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Postpartum depression can affect anyone, and it often sneaks in quietly, like a shadow in the corners of a new mother’s life. It presents significant challenges for around 1 in 7 new mothers, affecting their emotional well-being and overall quality of life and that of the newborn.

Many – if not most – women experience the “baby blues,” or generalized feelings of sadness, worry, unhappiness and exhaustion, in the initial days after giving birth. In most cases, these mood changes are resolved in the first two weeks after having a baby. In contrast, the symptoms of postpartum depression endure for more extended periods, sometimes lingering for up to three years.

The symptoms can also start during pregnancy. Research shows that more than half of women who experience depression symptoms during pregnancy will develop postpartum depression too.

A much more rare and severe psychiatric disorder following delivery is called postpartum psychosis. Its onset is rapid and severe, with hallucinations, delusions and emotional distress, along with bizarre and sometimes dangerous behaviors. About 1 or 2 in 1,000 women experience postpartum psychosis after giving birth.

We are a clinical nurse specialist and a licensed mental health counselor, and together we have over 45 years of experience as educators and clinicians.

With proper awareness, education and intervention, perinatal mood disorders are nearly 100% treatable. We want women to realize that they are not alone, they are not to blame, and with help they can be well again.

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Crying, sadness and lack of bonding

Following pregnancy, many women experience normal changes that can mimic symptoms of depression, such as sadness, worry and exhaustion. The transition to motherhood, particularly with a new baby in the home, can be overwhelming. However, it’s essential to distinguish between these common adjustments and more concerning signs of depression.

If you or someone you know finds themselves experiencing any of the following symptoms persistently for over two weeks after giving birth, it’s crucial they reach out to their doctor, nurse or midwife. Here are some of the most-reported symptoms of postpartum depression:

• Lack of bonding and feeling disconnected from the baby or experiencing a lack of interest in them.
• Restlessness or moodiness and feeling unusually agitated or irritable.
• Persistent feelings of sadness, hopelessness or being overwhelmed.
• Experiencing physical symptoms such as persistent headaches, other body aches and pains or digestive issues that don’t resolve.
• A profound lack of energy or motivation, making daily tasks feel daunting.
• Significant changes in appetite and either eating too little or too much.
• Disturbed sleep patterns, such as sleeping too much or too little, even when given the opportunity to rest.
• Difficulty concentrating or making decisions, or experiencing memory problems.
• Overwhelming feelings of guilt, worthlessness or inadequacy as a mother.
• A notable decline in interest or pleasure in activities previously enjoyed.
• Isolating from friends and family, avoiding social interactions.
• Thoughts of harming the baby or themselves. These should be taken extremely seriously and warrant immediate attention.

Some risk factors associated with higher likelihood of postpartum depression include life stress, depression history, maternal anxiety, lack of social support, infrequent exercise, unintended pregnancy and intimate partner violence.

https://www.youtube.com/embed/VkpM1WtKW_c?wmode=transparent&start=0Knowing the warning signs of postpartum depression could prevent a tragedy.

Real-life examples

People dealing with depression not only have to manage their symptoms but may also face the stigma and discrimination that these conditions often bring. There is an expectation that new parents will be happy after delivery. Sadness, stigma, shame or guilt greatly affects a person’s willingness to seek help. Studies show that many people opt not to seek treatment to avoid being perceived as unfit parents by health care providers or family.

As a nurse and a mom who has experienced postpartum depression, I (Nicole Lynch) frequently share my story with others. Years ago, another mom shared with me how helpful it was to hear that she wasn’t alone. Knowing that other women – dedicated parents who love their children – can feel this way and that things can get better gave her hope.

Throughout my career, I (Shannon Pickett) have worked with several mothers and prospective parents who have struggled with postpartum depression. For instance, I worked with one woman for several years about her anxiety and her struggle to conceive. After years of trying, she finally became pregnant. Both she and her husband were overjoyed and could not wait to become parents.

The pregnancy went smoothly and there were no complications. She had never shown any signs of depression previously, but once the baby was born, that changed. My client had trouble bonding with the baby and did not want to hold or console her new son when he needed soothing.

Her husband would often step in to comfort the infant and would ask my client, “What is wrong with you?” It caused frustration within their marriage because the father felt as though he was doing the caregiving alone and that my client was withdrawn. She had planned to take a break from therapy for a bit after the baby was born, but her husband encouraged her to reach out to schedule an appointment.

I could tell right away that she was struggling with postpartum depression. She barely smiled, had difficulty engaging in and concentrating on our conversation and cried throughout most of the session.

We talked a lot about the guilt she felt over not wanting to be around her son or hold him, even though she had fought for so long to become a mother. After receiving a proper diagnosis and starting an antidepressant medication, my client was able to recover and bond with her son. The medication did take a few weeks to get into her system, so the results were not instant. Maintaining her sessions and using her support system were important for her recovery as well.

Heightened risk

While postpartum depression can affect anyone regardless of their socioeconomic status or their background, some women affected by social inequalities have increased risk of many common postpartum mental disorders and their adverse consequences.

One study found that new mothers with low incomes, those who had not earned a college degree, were unmarried or were unemployed were 11 times more likely than women with no risk factors to have clinically elevated depression scores three months after having a baby.

Inadequate support

The Centers for Disease Control and Prevention estimates that about 20% of pregnant women were not asked about depression during a prenatal visit, and more than half of women with postpartum depression remain untreated for their symptoms.

What’s worse, there is a lack of access to mental health services for women after delivery. Many promising treatments are underexplored, especially in scientific studies. While more people are talking about postpartum depression, there is still stigma around seeking help.

https://www.youtube.com/embed/9085YWhyUTU?wmode=transparent&start=0A new oral medication may begin to relieve postpartum depression within three days.

A new medication offers hope

It’s vital to remember that postpartum depression is a treatable condition. Seeking help from health care professionals is a courageous and necessary step.

In August 2023, the Food and Drug Administration approved the first oral medication, Zurzuvae, specifically intended to treat severe depression after childbirth. It holds promise for addressing the complex array of symptoms associated with postpartum depression and offers newfound hope for affected mothers and their families.

If you are experiencing symptoms of postpartum depression, consider finding a therapist in your community for either telehealth or in-person sessions.

There are also postpartum support groups that meet in person and online.

Supportive therapies, including counseling, medication and lifestyle adjustments, can significantly alleviate symptoms and improve overall well-being. Early intervention is key to a faster and more complete recovery, ensuring that mothers can enjoy the precious moments with their baby and find fulfillment in motherhood.

By Peg O Connor

We tend to shrink ourselves and our world when we lack self-respect.

ey points

• Active in our addictions, we shrink ourselves so that we and our use may go unnoticed.
• We may believe that we do not deserve to take up space in the world, which is a deficit of self-respect.
• Self-respect is an achievement of moral development that depends on love, care, and support.
• Addictions can cause us to lose self-respect. Does a deficit of self-respect contribute to addiction?

Active in our addictions, our worlds often shrink. We prune people from our lives who question our use. We remove ourselves from events and activities that once brought us joy. We become less willing to do or try new things. Where before possibilities had seemed like opportunities, now they just feel daunting and even threatening.

We make ourselves smaller. We start to take up less space in our own lives. As someone once said, I felt like a mouse running around the trim board of my own life. Our making ourselves smaller goes hand in hand with our social and physical worlds contracting; they aid and abet each other.

Why do we skitter around the margins of our own lives?

Some of us want to go unnoticed. We may tell ourselves, better to stay off the radar screen than have people judging us. We may take our not being noticed as evidence that we aren’t doing so badly.

If people do notice us and our use, we may automatically assume that they are judging us in the same harsh ways that we judge ourselves. Of course, there are plenty of instances when this is true. We cannot even imagine that they are standing by us and offering their support because, well, we don’t deserve it.

Others of us believe that we do not deserve to take up space in anyone’s life, including our own. This is especially true for people who lack self-respect.

Self-respect

Self-respect is an achievement within moral development; it is a lived conviction that a person has intrinsic worth and dignity. It is a basic sense that “I matter.” Self-respect is created against a background of care, love, and security. A person develops self-respect through having the opportunities to engage with others. Self-respect is not innate.

