House of cards

When leadership's the problem

Mental health services have spent years investing in leaders (myself included), leadership programmes, and transformation plans. In spite of this, services are still being found significantly wanting; commonly described as “broken”. But what if the problem is not a deficit of leadership at all, but the way leadership itself has come to be conceived; organising how change is imagined, pursued, and measured? Do we now need to consider the possibility that leadership has not simply failed reform, but in fact has become one of the ways reform is repeatedly deferred.

Early in my career, as I began to see how fundamentally flawed the conception, design, and delivery of mental health services could be, I assumed the explanation for this must lie with a set of people committed to keeping things as they were. I searched, but I could not find them. Again and again, I encountered thoughtful, decent, creative, compassionate people who were as frustrated by the system as I was.

So, who - or what - keeps a system going that is endlessly refreshed in intentions, language and policy, yet barely changes in substance?

What if leadership is merely a legitimating idea

As a former “leader” in the sector, perhaps this is time for some frank soul-searching. What if “leadership” in mental health - not the failure of leadership, not the wrong kind of leadership, but the concept itself - has become reduced to merely a legitimating idea. An idea that ensures genuine transformation is delayed, displaced, and made thinkable only in forms that the system can accommodate and absorb.

This is not a story about inadequate individuals. It is about a system trained to imagine change through leaders, programmes, and competencies rather than through relationships, working conditions, knowledge flows, and collective power. Leadership remains persuasive partly because it functions less as a testable explanation than as a portable language for narrating failure.

If leadership as sold to us were the answer, we would have stronger evidence of significantly substantive change by now.

Mental health services are not short of leadership roles, leadership frameworks, or leadership development. Nor are they short of strategies promising integration, prevention, early intervention, and person-centred / community-based care and support .Yet the pattern barely shifts: fragmented pathways, long waits, crisis-driven care, exhausted staff, and communities most affected by distress still poorly served.

The real question is not why mental health services need better leaders. It is why a leadership model that repeatedly fails to produce trust, continuity, and better care still retains such authority over how reform is imagined and “implemented”.

A Borrowed Category in a Caring System

Before asking what went wrong in mental health, it is worth refreshing ourselves about where leadership came from. It did not arise from the realities of care. It arrived as a borrowed category, carrying assumptions about hierarchy, control, direction, and legitimacy that were forged elsewhere and then installed as common sense. That language - vision, decisiveness, command - fits military, political, and corporate settings far more comfortably than mental health care.

Mental health work should depend on relationships, trust, uncertainty, and knowledge spread across clinicians, peer workers, families, communities, and people in distress themselves. “Leadership” could never a neutral import into that world.

It brought with it a familiar political grammar: change descends from above, direction is set at the top, and others are expected to align. In mental health, that grammar does not simply mis-describe good care. It reorganises attention away from the distributed judgement, local intelligence, and reciprocal trust on which good care depends.

Assumptions collide

In mental health services, these assumptions collide with the practical reality that care depends on shared judgement, reciprocal trust, contextual knowledge, and the ability to respond to what cannot be fully standardised in advance. The more tightly services are organised around hierarchy, “edicts from above” and top-down transformation, the more likely they are to suppress the very forms of intelligence they most need.

Vested interests

Leadership (arguably shaped by some vested interests) also became institutionally useful because it is endlessly renewable. When transformation fails, the answer is never that the model is wrong - only that leadership was insufficient. So new programmes, frameworks, and roles appear, while the harder work of redesigning care is deferred.

That is how a borrowed, command-oriented model became a professional virtue in a field that depends on collaboration, trust, and care. Its vagueness is not an accidental weakness. It is the condition of its institutional durability.

That self-protective vagueness matters because it enables a further drift away from the realities of care.

Over time, leadership in mental health became less a description of what helps services become more humane, relevant and effective and more an abstraction that could be attached to roles, programmes, strategies, and reform rhetoric, regardless of what actually changed for people using services.

How Leadership Drifted Away from Care

Over time, leadership in mental health drifted away from practice and toward abstraction. That made it less useful for improving care and more useful for organising status, training markets, and reform rhetoric.

The first shift was from “leading” to “leader”. Leading is visible in practice: redesigning services, improving access and choice, reducing coercion, changing routines with service users. Once the focus moves to the leader, attention shifts from what changed to who holds the role.
The second shift was from “leader” to “leadership”. Then the term could mean almost anything: authority, influence, innovation, authenticity, strategy, culture change. A concept that means everything is hard to disprove.

