Mental Health Treatment Modalities 101

A layman’s guide to understanding the landscape of treatments for depressive & anxiety driven disorders of the mind

TLDR; If you’re feeling sad/anxious/worried and you don’t know what to do about it, this will explain a bunch of options. Hopefully there will be one in here that makes sense and appeals to you.

Obvious caveat, I’m not a doctor (or an expert of any kind) so think of the below as a bouncing-off point, rather than empirical evidence or clinical advice.

A brief background

In my 20’s, I’d of described myself as having a high hedonic set-point (natural predisposition to be happy). Something (I don’t know what) has happened (or had already happened) over my 30s that has caused me to be increasingly sad, anxious and anhedonic, lacking the ability to experience pleasure in things I previously found to be pleasurable. Over the past few years, I’ve felt like life is no longer worth living. Thankfully, it never got to the stage where I attempted to take my own life; but, had I been offered the option to not wake up tomorrow, I’d of regularly taken that option. I’m now in my 40s (well…40) and having studied Philosophy, Neuroscience and Psychology, I feel like I’ve got a much better (albeit incomplete) understanding of the landscape of my mind.

To that end, over the past few years, my primary interest has evolved into understanding what has caused me to feel like this, from a multitude of perspectives. I’ve spoken about this at length in this podcast but wanted to put something in writing.

When I first started to investigate how I might tackle my mood, I really wanted a brief overview of the different approaches to the problem. What I found were lots of books and websites on each of the different treatment modalities, but nothing that gave an overview of them all. All too often, they were written from a biomedical or spiritual or psychoanalytic perspective. This post hopes to serve my original purpose. Here is a snapshot of the major (and some minor) players in the mood-disorder-amelioration racket. With a few of the treatments, I’ll try to recommend a good starting place/book if you want to delve deeper. Without further ado…

First, let’s start with (as I understand it) the different ways one might approach the problem before we go into the actual treatments (each treatment broadly falling into 1 or more of the below approaches — these are ordered so I can refer back to them, not in any sort of hierarchy)

• A Understand why you’re thinking and/or feeling the way you are/do
• B Change the relationship with the thoughts your having
• C Changing the actual thoughts (and thus, feelings)
• D Change the chemistry of your brain to force it to behave differently
• E Understanding stress factors that influence your propensity to think and feel a certain way

Psychotherapies

Psychotherapy is the term used for a myriad of different therapies that address the mind (psyche). Well known psychotherapists include Freud, Jung & Klein. Broadly, the game plan here is to talk to a therapist. They’re often referred to as “talk therapy”. I think many people are under the misapprehension that all psychotherapies revolve around A above, delving into your past to understand why you’re feeling the way you are. This is not the case. However, let’s start with one that is…

Psychodynamic Psychotherapy — A

Talk therapy based on the belief that the unconscious & childhood conflicts, impact behaviour. Typically a client/patient talks about their past, and the therapist tries to help the client themselves discover the hidden (usual subconscious) causes with very gentle — but directive — active listening. Very often, this yields understandings or realisations of past traumas, frequently in childhood.

e.g. a patient tells the therapist about their childhood, while the therapist increasingly enables the patient to reveal more and more, thus eventually uncovering the cause of the patients fear of abandonment

Behaviour Therapy — C

If you’ve heard of Pavlov’s Dogs/Pavlovian Conditioning then this is the behaviour we’re referring to. It uses the principles & rules of learning, and applies them to change undesirable behaviours.

e.g. a patient learns to overcome a fear of elevators through several stages of relaxation techniques

Cognitive Therapy — B, C & E

Cognitive and Cognition broadly means “thought”. What we’re talking about here is using rational thinking to interrogate less rational thinking. The hope being that, awareness of cognitive processes, helps patients eliminate thought patterns that lead to distress.