A person with self-respect understands that she deserves to be treated respectfully by others because she has the same moral worth as everyone else. She also understands that she needs to treat herself in ways that recognize and preserve her dignity and autonomy.

Self-respect is what enables a person to judge that she is measuring up not just to others but to her own standards. When a person with self-respect recognizes that she is not meeting her own measure, she may change her actions so that she preserves her self-respect.

Self-respect and addiction

Self-respect is easily lost in addiction. There are many cases where a person has had self-respect but has lost it, often through their own actions. Someone who has had a good, meaningful, and happy life may lose respect for himself when he develops an addiction later in life and begins to act in ways that are out of character.

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We may start trading away our values and commitments. We may do things that cut against our grain. Instead of seeing ourselves as having dignity and worth, we come to see ourselves as insignificant and worthless. We start to treat ourselves this way.

The more we feel worthless, the more we contract into ourselves. In the worst throes of addiction, the world is reduced to us and our substances and behaviors. Our minds and the entire world may seem like a hellscape.

Some people have only ever had a very small degree of self-respect because they never had the opportunity to develop the skills and arts that underpin self-respect. Where love, care, and security are missing, it becomes far more difficult for a child to develop the arts and skills that are necessary to create, reinforce, and cherish self-respect.

Children who have been traumatized may have had many of the opportunities necessary to develop self-respect foreclosed. A child who has never been treated with love and respect or treated in ways that twine abuse with love will not have the opportunities to learn how to create, act on, and protect their self-respect. They have not been treated respectfully by others, so it is challenging to learn how to treat themselves and have a clear sense of what they rightly deserve.

Traumatized children, and later adolescents and adults, are more likely to develop an addiction than children who have not been traumatized.

While a loss of self-respect is a consequence of addiction, I believe a lack of self-respect is also a driving force of addiction. People who have experienced childhood trauma and haven’t been able to practice self-respect have already known a world of pain, insecurity, and uncertainty. They may already have a sense of just how unfair the world is along with a fatalism about their place in it. They understand what it is like to have few good opportunities available to them. They see others around them suffering and can’t even imagine their lives going differently.

When a person believes she has no value and that people like her deserve no better, the allure of addictive substances and behaviors may seem great. She may know that her world is full of pain and suffering; shrinking that world and finding some relief from the suffering makes sense.

Those addictive substances and behaviors can also ignite a sense of being alive, having fun, and making connections to others, all of which childhood trauma hinders. The addictive substances and behaviors most often bring us something we want or need in the beginning. Their bill comes due at some point, putting whatever shards of self-respect a person has at risk.

In recovery, we begin to gain or regain self-respect, which is crucial to flourishing.

A lot can happen before you ever say a word in therapy. You may open a search tab, compare a few profiles, close the tab, and tell yourself you will try again later. If you are wondering how to start therapy online, the goal is not to make a perfect decision on the first try. It is to take one informed, manageable step toward support that feels right for you.

Online therapy can make care more available when commuting, schedules, mobility, cost, or privacy concerns have made traditional appointments difficult. It can also feel unfamiliar at first. Knowing what to look for can help you move from “maybe someday” to a first appointment with more clarity.

Start With What You Want Help With

You do not need a diagnosis or a polished explanation to begin therapy. “I have been anxious lately,” “my relationship feels strained,” or “I cannot get out of this rut” is enough to start. A therapist can help you put language to what is happening and identify practical goals together.

Still, taking a few minutes to reflect can make matching easier. Consider whether you are looking for support with anxiety, depression, grief, trauma, stress, family conflict, life transitions, identity concerns, or another challenge. Think about what you hope will feel different in a few months. You may want better coping skills, a place to process difficult experiences, stronger boundaries, or simply the chance to be heard without judgment.

Your preferences matter, too. Some people feel more comfortable with a therapist who shares part of their background or identity. Others want someone with experience in a specific concern, such as postpartum mental health, substance use, LGBTQ+ affirming care, or couples counseling. There is no wrong preference. Naming what matters to you helps narrow the search.

How to Start Therapy Online: Check Credentials and Fit

A warm profile is a good start, but qualifications should come first. Look for a licensed mental health professional who is authorized to provide therapy in the state where you are physically located during sessions. Depending on their training and state, this may include a licensed professional counselor, clinical social worker, marriage and family therapist, psychologist, or psychiatrist.

Credentials alone do not guarantee a personal connection, but they help establish that a provider has completed required education, supervised experience, and licensing standards. A trustworthy matching platform should vet providers and clearly present their qualifications, specialties, availability, and approach to care.

Then consider fit. Therapy is personal, and it is reasonable to want a clinician whose communication style works for you. Some therapists are more structured and skill-focused. Others are more reflective and exploratory. Many blend approaches based on a client’s needs. If you are unsure what you prefer, that is okay. You can ask a prospective therapist how they typically work with people who are facing concerns similar to yours.

A short consultation can be useful when it is available. You might ask whether they are accepting new clients, what a typical session looks like, how they approach your main concern, and what they expect from clients between sessions. You are not interviewing them to find a flawless answer. You are listening for whether you feel respected, understood, and comfortable asking questions.

Understand Cost Before You Book

Cost is often one of the biggest barriers to care, so it deserves a direct conversation. Ask about the session fee, whether the provider accepts your insurance, what your copay may be, and whether they offer a sliding scale based on income. Some therapists have reduced-fee openings, while others can provide documentation you may submit to an out-of-network insurance plan for possible reimbursement.

Online therapy is not automatically less expensive than in-person therapy. The price depends on the clinician’s credentials, location, specialization, insurance participation, and session length. But virtual care can reduce indirect costs, such as travel, parking, childcare, or time away from work.

Be cautious about choosing based on price alone. Affordable care needs to be sustainable, but the lowest fee is not always the best value if the therapist’s expertise or availability does not meet your needs. A good match balances clinical fit, access, and a cost you can realistically maintain.

TheraConnect helps clients begin this process at no cost by connecting them with vetted providers based on their needs, preferences, and budget. You can get started by sharing what kind of support you are seeking and reviewing matches that fit your situation.

Set Up a Private, Realistic Space

You do not need a picture-perfect home office for online therapy. You do need a place where you can speak as freely as possible and hear your therapist clearly. A bedroom, parked car, private office, or quiet outdoor space may work depending on your circumstances. Headphones can add privacy if other people are nearby.

Before your first session, test your internet connection, camera, microphone, and device battery. Keep a charger nearby. If video does not feel accessible because of bandwidth, disability, or personal comfort, ask whether phone sessions are an option. The best format is the one that allows you to participate consistently and safely.

It also helps to make a plan for interruptions. If you live with family or roommates, you might let them know you need uninterrupted time without explaining why. If privacy is limited, tell your therapist. They may be able to adjust pacing, discuss practical options, or help you create a plan that protects your confidentiality.

Know What to Expect in the First Session

The first session is usually an intake. Your therapist may ask about your current concerns, history, relationships, work or school, physical health, past therapy experiences, and what you hope to gain. They should also explain privacy, payment, cancellation policies, and the limits of confidentiality.

You are allowed to ask questions at any point. If a question feels too personal too soon, you can say that you are not ready to discuss it in detail. Therapy involves honesty, but trust is built over time. You do not have to tell your whole life story in one hour.

You may leave the first appointment feeling relieved, tired, emotional, hopeful, or uncertain. All of those reactions can be normal. Therapy can bring attention to experiences you have been carrying quietly, and change rarely happens in a straight line.

Give the Relationship Enough Time, Then Reassess

One session can tell you whether a therapist is respectful and whether the logistics work. It may take several sessions to know if their approach is helping. Unless there is a serious concern, consider giving the process a little room before deciding it is not for you.

At the same time, you are not obligated to stay with a provider who repeatedly feels dismissive, judgmental, unprepared, or mismatched to your needs. If something is not working, bring it up directly if you can. A good therapist will welcome feedback. If the fit still does not improve, changing therapists is not a failure. It is part of finding care that serves you.