Concealing the real architecture of failure

That abstraction does more than blur meaning. It conceals the real architecture of failure. Service crises are recoded as leadership problems rather than the consequences of underinvestment, fragmentation, workforce depletion, punitive risk cultures, racism, or professional silos and self-interest in a status quo. The leadership frame turns both structural and moral breakdown into a problem of insufficient people and resourcing; (eg. “…we need a workforce development plan”).

How an industry attached itself to reform

By the time mental health services embraced transformation, a leadership industry was ready to attach itself to every reform effort. Its promise was simple: develop the right people and change will follow.

Transformative people do exist, but they are rarely produced by pipelines. They are often shaped by suffering, frustration, moral injury, community accountability, intellectual independence, or lived experience of systems that fail.

But the sector’s response was to standardise transformation into competencies, frameworks, and programmes. What scaled was mostly the image of transformation, not the conditions that make it real. “Transformation” and “change” came to be used interchangeably; they are of course quite distinct.

That is the contradiction at the heart of the sector’s reform language: institutions fund leadership development to improve themselves, while often neutralising the very people most capable of exposing their assumptions. Leadership proliferates; the underlying form of “treatment”, care and support remains recognisably intact.

When Leadership Becomes a Status Marker

Leadership then became less a practice and more a status marker. It attached itself to posts, programmes, and career pathways.

Now “leadership” usually means executives, senior clinicians, or designated transformation roles. But titles do not redesign care, build trust, or guarantee better judgement.

That narrows who gets seen. Peer workers / lived experience practitioners, family advocates, cultural advisers, frontline staff, and service users may be doing the most important system-shaping work, yet the leadership frame often renders them secondary or even invisible.

Once authority is confused with transformation, services begin mistaking motion at the top for change in care. Reorganisation, new titles, and strategic rhetoric can all look like progress (particularly when reported on) while leaving the lived experience of care and support almost untouched.

A Different Starting Point for Mental Health

If leadership is part of the problem, the answer cannot be yet another leadership model. The starting point has to shift from who leads to what forms of collective practice actually produce care, dignity, safety, continuity, and recovery.

The real test of change is straightforward: do people get help and support that they are seeking when they need it, face fewer gaps between services, experience less coercion, and encounter more trusted, humane care? This shift also makes room for coordination and advocacy: responsibility for fragile trust, vulnerable people, and those with the weakest institutional voice. It reveals a wider field of agency: the people who hold services together, repair trust after harm, notice where pathways break, and sustain continuity across handovers.

The peer worker rebuilding confidence

The peer worker rebuilding confidence, the administrator preventing someone being lost between appointments, the cultural leader restoring meaning, the clinician making space for uncertainty - these are system-shaping contributions. If leadership cannot see them, again that says more about the framework than the work.

Why the leadership industry fits so comfortably

The leadership industry fits mental health so well not because it solves deep problems, but because it translates them into manageable objects: national service frameworks, programmes, competencies, pathways, and visible activity.

But mental health transformation is local, it is relational, it is about connection and is context-bound. A model designed to be portable and teachable may travel well without helping services change.The capacities services most need - shared sense-making, humility, tolerance for uncertainty, power-sharing, and sustained attention to relationships - do not sit easily inside models built around visibility, decisiveness, professional distance and individual distinction.

That mismatch helps explain why so much leadership activity can coexist with so little change in lived care. The sector has invested in what is easier to organise and promote than the slower work of redesigning how people actually encounter help.

The thought mental health services need to entertain

Here is the thought mental health services most need to entertain: leadership, as currently structured and applied, is not just an individualised answer to a systemic problem. It is one of the concepts through which the system reproduces itself, displacing attention from the conditions that would have to change for care and support to become genuinely different.

Taking that seriously means starting not with who should lead, but with what conditions must change - and judging success by whether care and support becomes more humane, continuous, trusted, relevant and accessible.

And It also means asking whether the leadership industry has functioned less as a solution than as a sophisticated defence against deeper change. Until the sector can ask that honestly, it will keep mistaking movement among elites for change in the underlying logic of care. The point is not to search again for better leaders to rescue a failing design. It is to give up the absolute and total fiction that transformation can be delegated upward and delivered downward.

Mental health services will change only when they learn from the people and communities who endure their failures, trust the intelligence distributed throughout care, and remake the conditions in which help is sought, given, and sustained. Until then, leadership will remain less an engine of reform than an organising myth; a way of rendering failure intelligible without surrendering the institutional habits that reproduce it.

A most bizarre outcome where solutions are documented, well-known and hardly disputed, but their adoption and imple

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