A Brief(ish) History of Mental Health Care: Context & Compassion
- Karyn Resch Brackney
- 5 days ago
- 18 min read
Updated: 5 days ago
“Why did it take so long to get help?”
I hear some version of this question a few times a week in my therapy practice. It’s often part of the anger or grief stage of healing—the moment when a client, having recognized the depth of suffering they or their family endured, begins to realize that it shouldn’t have been that way. Sometimes, the question is, “Why didn’t my dad get trauma treatment, so he could have raised me without attachment wounds?” Sometimes, it’s, “Why didn’t anyone catch my depression/ADHD/autism/anxiety when I was a kid?” Sometimes, it’s “Why are my parents being so stubborn and refusing to go to therapy when it could improve our relationship?”
When I was in grad school, we studied the history of the field of mental health. What nobody told me, however, is how often I would be sharing that history with clients as a clinical intervention. Historical context matters. Part of the answers to the questions above lies in the complex (and sometimes ugly) history of mental health care. In this post, I want to summarize that history, not as an academic exercise, but in a way that will shed light on so many of our journeys to healing and wholeness, and that will hopefully inspire compassion for ourselves, those we love, and even those we can’t stand.
This post is long—maybe a good one to read in chunks. As a table of contents, I will cover:
The early 1900s: Freud’s horrific cover-up & the origins of modern psychology
The 1940s-1950s: Behaviorism & the start of cognitive therapy
The 1960s-1980s: Innovation, progress, & social change
The 1990s-2000s: Not that long ago, but still a different world
Post-2010: The impact of the ACA & current issues
But first, here is where we need to start: The field of mental health care is YOUNG.
Freud first started developing his “talking cure” at the tail end of the 19th century. Today, in 2026, the modern field of mental health is only about 130 years old. Let’s put that timeline in context. Benjamin Franklin first discovers (or proves the existence of) electricity in the 1750s; 130 years later, the field has evolved to Thomas Edison and Nicola Tesla inventing lightbulbs in the 1880s. That’s 130 years of development. Electric lighting won’t be available in homes for another 40 years. A second parallel: Transportation. Richard Trevithick built the first steam-powered locomotive in 1804. Fast-forward 130 years, and you’re in the 1930s. Air travel is exceptionally rare; most people travel long distances by train, and diesel-electric trains are new; the Ford Model A is replacing the Model T. That’s 130 years of progress.
So for all our sophistication in the field of mental health—with wonderful new treatments like ketamine-assisted psychotherapy, EMDR intensives, and injectable antipsychotics that don’t turn you into a zombie—remember, we are still at the stage of lightbulbs and Model Ts. We have a long way to go.
Now, let’s rewind back to Freud.
The early 1900s:
Freud’s horrific cover-up & the origins of modern psychology
Freud gets a lot of attention as the father of modern psychotherapy. Freud had much to offer, in creating one of the first stage models of human development and launching the study of psychology. But when it comes to father figures, he was not of the let’s-play-baseball-in-the-front-yard variety. Through his early endeavors, he uncovered an appalling epidemic of incest and sexual abuse against women and girls. However, for a variety of patriarchal and frankly disgusting reasons, he soon revised his theory and blamed the victims, saying that the assaults they were reporting were imagined events, indicative of psychosexual yearnings. These young women weren’t being molested by their fathers; they were neurotic, “hysterical,” and these “memories” were psychotic expressions of a secret longing for sexual intimacy with their fathers.
Meanwhile, in France, a contemporary of Freud, Jean-Martin Charcot, was working with hysterical women at La Salpetrière, a mental hospital. Unlike Freud, Charcot understood his patients’ “abreactions” as visceral expressions of real trauma, and used hypnosis to release repressed memories and reduce their suffering. However, today it’s Sigmund Freud who is a household name, and almost nobody has heard of Charcot. This is both infuriating and, once you understand how the world works, entirely predictable—but that is beyond the scope of this post.
Psychoanalysis was the first standardized form of mental health treatment.
The classic image of a patient lying on a couch, free-associating while a blank-slate psychiatrist in a suit records notes on a clipboard, makes interpretations, and cures his patient with a combination of god-like insight and intense catharsis still lingers today. While Jungian and Adlerian therapies also existed in the early 1900s, they didn’t have nearly the clout of psychoanalysis. Traditional psychoanalysis, however, required 2-5 years of work with an analyst, with sessions as often as five days a week. Clearly, this was not an efficient or widely accessible approach to healing.