Keep Safety in Mind

Online therapy is valuable support, but it is not designed for immediate emergencies. If you are in immediate danger, thinking about harming yourself or someone else, or unable to stay safe, call 911 or 988 in the United States, go to the nearest emergency room, or contact local emergency services. Tell the therapist or platform about urgent safety concerns as soon as possible.

For everyday privacy, use a secure device when you can, avoid shared passwords, and review the platform’s privacy practices. Your therapist should explain how they protect your information and what to do if a connection drops during a session.

Taking the first step can feel vulnerable, especially when you have been handling a lot on your own. You do not need to wait until things get worse or until you can explain everything perfectly. Check your options, choose a qualified provider, and book the conversation that gives you room to be human.

A $150 session can feel out of reach. A $25 copay may be manageable, but only if you can find a therapist who takes your insurance, has availability, and feels like the right fit. That gap is why asking what makes therapy affordable is more useful than asking whether therapy is simply “expensive” or “cheap.” The real cost depends on how care is delivered, paid for, and matched to your needs.

Affordable therapy should not mean settling for unqualified care, rushing through sessions, or choosing the first option you find because it is the lowest price. It means having a realistic way to access consistent, quality support without creating a financial strain that makes it hard to continue.

What Makes Therapy Affordable for Different People

There is no single price that makes therapy affordable for everyone. A college student with limited income, a parent managing a high-deductible health plan, and a working professional without insurance may all need different options. For some people, affordability means using insurance. For others, it means a lower self-pay rate, flexible appointment times, or virtual sessions that reduce the cost of travel and time away from work.

The most sustainable option is usually one you can maintain over time. Therapy often works best when you have room to build trust, practice new skills, and return to the issues that need attention. A low introductory rate that rises beyond your budget after a few sessions may not be as helpful as a predictable rate you can plan for each month.

Cost also needs to be considered alongside fit. A therapist may have a reasonable fee, but if their approach does not match what you are looking for, you may spend time and money without feeling supported. Finding a provider with relevant experience, appropriate credentials, and a communication style that feels comfortable can make each session more worthwhile.

Insurance Can Lower the Price, With Some Limits

Insurance is one of the most common ways people reduce out-of-pocket therapy costs. If a therapist is in your plan’s network, you may pay a copay or coinsurance rather than the full session fee. That can make weekly or biweekly care more realistic.

Still, insurance coverage is not always straightforward. Many plans have deductibles, which means you may pay the full contracted rate until you have met a certain annual amount. Some plans limit which providers are covered or require you to use a specific network. It is also possible to find a therapist you like who does not accept your insurance.

Before scheduling, ask practical questions: Is the provider in network? What is the expected cost per session? Have you met your deductible? Is telehealth covered at the same rate as in-person care? A quick check can prevent an unexpected bill later.

If you choose an out-of-network therapist, your plan may still reimburse part of the fee. This option can expand your choices, but it usually requires paying upfront and submitting paperwork. Whether it is worthwhile depends on your benefits, the therapist’s rate, and how much flexibility you need in choosing a provider.

Sliding Scales Make Fees More Flexible

A sliding-scale fee is adjusted based on factors such as income, household size, employment status, or financial hardship. Instead of one standard rate for every client, the provider offers a range that makes room for people with different budgets.

Sliding scales can be especially helpful if you are uninsured, underinsured, self-employed, between jobs, or facing a temporary financial change. However, availability may be limited because each therapist can only offer so many reduced-fee appointments. Ask directly whether a provider has sliding-scale openings and what documentation, if any, they require.

It is reasonable to be transparent about what you can afford. You do not need to share every financial detail to ask a simple question such as, “My budget is around $60 per session. Do you have a rate in that range or a referral you would recommend?” A good provider or matching service should treat that question as a normal part of finding care.

Why Online Therapy Can Change the Total Cost

Virtual therapy is not automatically less expensive than in-person therapy. Licensed clinicians bring the same training, ethics, and clinical responsibility to online sessions, and fees can reflect that. But online care can lower the total cost of getting support in ways that are easy to overlook.

You may save on gas, parking, public transit, child care, and time away from work. You can also search beyond the immediate area where you live, as long as the therapist is licensed to provide care in your state. That broader choice can be especially meaningful in communities with few local providers or long waitlists.

Convenience has value, too. When therapy fits into a lunch break, a quiet hour at home, or a schedule with caregiving responsibilities, it may be easier to attend consistently. Regular attendance is not the only measure of progress, but it gives you and your therapist a steadier foundation.

Online care does have trade-offs. You need a private place to talk and a reliable internet connection. Some people simply feel more comfortable meeting face to face. If privacy at home is difficult, an in-person office may be the better choice even if virtual sessions cost less overall.

The Right Match Prevents Wasted Time and Money

Choosing therapy based only on price can lead to a frustrating cycle of starting, stopping, and searching again. Affordability includes the likelihood that a provider can actually help with your goals. A therapist’s specialty, therapeutic approach, availability, and experience with concerns similar to yours all matter.

For example, someone seeking help with panic attacks may want a therapist who regularly uses evidence-based approaches for anxiety. Someone navigating grief, relationship stress, trauma, or identity-related concerns may benefit from a provider who understands the specific context involved. You do not need a perfect match on day one, but you should feel heard and able to ask questions.

This is where thoughtful matching can make a difference. TheraConnect helps people connect with vetted mental health professionals based on needs, preferences, and budget considerations, without charging clients to sign up. The goal is not to make therapy one-size-fits-all. It is to reduce the guesswork that can make finding care feel overwhelming.

Ask About Frequency, Not Just the Session Rate

When comparing options, look at the monthly cost rather than only the price of one appointment. A $75 weekly session costs differently from a $110 session every other week. Neither schedule is universally better. The right frequency depends on what you are working through, your therapist’s recommendation, and what you can realistically sustain.

Some clients begin with weekly sessions to establish momentum, then move to every other week as they gain stability or meet specific goals. Others may need more frequent support during a difficult period. It is okay to discuss budget openly with your therapist. They may be able to help create a plan that respects both your clinical needs and your financial reality.

Be cautious with services that promise very low prices while offering little clarity about who provides the care, how providers are licensed, or what happens if the fit is not right. A lower fee is meaningful only when the care is ethical, qualified, and appropriate for your situation.

A Practical Way to Compare Therapy Options

Start with the amount you can comfortably spend each month, not the highest amount you could possibly stretch to during a good month. Then check your insurance benefits, including your deductible and telehealth coverage. If insurance is not an option, look for providers who offer sliding-scale rates or payment flexibility.

Next, compare the full picture: credentials, specialties, appointment availability, session format, and location or state licensure. Ask about cancellation policies, because missed-session fees can affect your budget. If you are unsure whether a therapist is a fit, ask whether they offer a brief consultation before the first full session.

You deserve care that respects your time, finances, and reasons for reaching out. Start where you are, ask clear questions, and choose the option that gives you the best chance to keep showing up for yourself. When you are ready, Get Started and look for support that feels both attainable and right for you.

You have finally decided to ask for support, and the last thing you need is a string of unanswered calls or a first opening three months away. Learning how to get therapy appointments fast is often less about settling for the first available provider and more about widening your options while staying clear about the help you need.

A quick appointment can be a meaningful first step, especially when anxiety, grief, burnout, relationship strain, or a major life change is making everyday life feel harder. You deserve care that is timely, qualified, and realistic for your budget.

Start with the level of support you need

Before searching, take two minutes to name what is bringing you to therapy. You do not need a perfect explanation. A simple note such as, “I am having panic attacks,” “I need support after a breakup,” or “My family conflict is affecting my sleep” helps you look for a provider with relevant experience.

Also consider whether you need routine therapy, more urgent clinical support, or immediate emergency help. If you are in danger of harming yourself or someone else, call or text 988 in the United States for the Suicide & Crisis Lifeline, call 911, or go to the nearest emergency room. A therapy appointment is valuable, but it is not a substitute for emergency care.

For non-emergency concerns, decide whether virtual therapy works for you. Online sessions can significantly expand your choices because you are not limited to offices near your home or commute. Therapists must generally be licensed in the state where you are physically located during the session, so confirm that detail early.

