Across the United States, debate is intensifying about overprescribing, medicalisation and the dominance of biomedical approaches within mental healthcare. Robert F. Kennedy Jr.’s recent comments about antidepressants and psychiatry have brought these issues back into the public spotlight, but concerns about over-medicalisation are not new. Service users, survivors, psychologists, social psychiatrists and critical mental health researchers have been raising similar concerns for decades. The question, however, is not simply whether psychiatry has become overly medicalised. The more difficult question is what genuine alternatives look like in practice.
England offers an interesting and somewhat contradictory example. For over twenty years, national clinical guidelines have recognised that people experiencing psychosis should have access to psychological therapies and wider psychosocial support—not simply medication alone. At the same time, however, access to the recommended psychological therapies remains highly uneven and many services continue to rely heavily on biomedical and risk-focused approaches.
This tension reveals something important: moving beyond over-medicalisation requires far more than changing rhetoric. It requires investment, workforce development, training, supervision, and a fundamental cultural shift in how we understand psychosis and recovery. For many people who experience psychosis, one of the hardest things is not simply the experience itself—it is trying to find help that feels validating, collaborative and genuinely useful.
For decades, many service users and survivors with psychosis have said the same thing: they want more than medication or symptom-focused treatment. They want to be listened to, they want help making sense of their experiences, they want help to deal with the impact of distressing voices, with paranoia and extreme mistrust and with the impact trauma has had on their lives… they want choice. And yet, despite this, access to psychological therapies for psychosis that can deliver this, remains surprisingly limited in England.
What makes this particularly frustrating is that the argument about whether therapy should be available has already been settled—at least officially. For over twenty years, the National Institute for Health and Care Excellence (NICE) in England has recommended that people experiencing psychosis should be offered psychological therapy. This is not fringe thinking, it is national guidance, and the evidence base behind this recommendation is becoming stronger, not weaker.
As the psychological mechanisms explaining the development of psychotic experiences become clearer, newer psychological approaches for psychosis that target these mechanisms—including therapies targeting distressing voices, paranoia and overwhelming threat states, insomnia and PTSD—are producing treatment outcomes that would be considered impressive in many areas of mental health care. At the same time, growing numbers of people with lived experience are challenging the old idea that psychosis is simply a lifelong brain disease requiring medication compliance above all else.
None of this means medication cannot help some people. For many people it absolutely does. But what service users and survivors have repeatedly argued for is choice—not replacement of one form of dogma with another. The problem is that, in practice, many people in England still cannot access the therapies that could potentially transform their lives and that national guidelines say should be available to them.
There are many reasons for this: mental health services are under enormous pressure and resources, including financial resources, are limited. Community teams are often overwhelmed by crisis management, staffing shortages, administrative demands and risk-focused cultures. Therapy can end up being treated as a luxury rather than a core intervention. There are also simply not enough trained therapists. In some services, only a tiny number of clinicians, if any, have specialist training in therapies for psychosis.
But workforce shortages are only part of the story, there are still cultural barriers within services. Some professionals continue to view psychosis primarily through a biomedical lens, where medication is seen as the “real” treatment and psychological approaches are viewed as secondary, unrealistic or even inappropriate. Many service users will recognise this immediately. They may have been told—directly or indirectly—that recovery is unlikely, that their experiences are symptoms to be managed rather than understood, or that psychological therapy would not help them because they are “too unwell.” Survivors have often been saying the opposite for years.
One of the most important changes in England over the last decade has been national policy for Early Intervention in Psychosis (EIP) services. In 2016, England introduced a national standard stating that everyone experiencing a first episode of psychosis should receive a NICE-recommended package of care within two weeks. Importantly, this package is not just medication; it includes access to CBT for psychosis, Family Interventions and wider psychosocial support. This may sound basic, but it represented a significant cultural shift. Psychological therapies were no longer being positioned as optional extras for a fortunate few—they became part of what the NHS formally recognised as appropriate care.
This matters because policy changes can slowly influence culture. Many younger clinicians entering psychosis services today are being trained within a more trauma-informed, psychologically minded and recovery-oriented framework than existed twenty years ago. There have also been wider attempts to improve access to therapy across community mental health services through new therapist training programmes, trauma-informed care initiatives and psychologically informed workforce development. But progress remains uneven. In some services in England, people can now access sophisticated evidence-based therapies for psychosis and in others, people may still struggle to access any psychological support. This means access to psychologically informed care can still depend heavily on where you live.
In many ways, England’s experience highlights both the strengths and weaknesses of current international attempts to move beyond purely biomedical models of care. Policy can change relatively quickly; culture, workforce capacity and access to meaningful alternatives often change much more slowly.
Perhaps the most important point is this: the debate is no longer about whether psychological therapies for psychosis can help. The bigger question is why systems still struggle to make them genuinely accessible. Too often, mental health systems still prioritise risk management, throughput and crisis containment over relationships, meaning and recovery. Yet what many people experiencing psychosis want is not especially radical. They want hope. They want to be understood rather than reduced to a diagnosis. They want genuine collaboration. They want support to rebuild lives that feel meaningful and safe.
Psychological therapies can provide this, and the evidence increasingly suggests they should be available. In the two decades since NICE guidance was published, England has undoubtedly made some progress, but there remains a profound gap between what is recommended on paper and what many people actually experience in reality. As international debate grows around overprescribing and medicalisation, England’s experience offers both hope and caution. It demonstrates that it is possible for national systems to formally recognise psychological and trauma-informed approaches to psychosis, but it also shows that meaningful change requires more than criticism of medication or psychiatry alone.
If psychological therapies are to become genuine alternatives rather than rhetorical aspirations, mental health systems must invest in the people, training, supervision and cultural change required to make them truly accessible, otherwise, calls to move beyond overmedicalisation risk becoming little more than another unmet promise to the people most affected and often harmed by the system itself.
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This post was originally published on Mad In America.