The 1940s-1950s:
Behaviorism & the start of cognitive therapy
The field of mental health took a step forward in the 1940s and 1950s. Around this time, psychological research led to a focus on behaviorism. Figures like B.F. Skinner and John B. Watson, building on Ivan Pavlov’s classical conditioning experiments (remember the salivating dogs from Psych 101?), developed the concept of “operant conditioning.” Behaviorism, the notion that behavior could be shaped by rewards and punishments, was introduced into education and mental health, and still shows up in parenting coaching, ABA therapy for autism, and the treatment of behavioral-based disorders like addictions and eating disorders. While its principles seem self-evident today, operant conditioning’s inclusion of positive reinforcement was a big deal in the “spare the rod, spoil the child” culture of that era. (I’ll add that there is quite a bit of controversy today about behavioral therapy, but that’s beyond the scope of what I can address here.)
Soon after, Albert Ellis developed Rational Emotive Behavior Therapy (REBT). This paved the way for Aaron T. Beck to create Cognitive-Behavioral Therapy (CBT) in the 1960s. These cognitive therapies used behavioral principles to understand and treat issues like anxiety, depression, and phobias. Operant conditioning shows us how negative experiences associated with a stimulus lead to a behavioral aversion to that stimulus (e.g., school + bullying = “I hate school”), while positive experiences encourage our engagement (e.g., school + teacher’s praise = “I enjoy school”). Similarly, CBT highlights how negative thoughts or cognitive distortions about yourself or your experiences lead to negative emotions and unhelpful behaviors. Thus, if you just change your thoughts, CBT promises, you can change your emotions and free yourself up to behave in more prosocial and satisfying ways.
A note about “evidence-based therapy”:
Approaches like CBT have been with us for a long time. And for decades, there weren’t very many treatment options in the world of psychology. Because of this, the mental health community has had tons of time and resources to spend researching the effectiveness of CBT. In addition, CBT is also quite easy to research. It’s manualized, short-term, and usually focuses on easily observable (i.e., chartable) symptoms. So CBT is now considered “evidence-based.” What I want you to remember, though, is that the term “evidence-based” does not necessarily mean “superior to non-evidence-based therapies.” All it means is, “there has been time and money poured into proving the validity of this therapy.” Which really means, “people with access to resources have had a vested interest in proving the validity of this therapy.”
The 1960s-1980s:
Innovation, progress, & social change
The 1960s and 1970s were an exciting time in the field of mental health. All the theories that had begun a decade or two ago began to take off, including CBT and Family Systems Therapy. Charismatic and influential people like Virgina Satir, Irvin Yalom, and Carl Rogers were crafting their beautiful and enduring legacies. Person-centered approaches began to replace psychoanalytic approaches; therapists became the empathetic and affirming figures we think of today, rather than that of the cold, removed expert. Attachment theory, which John Bowlby had begun developing through observations of pediatric hospital patients in the 1950s, began to expand under the hands of Mary Ainsworth, Mary Main, and others. While it wasn’t until the 1980s-90s that attachment-based approaches began to show up in direct treatment (Emotion-Focused Therapy from Sue Johnson, Internal Family Systems from Richard Schwartz, and eventually, Interpersonal Neurobiology from Daniel Siegel), attachment theory was the bedrock of so much that came after.
The 1970s were also when somatic therapy began gathering momentum. Ron Kurtz (Hakomi), Peter Levine (Somatic Experiencing), and Pat Ogden (Sensorimotor Psychotherapy) were doing their early work in the 1970s, playing around with wild stuff in experiential group settings and trying new methods on individual clients, as they learned about the role of sensation, experience, and movement in healing. These visionaries were drawing on a body of much older work—from Moshé Feldenkrais to our friend Charcot, and all the way back to Lao Tzu. It would be a few decades, however, before the science caught up with what they were feeling out.
While there was much that was exciting in the field of mental health through the 1970s and into the 1980s, there were also massive issues.
Mothers were blamed for their schizophrenic children’s symptoms. Being gay was still considered a mental illness, and as the gay rights movement took off, so did conversion therapy. Not until the mid-70s did ethics boards finally begin to regulate psychological research, putting a stop to harmful and traumatizing studies (if you’re into disturbing content, look up Little Albert, the Stanford Prison Experiment, or the Milgrim Obedience Study). Post-Traumatic Stress Disorder didn’t have an official name until 1980, and it was only in the wake of the Vietnam War, as the country was flooded with traumatized veterans returning home, that psychologists began to reckon with the need for trauma treatment. Lobotomies had been phased out, but the tranquilizing medications that replaced them were still debilitating for patients suffering from severe and persistent mental illness. The deinstutionalization movement in the 1950s and 60s had ended the forced, often lifelong hospitalization of thousands of mental health patients (treatment that was more incarceration than anything), but as a result, access to community care became a pressing issue. Insurance didn’t cover mental health care, and there weren’t enough providers even for those who could afford them. Many of these patients, unable to succeed in independent living, became homeless or ended up in prison—a problem we are still experiencing today.