How to get therapy appointments fast without rushing the match

Speed matters, but fit matters too. A therapist who has an opening tomorrow may not be the right choice if their approach, availability, or fees make ongoing care difficult. The goal is to get a first conversation quickly, then make an informed decision about continuing.

Use a matching platform or therapist directory that lets you filter for availability, state, specialty, insurance or self-pay preferences, and virtual sessions. A well-designed matching process can save time compared with contacting providers one by one. TheraConnect, for example, is built to connect clients with vetted providers based on individual needs and budget, and signing up is free for clients.

When completing an intake form, be specific about your schedule. Include whether you can meet during the day, in the evening, or on weekends. A provider with a Tuesday afternoon opening is not truly available if you cannot take time away from work. Giving accurate preferences makes a fast match more likely to be one you can keep.

Be flexible in the first week

If your schedule allows, accept a daytime appointment for the initial consultation even if you ultimately need an evening slot. Some therapists can meet sooner for a first session and then help you find a recurring time. You can also ask whether they have cancellations, short-notice openings, or another clinician in their practice who is accepting new clients.

Flexibility does not mean ignoring your boundaries. If you need a therapist who understands a particular cultural background, identity, language, faith, trauma history, or life experience, say so. The right match may take an extra day or two, and that can be worthwhile.

Send a short, clear request

Long messages are not necessary. Whether you are reaching out through a platform, email, or phone intake line, state that you are looking for an appointment soon, whether you prefer virtual care, and the days or times you can meet. Mention the general issue you want help with and ask about the earliest available consultation.

For example: “I am looking for virtual therapy for anxiety and would like to start as soon as possible. I am available weekday mornings and Thursday evenings. Are you accepting new clients, and do you have any openings this week?”

That message is respectful, easy to answer, and gives the provider enough information to direct you quickly.

Check cost and coverage before you book

An appointment that you cannot afford to continue can create more stress, so address cost upfront. Ask whether the therapist accepts your insurance, is in-network, provides superbills for out-of-network reimbursement, or offers a sliding-scale fee. If you plan to use insurance, contact your insurer or check your member portal to understand your deductible, copay, and telehealth coverage.

Do not assume that a lower session fee means lower-quality care. Many qualified clinicians reserve reduced-fee slots, work with community programs, or offer flexible payment arrangements. At the same time, be cautious about anyone who will not clearly explain their credentials, rates, cancellation policy, or privacy practices.

If insurance directories feel confusing, it may be faster to begin with a platform that lets you share your budget and coverage preferences during the matching process. Transparency early on prevents the frustrating cycle of finding a therapist you like, then learning the sessions are not financially sustainable.

Confirm qualifications and practical fit

Fast access should never require you to skip basic checks. Look for a licensed mental health professional, such as a psychologist, licensed clinical social worker, licensed professional counselor, marriage and family therapist, or psychiatrist when medication evaluation is needed. Licensure titles vary by state, but a trustworthy provider should be able to explain their training and license status.

A brief consultation is also a chance to ask practical questions. You might ask how they work with your concern, what a typical session looks like, how frequently they recommend meeting, and how scheduling works after the first visit. If virtual privacy matters in your household, ask whether audio-only sessions are available when video is not possible, and what secure technology they use.

You do not need to interview a therapist like you are hiring an employee. Pay attention to whether you feel heard, whether their answers are clear, and whether their plan makes sense to you. Therapy can feel uncomfortable at times, but you should not feel dismissed, pressured, or confused about basic logistics.

Use cancellation lists thoughtfully

Cancellation lists are one of the simplest ways to get in sooner. Tell the office exactly how much notice you can manage. If you can accept a same-day appointment, say so. If you need at least 24 hours because of childcare or work, that is useful information too.

Keep your phone notifications on and respond promptly when an opening appears. Many practices offer a cancellation to the next person who replies, so a delayed response can mean losing the spot. Only accept appointments you can reasonably attend. Repeated no-shows can make it harder for both you and the provider to establish a dependable schedule.

What to do while you wait for the first session

Even a short wait can feel long when you are struggling. Give yourself one small support task rather than trying to solve everything alone. You might write down what has been hardest lately, track when symptoms appear, or identify one person you can contact if the day feels overwhelming.

Prepare a few notes for your appointment: what you want help with, any past therapy experience, medications or health issues that may be relevant, and what you hope will be different after a few months. You do not have to share every detail in the first session. These notes simply give you a place to begin when nerves make it hard to find the words.

If the first therapist is not a fit, that does not mean therapy will not work for you. It means the match needs adjusting. Ask for a referral, return to the matching process, and keep the parts that worked, such as your preferred session time or communication style. Getting care quickly is possible, and taking one clear step today can move you closer to support that feels steady, respectful, and right for you.

Christopher Nolan’s “The Odyssey,” a new adaptation of Homer’s epic tale of Odysseus’ perilous journey home after the Trojan War, is already being described as a case study in post-traumatic stress disorder.

But even more so, actor Matt Damon’s tortured and broken portrayal of Odysseus offers a look into what psychologists call moral injury.

According to The Moral Injury Project at Syracuse University, moral injury is “the damage done to one’s conscience or moral compass when a person perpetrates, witnesses or fails to prevent acts that transgress one’s own moral beliefs, values, or ethical codes of conduct.” Three clusters of experiences mark moral injury: spiritual or existential collapse; guilt and shame; and alienation from other people.

Homer’s works have long been heralded for highlighting the physical and psychological wounds of war. Yet director Christopher Nolan, far more than Homer, goes on to plumb Odysseus’ existential collapse, shame and guilt.

An invisible wound

I’m a PTSD researcher and clinician who has worked at four Veterans Affairs hospitals, and I’ve long taught my students that Homer’s epics contain some of the oldest written examples of PTSD symptoms, even though the formal diagnosis of PTSD did not exist until 1980.

Moral injury is not simply another name for PTSD, although the two often travel together.

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PTSD is a fear-based disorder characterized by reexperiencing past trauma, avoidance of anything that triggers memories of that trauma, negative changes in mood and thought, and being constantly on guard.

Not everyone with PTSD experiences moral injury, and not all types of moral injury induce PTSD. But the two can overlap, particularly when someone violates their deeply held moral beliefs in a way that’s connected to a profound sense of guilt or shame.

In his books “Achilles in Vietnam” and “Odysseus in America,” psychiatrist Jonathan Shay explored moral injury in the context of the Vietnam War.

Shay focused on the American military institutions and leaders who undermined the trust and ideals of their soldiers through unclear goals and unjust orders. His exploration of moral injury is important. But it emphasizes the psychological consequences for soldiers when they’re betrayed in high-stakes situations. A more expansive view of moral injury, advanced by psychologist Brett Litz, shows it can also result from an individual’s own actions – what’s known as perpetration-based moral injury.

Released in 1989, the critically acclaimed movie “Born on the Fourth of July,” which is based on Ron Kovic’s 1976 autobiography, centers on this type of moral injury.

Kovic, played by Tom Cruise, is haunted by acts he committed while fighting in Vietnam. In a friendly fire incident, he accidentally kills a fellow Marine during a chaotic firefight. Later, he witnesses and participates in an attack in which his unit kills Vietnamese civilians, including women and children.

Moral injury in ‘The Odyssey’

Kovic’s actions and ensuing trauma reflect the same kind of moral injury seen in Damon’s Odysseus.

After 10 long years of fighting the Trojan War, Odysseus devises a plan to end the conflict: He and his troops infiltrate Troy by hiding inside a massive wooden horse. They build it as an apparent peace offering, climb inside and wait until their enemies pull “the gift” inside the city walls. Then they attack.

The military maneuver is brilliant and effective. But it also requires Odysseus to break Zeus’ law of xenia: the sacred obligation of hospitality between host and guest. He crosses another moral boundary by using deception. During the ensuing massacre, he violates the principle – even between enemies – of treating others how you would want to be treated.

