Current services for those with mental disorders show two trends. Psychiatric services are becoming concentrated on the care of those with “severe mental illness,” largely (but unjustifiably) synonymous with chronic psychosis. The retreat of psychiatry from the care of those with non-psychotic mental disorders has helped the growth of counselling services for these patients. However, there is no evidence that non-directive counselling is effective for such disorders, in contrast to the evidence for the effectiveness of other treatments that are usually delivered by psychologists or community psychiatric nurses. By retreating from the concerns of general practice and general medicine, psychiatry is returning to the days of alienism: in Victorian terms, the care of “the mad.” Possible consequences include increasing expectations of psychiatric services that cannot be met, a loss of skills within psychiatry, and increased demoralisation in the mental health services.

According to recent media stories, British psychiatrists are becoming concerned that scarce resources are being diverted away from the care of seriously mentally ill patients and instead are being given to unnecessary and inappropriate services such as counselling. One headline caught the flavour of the debate—“Worried well force aside the mentally ill.”1 Advocates of counselling respond to such charges with vigour, pointing to the popularity of counselling and claiming that such services can prevent mental disorder and reduce the use of other hard pressed services.

At issue is a fundamental question about mental health services. How can we balance the competing, and often contradictory, requirements of need, demand, and effectiveness? Who really is in need? Who best is able to meet that need? Should patients always get what they want anyway?

These issues have been brought to attention by two changes. The first is the rise in the availability of couns-elling services; the second is the shift of …