There were wonderful innovations taking place in the 1970s-1980s, but what those of us doing our healing work today need to remember is that, typically, it takes 10-20 years from the formation of a new therapeutic modality for it to become widely used and available to clients—and sometimes even longer than that before the general public begins to accept it as normal. So while much of what we consider therapy today was available when your parents were young, it was still mostly unheard of, and tremendously difficult to access for the average person. What’s more, the haunting memory of institutionalization still lingered in many people’s minds. Mental health problems were not something to be discussed with friends or in public settings; they were something to hide behind drawn curtains, to keep in the family. Postpartum depression got you taken away from your children and submitted to electric-shock therapy. Better to rely on alcohol to cope with your anxiety than to take tranquilizers that turned you into the walking dead. Unidentified trauma could earn you a personality disorder diagnosis and a lifetime of successive hospitalizations. Sure, if you were rich, you could go lie on a couch and talk about your problems—but if you were a regular person, you were mostly on your own.
This is why your parents, and their parents, never went to therapy.
It’s why generations of your family have suffered in silence. It’s why many older folks still believe it’s better to just not talk about problems. It’s why the mental health issues that scarred your childhood went unnoticed, or at least unnamed, for so many years. It’s why a lot of things. Remember: lightbulbs and Model Ts. We have come a long way. But there is a long way left to go.
The 1990s-2000s:
Not that long ago, but still a different world
The 1990s into the 2000s finally ushered in the slow—and I mean very slow—normalization of mental health care. These were the years of my childhood and adolescence, so I have a lived experience of that time that my young adult clients don’t. My conservative religious culture influenced my experience. Inside the evangelical church, people were mostly just told to pray harder or confess sin if they were struggling with depression or anxiety, and anything “weirder” than that was given some form of the exorcism treatment. There was profound suspicion of therapy and psychiatry, and a shocking (in retrospect) lack of knowledge of basic mental health symptoms and etiology. Because I was somewhat isolated from mainstream culture until college, I won’t speak for everyone’s experience of those years. But here is what I remember:
My “geriatric Millennial” experience of mental health was characterized primarily by confusion, labeling, and insufficient information.
I remember a childhood friend whose older brother was in a constant state of dysregulation. He struggled socially, and was loud and sometimes disruptive. By age 9, I'd picked up on a vague sense of frustration and overwhelm in his family. They loved him, but they didn’t know what to do to help him. I felt embarrassed around him. Why couldn’t he just act like my brother, who was quiet and easy to play with? Looking back now, I feel so much sorrow and compassion for a family with neither the language nor the tools to assist a child who was likely autistic. These days, Daniel Tiger teaches preschoolers to understand that some kids are wired differently; my 5yo accepts this easily. I had no such framework.
I grew up watching TV commercials for Zoloft and Prozac. These medications were new, and the commercials themselves were little bite-sized morsels of psychoeducation, introducing the average American family to disorders most people didn’t talk about. There was plenty of undiagnosed and unacknowledged depression and anxiety in my family and my community. But the adults around me viewed medication with suspicion—and anyways, insurance didn’t often cover it. Plus, you could even be denied future coverage based on a pre-existing condition if you had a depression diagnosis in your medical file, so there was little incentive to seek help.
In 2007, I experienced a traumatic incident, and began showing flagrant symptoms of PTSD. What followed was a series of misdiagnoses, unhelpful medication management, and poorly-aimed therapy. I recovered, but it took a decade longer than it should have. I didn’t receive any actual trauma treatment until years into my own career as a trauma therapist. Looking back at some of the huge, obvious trauma reactions I had in extremely public places as a college student, it’s baffling to me that nobody recognized what was happening. I think of all the movies I’ve seen of soldiers returning from war, all the scenes of combat trauma flashbacks and the behaviors that go with them. Couldn’t people see that I was going through the exact same thing? But then, I have to remind myself, most of these movies didn’t come out until the end of the 2000s and later.
Speaking of trauma treatment: The first time I heard of EMDR was during my freshman year of college, when a friend whose family fostered children with severe trauma talked about helping her mom drive a foster brother to therapy in the city. When she described EMDR to me, I thought it sounded like witchcraft. Only six or seven years later, in grad school learning to become a therapist myself, it seemed like everyone was doing EMDR. Recalling my first encounter, I marveled at how little time it had taken for something so weird to begin to feel so normal. (In 2019, EMDR was featured in a character’s storyline in Grey’s Anatomy, another big step toward mainstream acceptance.)