Odysseus’ self-imposed exile – evocative of the social alienation that’s so prevalent among sufferers of moral injury – keeps him away from home for 10 long years after the war ends. Yet even time and space fail to heal him, and Odysseus remains haunted by guilt and shame: “We left them a gift, an offer of peace, that they took into their home,” Damon’s Odysseus says. “We violated all that’s sacred between people.”

The warriors I have known

Nolan’s characterization of Odysseus reminds me of the veterans I have treated.

In addition to moral injury, Damon’s Odysseus almost certainly has PTSD. He has recurrent nightmares; he tries to suppress his shame by consuming memory-erasing lotus flowers; and he feels overwhelming guilt and rage. Yet he appears most distraught by the thought that a part of himself has died and is irrevocably broken. While disguised as a beggar, he utters to his wife, Penelope, “What if the Odysseus you knew lost his way?”

It’s a version of what many of the veterans I’ve treated have told me: “If you really knew me, you wouldn’t love me.”

Many of them go on to admit that they feel they are unworthy of love. Actually, it’s more than just a feeling. It’s a moral conclusion that they reach after replaying and relitigating their actions at war.

Many of my clients describe their most significant trauma as something they did or failed to do, such as shooting a civilian or hiding instead of fighting during an attack.

Trauma taking place via personal acts of commission or omission usually does not come to mind when you think of PTSD. But you can, in fact, be a war hero – as Odysseus was – and you can also become haunted by your own actions, which linger long after the war ends.

Toward healing

Effective strategies for mitigating the fear reactions that PTSD can elicit, including treatments I’ve developed, exist.

But moral injury is a different beast from PTSD, and it can be especially challenging to help someone suffering from moral injury who believes they are unlovable.

A number of therapies centered on resolving moral injury have emerged in recent years. One of those, developed by psychologist Shira Maguen, is called the “impact of killing,” and it centers on the moral and emotional aftermath of killing someone during war.

It’s seen as an especially promising tool for improving veterans’ quality of life. She finds that among veterans who had already completed traditional trauma therapy, her intervention can further bolster veterans’ willingness to take part in community events and confide in loved ones.

Some people assume “The Odyssey” has survived over the years because it is a classic story of war, resilience and homecoming. But plenty of war stories were lost to history during the illiterate centuries after the collapse of the Bronze Age. “The Odyssey” endures, I think, because it centers on a tortured hero whom the audience admires but cannot fully absolve. His cunning is entwined with his crime.

Odysseus isn’t easily redeemed, excused or pitied. As fresh waves of troops continue to be exposed to the horrors of war, Odysseus’ trauma also continues to hit home.

Grief doesn’t move in a straight line. Some days feel manageable. Others, a song, a smell, or an empty chair at the table brings it all back like it just happened. If you’ve been telling yourself you should be “further along” by now, that pressure alone can make grief feel even heavier (Psychology Today, “Grief: The Process and the Practice”).

Grief therapy isn’t about rushing you past loss. It’s about giving you a steady place to process it — at your own pace, with support that actually understands what you’re carrying.

What Grief Therapy Actually Helps With

1. Making Sense of Complicated Emotions
Grief isn’t just sadness. It can bring guilt, anger, relief, numbness — sometimes all in the same day. A grief therapist helps you understand that these reactions are normal, not something wrong with you.

2. Working Through “Unfinished” Feelings
Unresolved conflict, things left unsaid, or a loss that happened suddenly can leave emotional loose ends. Therapy creates space to work through those threads instead of carrying them silently.

3. Rebuilding a Sense of Routine
Loss can make ordinary life feel unfamiliar — waking up, eating, going to work. Grief therapy can help you rebuild a rhythm to your days without feeling like you’re “moving on” from the person or the loss.

4. Supporting the Body Through Grief
Grief isn’t just emotional — it lives in the body too. Exhaustion, appetite changes, trouble sleeping, tension held in the chest or shoulders — grief can show up physically long after the initial loss (Psychology Today, “Love and Grief: How the Body Remembers”). A whole-person approach to grief support addresses the body’s response, not just the mind’s.

5. Navigating Grief That Doesn’t Fit a Timeline
Anniversaries, holidays, and unexpected triggers can bring grief back sharply, even years later. Therapy gives you tools for those moments — not to “fix” grief, but to move through it without it overwhelming you.

How to Know If It’s Time to Reach Out

You don’t need to hit a crisis point to benefit from grief support. Consider reaching out if:

• Grief feels like it’s affecting your daily functioning (work, relationships, sleep, appetite)
• You feel stuck, numb, or unable to process what happened
• You’re carrying grief alone and want space to talk it through
• A loss — recent or long past — still feels unresolved

Finding the Right Grief Support

Grief therapy looks different for everyone. Some people benefit from a licensed grief counselor. Others find real value working alongside a wellness coach who supports them through the practical, day-to-day rebuilding process. There’s no single “right” way to grieve, and there shouldn’t be a single path to support, either.

TheraConnect makes it simpler to find that support — a free directory connecting you with licensed therapists and experienced wellness coaches, including those who specialize in grief and loss. No insurance required, no waitlists. Just people ready to help, when you’re ready.

You Don’t Have to Carry This Alone

Grief is proof of love, not a problem to solve quickly. Whatever stage you’re in — the sharp early days or the quieter grief that resurfaces years later — support is available, and reaching out isn’t a sign that you’re struggling wrong. It’s a sign you’re taking care of yourself.

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Sources

• Psychology Today — “Love and Grief: How the Body Remembers” — https://www.psychologytoday.com/us/blog/bodhisattva-wannabe/202608/love-and-grief-how-the-body-remembers
• Psychology Today — “Grief: The Process and the Practice” — https://www.psychologytoday.com/us/blog/law-disorder/202608/grief-the-process-and-the-practice

A hard conversation with your partner keeps replaying in your head. You are getting through work, school, parenting, or everyday responsibilities, but everything takes more effort than it used to. You may wonder, when should you start therapy if nothing has completely fallen apart?

For many people, the answer is sooner than they think. Therapy is not reserved for a crisis, a diagnosis, or a moment when you have run out of options. It can be a practical place to understand what is happening, build skills, and feel less alone while a problem is still manageable.

When Should You Start Therapy?

A useful rule of thumb is this: consider therapy when your thoughts, feelings, relationships, or habits are causing distress or making daily life harder. You do not have to prove that your pain is “serious enough” before asking for support.

Sometimes the need is obvious. Grief, panic attacks, a major life transition, trauma, or persistent sadness can all be clear reasons to reach out. Other times, the signs are quieter. You may be functioning on the outside while feeling disconnected, exhausted, irritable, or stuck on the inside.

Therapy can also be proactive. People start because they want to communicate more clearly, set boundaries without guilt, understand relationship patterns, prepare for parenthood, or make a career decision with more confidence. Waiting until a concern becomes overwhelming is not required.

Signs It May Be Time to Talk With Someone

No single feeling means you must begin therapy. But if one or more of the following patterns has lasted for a couple of weeks, keeps returning, or is interfering with your life, a conversation with a qualified mental health professional may help:

• You feel sad, anxious, numb, angry, or overwhelmed more often than you feel like yourself.
• Sleep, appetite, energy, focus, motivation, or physical comfort has noticeably changed.
• You are avoiding people, responsibilities, places, or situations you used to handle.
• Conflict with a partner, family member, friend, or coworker keeps repeating without resolution.
• You are relying more on alcohol, substances, spending, scrolling, food, work, or other habits to get through difficult feelings.
• A loss, breakup, move, health concern, job change, or other transition is harder to process than you expected.

These signs do not automatically mean you have a mental health condition. They do suggest that you deserve space to look at what is going on. A therapist can help you sort through the difference between a temporary rough patch and a pattern that needs more support.

You Do Not Need to Be in Crisis

One of the most common reasons people delay therapy is the belief that someone else has it worse. Comparing your struggles to another person’s does not make your experience less real.

Therapy is not a competition for who is suffering most. If a problem is affecting your peace, choices, health, or relationships, it is worth paying attention to. Early support can sometimes prevent stress from building into burnout, isolation, or a more serious struggle.

