I’m not ill, I’m hurt

By Laura Batstra & Sami Timimi

More than 10 years ago, counselling psychologist Paul Moloney published his book The Therapy Industry: The Irresistible Rise of the Talking Cure, and Why It Doesn’t Work. “I’m not ill, I’m hurt”, words from Scottish mental health service user David Adam, is the title of chapter 5 about the hidden injuries of social inequality. In our article ‘Is more psychotherapy a dead horse?’, we argue for less investments in (research into) individual psychotherapy, and more focus on the social determinants of increasing mental suffering in our society.

More than 500 forms of psychotherapy have been documented, with new approaches emerging each year. Despite this proliferation, therapeutic outcomes have not improved commensurately. While since the 1980s, access to mental health treatment has expanded substantially, the prevalence of mental health conditions has increased rather than declined over the same period. This apparent contradiction has been described as the Treatment Prevalence Paradox (TPP): increased availability of treatment does not translate into a reduced population-level burden of mental disorders. If treatments were effective, one would expect a decline in the proportion of individuals meeting diagnostic criteria over time.

An umbrella review by Leichsenring et al. (2022), which included only high-quality meta-analyses in response to the substantial risk of bias identified in much of the existing meta-analytic literature, confirms that the effectiveness of individual therapy in alleviating psychological problems is limited, with estimated effect sizes not exceeding the small-to-moderate range (g ≈ 0.34 for psychotherapies and 0.36 for pharmacotherapies).

In a rigorous meta-analysis, Cuijpers et al. (2024) showed that the absolute benefits of psychotherapy are modest. On average, approximately five individuals need to receive psychotherapy for one additional favorable outcome compared with control conditions, although this number differs by disorder and type of control group. Importantly, adjustments for publication bias reduced effect estimates, suggesting higher numbers needed to treat in more conservative analyses. Overall, these findings indicate that the incremental benefit of psychotherapy over waiting lists or care as usual is limited.

Despite these modest effects, many researchers, treatment developers, and service providers continue to call for expanded access to psychotherapy and further investment in the development of new therapeutic models. Substantial resources are devoted to interventions targeting individuals, while powerful social determinants of mental ill health—such as poverty, inadequate housing, social injustice, discrimination, and social exclusion—remain largely unaddressed. How can this discrepancy be explained? At least three structural mechanisms—at the levels of public policy, economic organization, and scientific knowledge production—seem to play a role in sustaining an individual-centered treatment paradigm despite modest outcomes.

First, individual therapy allows society to look the other way and avoid taking responsibility for the consequences of structural inequities. By locating mental suffering primarily within the individual, it obscures the role of broader determinants such as poverty, marginalization, and discrimination. This individual framing aligns with policy environments in which social and economic reforms are politically costly. By emphasizing individual responsibility, it allows those in power to evade accountability for the social harms produced by inadequate and inequitable policies, shifting their consequences onto individuals and the mental healthcare system.

Second, the dominance of individual-level interventions is reinforced by their compatibility with established revenue models. Mental healthcare institutions, professional roles, and funding streams are largely built around the assumption that taking medication or talking to a stranger effectively reduces psychological distress. By contrast, there are few institutional incentives to invest in the diagnosis and remediation of harmful social contexts, and limited professional pathways devoted to contextual or structural interventions. As a result, resources continue to flow toward approaches that have limited impact at the population level.

Third, academic research practices and career incentives further entrench this focus. Comparative studies evaluating one psychotherapeutic of pharmacological intervention against another fit well within the randomized controlled trial (RCT) paradigm, which is widely regarded as the gold standard for evidence generation. In contrast, research aimed at diagnosing harmful contexts or evaluating context-level interventions does not easily conform to conventional RCT designs and is therefore less likely to receive competitive funding. Although qualitative approaches are well suited to examining broader theoretical frameworks and lived experiences, they remain comparatively underfunded. This structural underinvestment not only constrains knowledge production beyond the individual level but also indirectly perpetuates the marginalization of minority groups, who are frequently underrepresented in RCTs and underserved in mental healthcare systems.

The global mental health market size reached USD 460.6 Billion in 2025 and is expected to reach USD 581.2 Billion by 2034, exhibiting a growth rate of 2.62% during 2026-2034. If only a minority of treated persons meaningfully improve (and relapse rate is relatively high) and the development of more effective treatments has stagnated, many billions are wasted each year. Calling for more individual treatments is like riding a dead horse—that is, continuing to invest more time, effort, or resources into a relatively ineffective endeavour. Letting go of the horse (i.e., relinquishing the idea that individual therapy is the best solution to mental suffering) will be challenging due to the many financial and professional vested interests of stakeholders such as the therapy industry, academic researchers, and patient advocacy groups. However, less focus on individual therapy may make room for more primary prevention addressing the relatively neglected social determinants that are known to cause mental ill health.

Greater investment in promoting equality, social justice, inclusion, and improved living conditions may reduce the reliance on individual therapies. Evidence increasingly suggests that current mental health services are primarily mopping with the tap open. Accordingly, a shift is needed from the dominant focus on individual-level treatments toward addressing the structural and contextual factors that contribute to psychological distress. It is the

responsibility of policymakers and society at large to take coordinated action to create conditions that support mental well-being at a population level.

Laura Batstra is a Psychologist and Professor Medicalization of behavioural, educational and societal problems.

Sami Timimi is a Child and Adolescent Psychiatrist, Psychotherapist and Author.