I started graduate school in 2013, the year the DSM-V was released. This was the first edition of the DSM to take a small step toward depathologizing non-conforming gender identities—a teeny-tiny step, but still something. My conservative evangelical seminary struggled with how to teach about gender identity in light of new diagnostic criteria and conceptual frameworks. Looking back, I see historical parallels: homosexuality was removed from the DSM in 1973 (the year of Roe vs. Wade). Less than a decade later, the AIDS crisis began, and suddenly, gay people found themselves in a harsh and unforgiving spotlight, at the center of a political fight disguised in the inflammatory language of morality, fear, and public safety. Today, only a few years after having their identity depathologized, transgender people find themselves the unwilling civilian casualties of a battle over their personhood and basic rights, with hatred once again disguised in language of morality, fear, and public safety.
I don’t think I knew a single adult female with an ADHD diagnosis until after I’d finished graduate school. Now, I walk alongside adult women of all ages on a regular basis (both clients and friends) who are beginning to name their own neurodivergence. Much of our general understanding of ADHD is still informed by the rambunctious 6-year-old boys who were the first recipients of the diagnosis. It has taken far too long for far too many people to find compassionate ways to understand their own experience and unburden themselves of labels like “lazy” and “too sensitive." We still have a lot of work to do create a strengths-based, identity-affirming, fully accessible world for the neurodivergent people who have always been here with us.
Post-2010:
The impact of the ACA & current issues
We are still learning so much. The field of mental health has many horrors to grapple with: the long shadow of Freud’s cover-up of incest and sexual abuse; decades of harmful and unethical research, appalling inpatient conditions, inhumane treatment of patients, and harsh, shame-based addiction treatment; education systems and professional organizations still gate-kept by white, western, patriarchal hierarchies; lagging cultural competence and unaddressed issues of racial justice. Like the field of medicine, it’s irresponsible to focus on the bright, shiny progress while ignoring the long history of suffering on which that progress was built.
In my assessment of where the field of mental health stands today, I see two primary issues:
The first is our toxic relationship with the Medical Industrial Complex (insurance companies, Big Pharma, politics, etc.). The second is our plagiarizing and colonization of indigenous healing traditions. While these things might seem like opposites, I think they’re related.
It’s hard to quantify the impact of Obama’s 2010 Affordable Care Act on the field of mental health.
For the first time, most insurance plans were required to cover mental health care to the same extent as medical treatment (mental health parity). For the first time, average people could access therapy, psychiatric medication, and addiction treatment. For the first time, people couldn’t be denied health care coverage due to their mental health history. I was a grownup in 2010 (a baby grownup, but still a grownup). This means Gen Z is the first generation to grow up predominantly in a pro-therapy world, where friends compare Zoloft side effects over coffee and text each other about what their therapist said this week, where it’s not unusual for dating couples to discuss their attachment styles and trauma-informed language has become its own lexicon of slang, where people discover diagnoses on TikTok and social workers and child psychologists are major online influencers (Brené Brown and Dr. Becky come to mind).
Side note: If you are of the age to have ever watched your parents struggle with smartphones or social media etiquette, take a moment to appreciate: this is all new to them. It’s new, and a little scary. They grew up, and made most of the formative decisions of their lives (including how they raised you), without any of this language, knowledge, or framework. Can you imagine how uncomfortable it is, after 50 or 60 or 70 years of doing things the way you do and understanding the world the way you always have, to be told by people thirty years your junior that you’ve gotten it wrong, that you’ve been making mistakes this whole time without knowing it? I hope, if I’ve accomplished anything with this post, it’s to help us hold the dialectic of both compassion and accountability for the generations whose experiences are different than ours.
I began grad school only three years after this massive cultural shift toward a pro-therapy world. It’s been a good time to be a therapist.
While this shift has opened up access to care in tremendous ways, however, it has come with some ugliness. Access is still not what it needs to be. Only two out of every three therapists in private practice accept insurance; in many areas of the country, it can still be tremendously challenging to find a therapist who accepts your insurance, treats someone with your clinical needs, and has openings. The reason only 67% of therapists accept insurance, though, is that accepting insurance mostly sucks. I’ve written about all of that here, but this toxic relationship with the Medical Industrial Complex still boils access to and quality of care down to money: who gets paid for it and how much; what types of care are considered worthy of coverage; what problems are bad enough to justify “medical necessity”; what types of treatment get the label “evidence-based”; the ways the preferences of billionaires influence policy, and how that trickles down to whose mental health needs are prioritized and whose are ignored (or criminalized).