That said, some situations call for immediate help rather than waiting for a routine therapy appointment. If you are thinking about harming yourself or someone else, feel unable to stay safe, or are experiencing a mental health emergency, call or text 988 in the United States for the Suicide & Crisis Lifeline, call 911, or go to the nearest emergency room. Online therapy can be valuable, but emergency support is the right first step when safety is at risk.

What If You Are Unsure Your Problem Is “Big Enough”?

Try asking yourself a few honest questions. Has this been going on longer than I expected? Is it changing how I show up at work, at home, or with people I care about? Am I spending a lot of energy pretending I am fine? Do I keep having the same problem without knowing how to move forward?

If the answer is yes, therapy may be worth trying. You do not need a perfectly worded reason to book a first session. You can simply say, “I have not felt like myself lately,” or “I am not sure what I need, but I know I need support.” A good therapist will help you put the pieces into words.

It is also okay if you start therapy and discover that your initial concern is connected to something else. Many people come in for stress and later recognize the role of grief, family dynamics, perfectionism, trauma, or untreated anxiety. Therapy makes room for that discovery without requiring you to have all the answers first.

When Online Therapy Can Be a Good Fit

For people with busy schedules, limited transportation, caregiving responsibilities, or few local options, virtual sessions can reduce a major barrier to care. Meeting from home may make it easier to attend consistently, especially if getting to an office would require time away from work or additional child care.

Online therapy is not identical to in-person care, and the best choice depends on your preferences and clinical needs. Some people focus more easily in a private office away from home. Others feel more comfortable opening up from a familiar space. Privacy matters in either setting, so consider whether you have a room, headphones, and a time when you can speak without being overheard.

The relationship with the therapist matters more than the screen. Feeling heard, respected, and understood is a strong foundation for therapy. A provider’s approach, experience, availability, cost, and licensing in your state are practical factors worth considering too.

Finding a Therapist Who Feels Like the Right Match

Starting therapy can feel vulnerable, so it helps to know what you are looking for. You might want someone experienced with anxiety, depression, relationship concerns, trauma, grief, identity questions, life transitions, or a specific community or cultural experience. You may also have preferences about a therapist’s communication style, gender, background, or therapy approach.

You do not need to know every clinical term to make a good choice. During an initial consultation or first appointment, pay attention to whether the therapist explains things clearly, listens without judgment, and welcomes your questions. It is reasonable to ask about their experience with your concerns, session fees, insurance or payment options, scheduling, and what treatment might look like.

Affordability is a real part of access. If cost has kept you from seeking care, look for transparent pricing, sliding-scale options, and a platform that helps you compare qualified providers based on your needs and budget. TheraConnect is designed to make that matching process easier, with vetted mental health professionals and virtual care options that meet clients where they are.

Give the First Sessions a Fair Chance

The first session may feel relieving, awkward, emotional, or all three. You are meeting someone new and talking about parts of your life you may not discuss often. That reaction is normal.

A therapist may ask about what brought you in, your current symptoms, your history, your relationships, and what you hope will be different. You are allowed to share at your own pace. You are also allowed to ask questions, correct misunderstandings, and say when an approach is not working for you.

Progress is rarely a straight line. Some sessions bring immediate clarity; others raise feelings that need time to settle. If you generally feel safe and respected but are unsure whether therapy is helping, bring that up directly. A skilled therapist will want to discuss your goals and adjust when appropriate. If the fit does not feel right after a reasonable effort, finding another provider is not a failure. It is part of advocating for the care you need.

A Small Step Can Be Enough

You do not have to decide today that you will be in therapy forever. You only need to decide whether a first conversation could help. Checking availability, reviewing costs, or writing down what has been weighing on you can be a meaningful start. Support is not something you have to earn by reaching a breaking point – it is something you can choose because your well-being matters now.

When BBC journalist Rory Carson sought online consultations for a potential mental health issue, three private clinics diagnosed him with attention deficit hyperactivity disorder (ADHD). They charged between £685 and £1,095 for these consultations, which lasted between 45 and 100 minutes, and all prescribed him medication.

ADHD is a highly controversial disorder which emerged in the US in the late 1950s during the cold war, and quickly became associated with stimulant drugs such as Ritalin. Now diagnosed throughout the world, ADHD is central to many debates about neurodiversity.

While Carson’s Panorama investigation into its treatment attracted plenty of criticism, the fact that this disorder could apparently be diagnosed quite casually online is concerning. When he subsequently had a more rigorous (but free) three-hour, in-person consultation with an NHS psychiatrist, he was told that he did not, in fact, have ADHD.

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Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. In this series, we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.

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Society’s increasing awareness of mental health issues and demand for mental health support has been driven, in part, by social media and easier access to information online. While this is no bad thing in many ways, the related increase in self-diagnosis (including among children and adolescents) is clearly open to abuse by some organisations offering costly diagnoses and treatments.

But there is another reason for this rapid growth in private mental healthcare. In England alone, the NHS spends around £2 billion per year on private hospital care for mental health patients – equating to 13.5% of its total mental health spend. Due to the reduction in NHS bed provision, nine out of ten privately-run mental health beds are now filled by NHS patients.

While the UK government says it is committed to spending more money on mental health, private investment companies are reportedly queuing up to “seize the opportunities offered up to them by the NHS crisis”. Private providers say they can do more to help avert a mental health emergency exacerbated by the COVID pandemic, yet a dozen of the 80-odd privately-run mental health hospitals in England were rated as “inadequate” in the Care Quality Commission’s latest report, which has warned of possible closures.

As a health historian, I find our worsening mental health crisis sadly predictable. Governments around the world have been involved in tackling mental illness since at least the early 19th century. While not all of their attempts were successful, many important lessons remain unlearned.

At the heart of them is this: amid ageing populations and the spiralling costs of mental illness to national economies, investing in people’s future mental health, based on what the key socioeconomic factors that we know are underlying it, is the only effective, long-term way to reduce this burden. As a major coalition of UK mental health organisations recently reported:

The risks to mental health, and the poor outcomes that follow, do not fall evenly across the population. People living in poverty, those with physical disabilities and illnesses, people with neurodevelopmental conditions, children in care, people from racialised communities, and LGBTQ+ people all experience much poorer mental health outcomes because of intersecting disadvantage and discrimination.

This all adds up to the life expectancy of a person with a severe mental illness being about 20 years shorter than someone without a diagnosis – and that gap is getting bigger. We understand the reasons why – so why do we seem unable to do anything about it?

Learning from history: the emergence of asylums

The first asylum in Britain was Bethlehem Hospital near London’s Bishopsgate, which began to specialise in insanity by the 15th century. Commonly referred to as “Bedlam”, what is now Bethlem Royal Hospital was often depicted negatively – including in A Rake’s Progress, a series of eight paintings by the 18th-century English artist William Hogarth.

Across the Atlantic, the treatment of patients in American asylums also proved very controversial. When Ebenezer Haskell escaped the Pennsylvania Hospital for the Insane in 1868, he immediately sued the hospital for unjust confinement and published an account of his ordeal, writing in the foreword:

The object of these pages is … simply to speak a few plain unvarnished truths [on] behalf of the poor, helpless and suffering patients put in these [institutions], and to show why a strong and positive legislative action should be taken for their protection.

The pamphlet included depictions of Haskell being punished and tortured, sometimes in the guise of treatment. In one, he is shown naked and lying on his back on the floor, restrained by four men while another performs “hydrotherapy” – dumping a bucket of water on Haskell’s face as a second man stands ready with another bucket.

Public perceptions of the brutal forms of care provided in mental asylums – and private “madhouses” – continue to be heavily influenced by films such as Shutter Island (2010), Girl, Interrupted (1999) and, perhaps most notably, One Flew Over the Cuckoo’s Nest (1975). Such films, and the novels that inspired them, portray asylums as harsh, unforgiving places run by mostly callous or sadistic staff. While this is justified in some cases, such portrayals mask the impressive ambition, care and expense that went into the building of many asylums by governments around the world during the 19th century.

https://www.youtube.com/embed/OXrcDonY-B8?wmode=transparent&start=0Trailer for One Flew Over the Cuckoo’s Nest (1975)

The provision of care for the mentally ill has long been considered a public responsibility. In Britain, the 1774 Madhouses Act was a response to concerns about abuse in private madhouses. Soon after, the County Asylum Act of 1808 and Lunacy Act of 1845 were passed in England and Wales to create dedicated public facilities for the mentally ill, so they wouldn’t languish in workhouses. Dozens of asylums began popping up all over Britain, regulated by the newly established Lunacy Commission.

