People with major mental distress often suffer multiple personal, social and economic losses. Our personal loss of power and self-esteem does not so much derive from the condition itself, but the attitudes we and others have towards it. We may feel shame. Those around us may feel pity and fear. Our paid helpers often reinforce these responses by pathologising our experience. Once our personal losses have taken hold, a cascade of social and economic losses tends to follow, such as isolation, under-education, unemployment, homelessness and poverty.

If the people who ran the mental health system honestly asked themselves, what single intervention would help the most people regain these losses, they wouldn’t have much trouble coming up with the answer. It’s work. Work reduces poverty, increases social contact, improves mental and physical health and increases social status. No other single intervention has so many benefits. Psychiatric drugs alone could never produce these benefits, and they have more dangerous side effects. Nor does a single minded focus on housing produce so many benefits; I’ve seen too many lonely people sitting in good houses leading diminished lives. If I had to put the majority of mental health dollars into one basket, I’d choose services to support people to succeed in education and employment.  I’m also mindful that supported employment services have an evidence base that would make most drug companies drool with envy.

Ask most people with ongoing major mental distress and they will tell you that medical interventions only fix a part of their problems if they’re lucky, and make them worse if they’re not lucky. The big problems they face are personal, social and economic. But if you look at where most of the funding for services for them goes in every country, you will find it pouring into clinical services, such as hospitals and community mental health centres where crisis responses and biological treatments dominate. 

Everyone who uses mental health services can reliably access psychiatric drugs, often with dubious benefits, and sometimes when they don’t even want them. But only a tiny percentage can access supported employment services. This is despite the undoubted benefits of work, despite the fact that over 90% of people who use services want to work, and despite a scandalous unemployment rate of 70% to 90%.

Allow me to suggest that the system is crazier than those of us it so often fails to serve.