For the field of mental health to grow beyond the “treatment” model (focused on symptoms and pathology) and become a true practice of healing, either we will need to break free from the Medical Industrial Complex, or the Medical Industrial Complex itself will need a thorough deconstruction and reconstruction. I honestly have no idea which option feels more impossible. But the issue of becoming a true practice of healing leads to the second major issue facing the field of mental health today.
Are we going to learn to relate to the other healing traditions of the world with respect and a spirit of collaboration, or are we going to keep plundering them while simultaneously denigrating them?
My biggest gripe with the field of mental health is that, like so many other aspects of western civilization, it has a tendency to arrogantly ignore centuries of indigenous wisdom, opt to reinvent the wheel, and then take forever to catch up to where older cultures already were a long, long time ago. And then, the field of mental health parades itself around as the greatest gift to humanity, as if we are the first people in 300,000 years of human history who have known anything about how to heal emotional pain. It’s preposterous—like a guy who thinks he’s a hero for loading the dishwasher.
As therapy evolves, however, it is following the slow rotation of its reinvented wheel back to the roots of human healing traditions, beginning more and more to resemble the practices non-white and non-western cultures have always had. It’s becoming more spiritual, more embodied, more integrated, more communal…more shamanic. Things like parts work and somatic healing have been practiced for thousands of years; concepts of ancestral curses or generational trauma seem cool and new to westerners, but have existed for all of time; hunter-gatherer cultures had secure attachment figured out just fine, and we’ve only had to invent attachment theory to fix what western civilization broke. The best of therapy—the pieces of therapy that actually heal—are not new. We did not invent them. We stumbled upon them, and we are still learning what they really are—like archeologists unearthing an ancient dildo in some stone age ruins and, after much surmising and writing of journal articles, concluding it must have been used for “fertility rites.”
*slow clap* Almost there, guys. Almost there. You’re just thinking way too hard.
It’s a beautiful thing that therapy is shifting back toward what has always worked—partly.
I imagine, though, that if you’re someone with roots in a people or community who still practices these ancient healing arts, or if you are descended from people who had their healing arts violently wrenched from them by colonizers, enslavers, missionaries, or any other kind of invader, it’s a special kind of pain to see the field of mental health claiming these “discoveries” are their own. It’s a massive tragedy of the human race, that we had access to all this wisdom, all this knowledge of how to heal, and then we all but lost it when western civilization tried to stamp it out. From the Roman Empire spreading Imperial Christianity to the witch-hunts of the medieval era and the burning of so many female healers to the colonization of Africa, the Americas, Australia, and more, we have lost so much collective magic. That we are finding some of it again, the long and hard way, is to me proof that the universe is loving and we are not totally alone with ourselves.
In recent decades, there has been a huge surge in alternative healing: reiki, ayurveda, acupuncture and traditional Chinese medicine, shamanic healing, chiropractic care and osteopathy, homeopathy, naturopathic medicine, massage therapy, qigong, psilocybin and ayahuasca, tapping, essential oils, and more. I recently spoke with a retired acupuncturist who began practicing in the early 1990s and had story after story to tell about what a different world it was back then—the judgment, the skepticism, the suspicion and even fear. We have reached a moment in history, however, where there are more healing methods available than ever.
But within the field of mental health care, regulated as it is by licensing bodies, accreditation, scientific research, and insurance requirements, integration is not possible for most providers. Those who do want to integrate are forced to give up their licenses and practice as “coaches,” losing a lot of structure and support along the way. And then, without the ability to bill insurance, they run into problems with access all over again, as few people in need of healing can afford the rates required for a provider to earn a decent wage. So you have to pick: either your ability to integrate is stagnant, or access is a barrier for your clients. It’s a hard choice for many brilliant healers emerging from western mental health to make.
What is the way forward? Where will we be in another fifty years? I have my dreams. I know what I’m hoping for. I’m getting a little clearer every year on the path I’m carving for myself. But as for the big picture…well. I doubt Thomas Edison could have envisioned Times Square on New Year’s Eve as he grinned at his first lightbulb. And I’m pretty certain Richard Trevithick wasn’t imagining Japan’s Shinkansen bullet trains as he sent that first steam locomotive bumping over the Welsh countryside.
I choose to believe that the field of mental health can grow into something amazing—but only if we learn to take our humble place among the healing traditions of human history, and only if we find the courage to name the skeletons in our collective closet and make peace with the harm we’ve caused.
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