Encouraged by the Age of Enlightenment, which spurred the idea that science could solve most of the world’s problems, Britain was among the pioneers embracing the concept of public health, with governments investing in public infrastructure to prevent infectious disease. In the case of asylums, little expense was spared even for so-called “pauper lunatics”.

At this time, asylums would have been among the most impressive buildings people would have seen – overshadowed only by cathedrals. However controversial, they were the first concerted, state-led effort to deal with mental illness. And while few mental health experts would recommend a return to the asylum era today, they might well envy the commitment that governments in Britain and elsewhere demonstrated in the facilities they provided for their mentally ill.

The disease that linked mental illness to poverty

Nineteenth-century experts provided numerous explanations for insanity. Some, such as masturbation, we would laugh at today. But financial insecurity, overstudy and overwork, or problems related to giving birth seem much more reasonable and still relevant. Just as heredity was cited as a cause in the past, today we cite genetic predisposition.

As governments began to invest more in hospital infrastructure to treat physical ills, due in particular to advancements in germ theory and surgery, asylum buildings and care standards were often left to deteriorate. In Alabama’s Mount Vernon Insane Hospital, for example, scandal surrounded the death of 57 African-American patients in 1906. But the cause of these deaths, pellagra – a disease that can affect the brain and cause severe psychiatric symptoms – has an important place in the history of public mental health treatment.

In northern Italy from the 1850s and the American South from the 1900s, asylums were suddenly filling up with pellagra sufferers. At this time, the disease was thought to be hereditary or contagious, and those afflicted, known as pellagrins, were shunned.

In fact, the real reason they were succumbing to pellagra was poverty. In both regions, landowners had introduced corn due to its high yields and attractiveness as a cash crop. At the same time, in Italy, a deterioration in agricultural working conditions meant that, by the 1870s, many workers relied on cheap corn for food in the form of polenta.

Similarly, in the post-Civil War American South, landowners devoted most of their property to growing cotton, leaving little room for other crops or livestock. So, tenant farmers relied on corn for food in the form of grits or corn pone, which left many suffering from malnutrition and, in particular, a severe deficiency of vitamin B3 (niacin).

This was the real cause of pellagra – but at this time, the role of vitamins in health was little understood. And even when the link between people’s over-reliance on corn in their diets, lack of niacin and mental illness was established by scientists, policymakers were hesitant to acknowledge the role of poverty and malnutrition in this explosion of mental illness.

In the US, New York physician Joseph Goldberger discovered the link between pellagra and poor diet in the mid-1910s – yet the overwhelming evidence he provided was rejected in the American South. For nearly 20 years, southerners were too proud to accept the disease was rooted in poverty, and continued to conduct fruitless research on other causes.

Even today, knowing that a poor diet contributes to poor mental health is one thing; tackling the poverty that leads to a bad diet is quite another. As researchers crystallise the link between diet and mental health – now widely framed in terms of the gut-brain axis – the need for governments to tackle the social determinants of a poor diet is clear and urgent. Namely, poverty and the food insecurity that goes with it.

When governments got serious about prevention

In 1929, a 13-year-old girl turned up to a Chicago social service agency, reporting that she had been raped by her brother-in-law. After a medical examination, her case was taken on by a team of social workers who visited her and her family, all Polish immigrants. The social workers took note of the family’s financial circumstances and helped the family press charges against the rapist, who was given a prison sentence. The girl attended counselling sessions for many months.

The agency overseeing this case was one of hundreds of mental hygiene and child guidance clinics founded in the US during its “Progressive Era” in the early 20th century. This was a period of political reform and social activism dedicated to countering the problems associated with industrialisation, urbanisation and immigration, and these child guidance and mental hygiene movements soon spread to Britain and elsewhere.

Prevention was the cornerstone of these movements, which espoused that it was much more efficient to prevent mental illness than treat it. In the US, the clinics were often funded by charities such as the Commonwealth Fund and the Laura Spelman Rockefeller Fund. But the state played an important role too – more so in other parts of the world.

In Britain, social welfare departments established to run similar clinics began to hire new types of mental health worker, such as psychiatric social workers and psychiatric nurses. From the 1930s, education authorities became more involved in child guidance activities, which were included in the 1944 Education Act.

While some conclusions drawn at this time appear shocking today – some mental hygienists and child guiders, for example, were sympathetic to eugenic explanations for mental illness, even if they also acknowledged the role of environmental causes – overall, the existence of child guidance and mental hygiene during the first half of the 20th century demonstrates how seriously preventive mental health was taken.

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Read more: Unlocking new clues to how dementia and Alzheimer’s work in the brain – Uncharted Brain podcast series

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Today, this is not the case. As in most areas of healthcare, the majority of public and private funding for mental health is funnelled towards researching and prescribing pharmaceutical treatments, rather than prevention.

Such investment has resulted in some effective medications, such as drugs to reduce the symptoms of schizophrenia or bi-polar disorder – although there are heated debates about this. But it has also distracted from the need to prevent upstream causes of mental illness, while pharmaceutical companies continue to aggressively lobby governments and politicians in the UK, US and elsewhere for more funding.

The peak of care in the community

In 1948, American journalist Albert Deutsch’s landmark book The Shame of the States exposed the parlous position of state-run mental hospitals throughout the US. In contrast to the good intentions that had led to the asylum era, Deutsch showed that many of these hospitals were now under-resourced, overcrowded and poorly staffed institutions characterised by deprivation, violence and abuse.

Around the same time, social psychiatry research was confirming what reformers had long believed: that poor socioeconomic conditions were a significant factor in the mental illness suffered by millions of people.

Dissatisfaction with mental hospitals and faith in psychiatry’s ability to prevent mental illness led to the community mental health movement. Proponents had two main arguments: that the mentally ill were best treated in their home communities, and that such illness could largely be prevented through community intervention.

https://www.youtube.com/embed/X3vkV9P2rAg?wmode=transparent&start=0JFK’s ‘special message’ to the US on mental illness and mental retardation, February 5 1963.

In the US and elsewhere, political will for radical change was strong. In February 1963, President John F. Kennedy argued that prevention should be central to the US’s approach to mental illness, highlighting the “harsh environmental conditions” in which it flourished. This momentum culminated in the 1963 Community Mental Health Act – the first time the US federal government had invested significantly in mental healthcare. Its ambition was to replace the traditional asylum system with some 2,000 community mental health centres, designed to both provide treatment and engage in preventive work. Fewer than 800 were ultimately built.

Not every psychiatrist wanted to work in community mental health, so other mental health workers were recruited including social workers, psychologists, nurses and “indigenous paraprofessionals” – people from the local community who lacked formal mental health qualifications. They worked closely with members of the public to help resolve the socioeconomic problems that were fuelling their poor mental health, and also liaised with schools, landlords, welfare officers, the justice system and medical professionals on behalf of their patients.

Yet despite their effectiveness, indigenous paraprofessionals were often an awkward fit within community mental health centres. In New York’s South Bronx neighbourhood, for example, their attempts to unionise, receive training and be respected resulted in rising tensions with the professional healthcare staff. Racism was one of the contributing factors, as most of these paraprofessionals were black or Latinx, while most of the professional staff were white.

In 1969, the South Bronx paraprofessionals went so far as to lock out their centre’s managers and run it themselves for more than two weeks, supported by the Black Panther Party – which further irked the management. While they eventually agreed to some of the paraprofessionals’ demands, the underlying tensions were not resolved and, when funding for community mental health decreased, the budgets for paraprofessionals were the first to be cut.

https://www.youtube.com/embed/aK_ALMA1NMk?wmode=transparent&start=19The story of the Lincoln Hospital occupation. Documentary by the New York Times.

