic relationship. The programme's own data shows that roughly half of those who complete a course of treatment achieve what is classified as recovery — a figure the programme's advocates cite as evidence of success and its critics cite as evidence that half of all treated patients leave without meaningful improvement. The definition of 'recovery' used by the programme has itself been questioned by academics, who have noted that it is based on symptom score thresholds that do not necessarily correspond to functional wellbeing in daily life.

More fundamentally, the Talking Therapies model is designed to address the psychological expression of distress — the catastrophic thinking patterns, the avoidant behaviours, the cognitive distortions — without addressing the circumstances that generate that distress. A six-session course of CBT delivered via telephone or video call is not equipped to address loneliness, financial precarity, family breakdown, or the absence of community and purpose. It is designed to change the way a person thinks about their situation, not to change the situation itself.

What the Therapy State Cannot Fix

There is a growing body of social research — much of it inconvenient to the therapeutic establishment — that identifies the primary drivers of population-level mental distress as social and cultural rather than neurochemical or cognitive. Robert Putnam's work on social capital, Jonathan Haidt's research on adolescent wellbeing and smartphone use, and a range of British studies on the relationship between community cohesion and psychological health all point in the same direction: people who have strong social bonds, a sense of belonging, meaningful work, and a stable family environment are dramatically less likely to experience serious mental illness than those who lack these things.

These are not conditions that a therapy programme can supply. They are conditions that a functioning society — with intact families, rooted communities, meaningful institutions, and a shared sense of cultural purpose — tends to generate organically. The accelerating breakdown of those structures over the past three decades has not been addressed by any government mental health strategy, because doing so would require acknowledging that the progressive dismantling of traditional social institutions has had costs as well as benefits.

The smartphone and social media question is particularly pressing. Sir Andrew Whitty's review of health, published in 2024, acknowledged the relationship between excessive screen use and poor mental health outcomes in young people. Haidt's 'The Anxious Generation', published the same year, marshalled substantial evidence that the mass adoption of smartphones by adolescents from around 2012 onwards coincided precisely with the deterioration in youth mental health that has since become a public health crisis. The government's response has been cautious — a few words about age verification and screen time guidance — while the mental health budget has grown to treat the consequences of a problem that policy has done little to prevent.

The Political Economy of Therapeutic Expansion

It is worth asking why, despite the evidence of limited population-level impact, the mental health industry continues to expand. Part of the answer is genuine: some individuals are helped, and helping them is worthwhile. But part of the answer is structural. The NHS mental health sector — including charities, social enterprises, and private providers contracted by integrated care boards — has a strong institutional interest in the continuation and expansion of funding. The language of mental health has become so thoroughly embedded in public discourse that any politician who questions the value of therapeutic spending risks appearing callous.

There is also a subtler dynamic at work. Medicalising unhappiness is, in a certain sense, politically convenient. It locates the problem within the individual — their cognition, their neurochemistry, their coping strategies — rather than in the social and economic conditions that the political class has presided over. A government that has overseen the fragmentation of community life, the hollowing out of civic institutions, and the normalisation of family instability can fund a therapy programme and declare that it takes mental health seriously. It is cheaper, politically, than confronting the deeper questions.

None of this means that mental health services should be defunded or that people in crisis should be left without support. It means that a serious approach to national psychological wellbeing would look beyond the clinical and ask harder questions about the kind of society we are building — and whether the therapeutic state is a solution to that problem or, at some level, a symptom of it.

Britain does not need more talking therapies. It needs more reasons to be well.