You’re describing a system that is structurally indifferent to the very people it claims to serve. The “lack of help” is not an accidental gap; it is a predictable output of how the apparatus is financed, measured, and ideologically framed. Below are six points that keep the discussion concrete and avoid the usual survivorship-bias deflections (“look at these inspiring recoveries!”).

1. Gate-keeping by performative wellness
   When clinicians ask “What do you want?” they often translate the answer into the language of SMART goals, engagement metrics, and discharge timelines. If the patient cannot articulate wants in those terms, the file is stamped “unmotivated.” This is not a clinical judgment; it is a bureaucratic risk-management device that protects budgets and reputations.
2. The 10-year gap is not a delay; it is a sieve
   WHO and NIMH numbers converge:
   • 100 symptomatic → 33 ever recognized → 20 ever reach specialty care → 6 ever receive minimally adequate treatment → 1–2 ever receive optimal treatment.
   Each narrowing step is a policy choice: no routine screening in primary care, prior-authorization walls, out-of-network carve-outs, etc. Calling it “delay” hides the fact that most people are actively screened out.
3. Undiagnosis as cost-containment
   In the U.S. the simplest way to keep Medicaid and commercial behavioral-health spending flat is to not identify the need. ICD-10 codes are attached only when there is a billable service. No service, no code, no epidemic—on paper.
4. Neoliberal recovery scripts and disciplinary loops
   • Funding flows through “outcome-based” contracts. Clinicians must show movement on PHQ-9 or GAF scores in 6–12 weeks.
   • Patients who cannot demonstrate rapid improvement threaten the provider’s KPIs. The rational response is to triage them out.
   • The survivor stories paraded by state agencies and nonprofits are therefore not cherry-picked for hope; they are cherry-picked to prove that the funding model “works.”
5. The non-compliant label as structural violence
   Resistance is coded as individual pathology rather than rational reaction to unhelpful or harmful care. Once “non-compliant” is in the chart, future clinicians pre-emptively withhold higher-touch services (e.g., ACT teams, long-term therapy). The label becomes a self-fulfilling prophecy.
6. Concrete escape routes (none easy, none individual)
   • Universal, opt-out screening.
   • Abolish prior authorization for first-line psychiatric meds and therapy sessions 1–12.
   • Tie provider payment to population-level symptom reduction, not per-client discharge speed.
   • Create statutory rights to second opinions and external appeals funded by the payer, not the patient.
   • Fund peer-run respites that do not require goal-setting as admission criteria.

Joe Perkins is not describing a personal failure of will; he is pointing to a system whose incentives make sustained, dignified help the exception rather than the rule. Any response that pivots to “but some people do recover” is simply another way of protecting those incentives.

To challenge the neoliberal framework in mental-health services we have to move on three fronts at once: (1) dismantle the ideological pillars that individualise distress, (2) restructure funding and governance so that care is a social right, not a commodity, and (3) rebuild collective, community-controlled alternatives from the ground up.

1. Unmask and contest the ideology
   • Refuse to translate suffering into “lack of self-management.” Use structural-competency training to make clinicians and students name poverty, racism, housing precarity and labour exploitation as primary risk factors .
   • Replace recovery metrics centred on employment or symptom scores with measures of social connection, housing security and democratic participation .
   • In therapy rooms, adopt models such as Contextual Therapy that explicitly challenge internalised neoliberal values (competitive individualism, self-blame) and foreground relational ethics .
2. Change the money and the rules
   • Campaign for universal, publicly financed mental-health care that removes fee barriers and prior-authorisation hurdles; the US healthcare industry’s $567 million annual lobbying budget shows why single-payer legislation is necessary .
   • Tie provider payments to population mental-health outcomes, not per-client discharge speed, to end the perverse incentive to triage “difficult” cases .
   • Repeal welfare policies that force clinicians to medicalise poverty (e.g., SSI requiring a psychiatric label for income support) and replace them with unconditional income guarantees .
3. Build counter-institutions from below
   • Resurrect and update the 1960s–70s social-psychiatry movement: publicly funded community mental-health centres controlled by local boards that include service users, neighbours and front-line workers .
   • Support service-user / worker alliances that occupy or co-opt threatened clinics, turning them into hubs for housing, legal aid and peer-run respites .
   • Scale low-cost, evidence-based community interventions such as Brazil’s Integrative Community Therapy (ICT) that strengthen social bonds instead of medicating alienation .
4. Professional and civic action
   • Use professional associations to testify for higher minimum wages, rent control, anti-eviction statutes and limits on corporate lobbying .
   • Create “structural formulation” templates in electronic health records that require clinicians to document social determinants and flag policy-level interventions as part of the treatment plan .
   • Adopt “de-implementation” campaigns that retire programmes (e.g., purely CBT-based resilience courses in schools) which responsibilise individuals while ignoring structural harms .

Neoliberalism survives by making collective solutions appear impossible. The evidence is clear: when market logic is removed—via universal systems, de-commodified housing, or community-run centres—mental distress falls . Our task is to normalise these alternatives until they are no longer seen as utopian, but as the baseline for any humane society.

LLM