By 1970, little preventive activity was occurring in community mental health centres. It turned out that President Lyndon B. Johnson’s “war on poverty” was more focused on “improving” the poor than progressive structural reform. Many social psychiatrists agreed that disadvantaged people needed to be “transformed” into upstanding citizens, rather than given material resources. This centuries-old idea of deserving and undeserving poor persists today throughout most of the world.

In the US, an increasing number of mentally ill people became homeless. Others ended up in prison or in nursing homes, while an increasing number were cared for by family members. In short, this marked a gradual return to the situation prior to the asylum era, when there was little public support for the mentally ill.

A shift towards treating the individual

The rise and fall of community mental health in the US is a cautionary tale. In the UK too, history shows that preventive approaches to mental health are soon weakened if not accompanied by genuinely progressive social policies that reduce poverty, inequality, racism, social isolation and community disintegration.

Following the election of US president Ronald Reagan in 1981 with a promise to reduce the role of government in most areas including healthcare and social support, and not long after his political soulmate Margaret Thatcher had come to power in the UK, the community mental health movement lost all momentum on both sides of the Atlantic.

But there was another reason for this: the publication, in 1980, of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). This “bible of psychiatry”, published by the American Psychiatric Association (a new edition emerges roughly every couple of decades), determines what constitutes a psychiatric disorder and how to diagnose it. In the US, if you want your psychiatric treatment covered by health insurance, you must be diagnosed with a disorder found in DSM.

Its third edition marked a major shift away from addressing mental health at a population-wide level, in favour of a focus on individual mental disorders. This led psychiatrists and patients away from environmental explanations for mental illness towards genetic and neurological explanations, or biological psychiatry.

This shift was mirrored by the rise of psychopharmacology – the ever-growing use of drug therapies to treat psychiatric patients. Faith in these medications – in particular, antidepressants such as Prozac – further reduced demands for preventive psychiatry. A 2011 study found that antidepressant use in the US roughly quadrupled over two decades from 1998. More recently, antidepressant use in England rose by 35% between 2015 and 2021.

https://www.youtube.com/embed/u3F928a9jdE?wmode=transparent&start=0The role of fentanyl in the US opioid crisis. (Bloomberg)

But psychopharmacology has not proved the panacea the pharmaceutical companies promised. One major study in 2022 found that only around 15% of participants in randomised, placebo-controlled trials experienced a substantial antidepressant effect. The fact that long-term use of antidepressants is likely to cause side effects, such as weight gain and sexual dysfunction, also raises questions about their widespread use.

The opioid crisis in the US indicates that we cannot rely on pharmaceutical companies to always do what is in our best interest. Sadly, it has also showed us that millions of Americans, and countless millions more around the world, are struggling to cope with mental as well as physical pain, and are desperate for solutions.

The dangers of privatised mental healthcare

In the UK, US and most other countries, there has probably never been more awareness of mental health issues among the general public – particularly in the wake of the COVID pandemic, whose impact on mental health has often led media headlines and dominated scientific discussions.

There is also much better evidence for what works – including, for example, the efficacy of talking therapies. In part because of concerns about the overprescription and ineffectiveness of drugs used to treat mental illness, the 21st century has seen a growth in popularity of talking therapies such as cognitive behavioural therapy (CBT) in the west.

However, accessing state-provided psychoanalytic treatments is very difficult, particularly in less well-off regions. In the UK, average waiting times for the NHS’s Talking Therapies programme vary enormously depending on where you live. There are nearly three times as many NHS consultant psychiatrists per 100,000 people in parts of London than there are in Yorkshire. Vulnerable children in some parts of the UK can wait two years for a first appointment, while those elsewhere are seen within a week.

Overall, while the number of successful referrals for talking therapies such as CBT have increased since the NHS programme’s inception in 2008, so have demands, and it has recently been missing its targets by about a third. As a result, an increasing number of people are reported to be seeking private treatment – despite the expense, and amid concerns about the reliability of some services offering these treatments.

As with physical health services, people also opt out of the NHS by purchasing private health insurance or waiting list “fast passes”. All of this creates a two-tier system that undermines the principles of universality and accessibility that are meant to underpin the NHS.

Most private mental health providers, like drug companies, are also motivated by profit and the demands of their shareholders. It is not in their interest to invest in preventive strategies with long-term, non-commoditisable outcomes. Equally, with people living longer and populations ageing rapidly, the future cost of not investing in preventive mental healthcare that makes a difference across whole populations will only grow with every year that passes. The onus is on governments to act now.

Three preventive strategies

The annual cost of mental illness to the UK economy is estimated to be at least £117.9 billion, or 5% of the UK’s annual GDP. Almost three-quarters of this cost is explained by the lost productivity of people living with mental health conditions and the unpaid, informal carers who look after them.

A new report by the children’s charity Barnardo’s has called for a national strategy for social prescribing, suggesting that “every pound spent on helping young people access activities and support in the community could save nearly twice as much in dealing with longer-term mental health problems”.

There are many different potential strategies that could be introduced. Here are three of my favoured options – based not only on new research into the social determinants of health, but also on historical approaches to preventive mental healthcare.

1. To address malnutrition, eradicate food inequality

Today, we are returning to an idea that physicians of the past would have taken for granted: that food is a major contributor to our brain’s health, as well as our body’s. New research on diet and mental health often centres on the “gut-brain axis”: a varied diet consisting of whole grains, legumes, nuts, seeds, fruits and vegetables is thought to provide the type of bacteria needed to maintain good gut-brain health.

But people in deprived communities often live in so-called “food deserts”, where most of the food available is highly processed, laden with chemicals and high in sugar, salt and fat. A bolder approach to food policy is needed that ensures everyone has access to healthy food – and the skills and means to prepare it.

During the first world war, national kitchens were established to provide people with inexpensive, healthy food in attractive communal settings. The return of such facilities would be welcome today amid the cost of living crisis – and they could also play a role in preventing mental illness.

2. To address poverty, introduce universal basic income

Interest in universal basic income schemes (UBI) – which provide everyone with a guaranteed income with no conditions attached – surged during the pandemic, when many countries introduced furlough or other income replacement schemes. Although UBI pilots have rarely studied mental health specifically, there is still evidence that a secure and sufficient income improves the mental health of participants.

UBI could prevent mental illness in numerous ways – from alleviating the stress associated with financial insecurity and which can cause inflammation in the brain, to reducing so-called diseases of despair that are associated with rising inequality, including the damaging stigma associated with welfare benefits (and the stress for people who work in the welfare system as gatekeepers).

It would also show people currently working as unpaid carers that their labour is valued. Many people find that volunteering benefits their mental health, and the efforts of volunteers contribute significantly to our communities. But it is often a privilege for those with time and money. A UBI would empower everyone to contribute to rebuilding their communities.

3. To tackle depression and isolation, get in touch with nature

During the COVID lockdowns, many people remarked how spending time in nature was their salvation. This built on existing evidence about the positive impact nature can have on our mental health.

However, much like access to healthy food, not everyone has access to natural beauty. Governments could do a great deal to reduce this inequality – for example, by providing inexpensive or free public transportation to national parks and other places of natural beauty. A priority should be ensuring that children from deprived urban backgrounds have regular access to nature.

In addition, more can be done to create new areas of natural beauty while protecting existing areas. Schemes that tackle biodiversity loss and climate change would reduce the clear impact these issues have on some people’s mental health – in part because worries about the climate are also known to trigger anxiety and depression.

Governments have a critical role to play

Responsibility for mental health should not lie solely with the individual. Sure, most of us can do something to improve our own mental wellbeing. But our lifetime mental health course is largely determined by socioeconomic, genetic and other factors, such as exposure to traumatic events, that may be mostly out of our control.

As centuries of evidence have shown us, governments play a critical role in creating the socioeconomic conditions that determine the mental health of their citizens. Yet, relatively speaking, many are doing less to address this today than they were decades ago. Until and unless this changes, state health providers such as the NHS will never be able to cope with the resulting demand for individual treatments. Those fortunate enough to do so will turn to the private sector. But what about everyone else?

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