e.g. a patient learns to not overgeneralise failure based on a single failure

CBT (Cognitive-Behavioural Therapy) — B, C & E

CBT is the combination of the 2 above. Here we’re first understanding the thoughts were having and trying to view them a little more rationally and objectively, while also employing behavioural learning techniques to modify the behaviours. We work to change cognitive distortions and self-defeating behaviours.

e.g. a patient learns to identify self-defeating behaviours to overcome an eating disorder

A good book to start with on this subject: Feeling Good by David D Burns

Humanistic Therapy- B & A

The phrase that best describes a key difference with Humanistic Therapy is “Unconditional Positive Regard”. Founded largely by Carl Rogers, one of the key principles in a Humanistic approach is that the patient feels wholly accepted, irrespective of the displayed behaviour/thoughts — if you’re a proponent of emerging theories of Free Will (as I happen to be), then this approach seems eminently more achievable. The therapist works on increasing the patients self-awareness and acceptance through focus on conscious thoughts.

e.g. a patient learns to articulate thoughts that keep her from achieving her goals in a non-judgemental and positive environment

Play Therapy- A

This is almost exclusively something used with children who would struggle to verbalise the inner workings of the mind. It’s a psychoanalytical therapy wherein interaction with toys is used instead of talk.

e.g. the patient (child) might act out family scenes with dolls

Mindfulness— B

The goal here is very much to change the relationship you have with your thoughts and feelings. Mindfulness typically works by increasing your ability to see/observe what’s happening in your head, understand the lack of control you have with what’s going on in your head, and eventually learn to change the relationship you have with these ever-emerging thoughts and emotions. I’ve just glossed over two and a half thousand years of teachings, but this is the jist.

e.g. you learn to see that your thoughts really do think themselves, and thus learn to welcome and befriend the fear & panic that have always plagued you

A good place to start on this subject: Waking Up app by Sam Harris

Psychopharmacology — D

Psychopharmacology follows a very physicalist view of the maladies of the mind. The theory is that there’s an imbalance somewhere in the body and the goal is to find and adjust that imbalance. This typically takes the form of messing around with serotonin levels. As a very brief (and simplified) lesson in neuroscience, the brain works by sending signals between brain regions. These signals are sent along neurons using electricity and then at the end and between the neurons with chemicals (neurotransmitters). Serotonin is a neurotransmitter and it’s one associated with positive (and in its absence, negative) mood states. The theory is that if there’s an imbalance with serotonin levels, we can boost them by either:

1. stopping the serotonin being reabsorbed into the presynaptic neuron (the neuron that released the serotonin). The presynaptic neuron eventually “Reuptakes” it, so it’s not around in the synapse (the gap between the neurons) to pass on the message. This is where SSRIs like Prozac come in, as they “Inhibit” the “Reuptake” of Serotonin. Hence Selective Serotonin Reuptake Inhibitors
2. inhibiting the metabolism of the serotonin when it’s “Reuptaked” (ok, this is getting silly) into the neuron that released it. This metabolism is done by an enzyme called Monoamine Oxidase (MAO), thus, taking an MAO inhibitor has the effect that more serotonin is waiting around ready to be passed on to the next neuron

There are more than the above two examples but these are the primary antidepressant psychopharmacology buckets

e.g. your doctor (or specifically a psychiatrist) will prescribe Prozac in the hope of “flattening” your mood

Bibliotherapy- All

Bibliotherapy doesn’t really fit into the A, B, C, D, E framework above. The idea is basically that by reading books you can absorb the knowledge required to make changes. One of the best known examples of this I’ve come across is the CBT book Feeling Good by David D Burns which has been tested against other forms of therapy (see F. Scogin & C. Jamison 1995) and shown statistically significant results in terms of it’s efficacy.

It’s worth noting that with many of the subjects one could learn about, unlike what G.I. Joe says, “Knowing is not Half the Battle”. Putting the things you’ve learned into practice is where the battle is won (continuing the unnecessary fighting metaphor: 🔫 pew pew pew)

e.g. you read a book (or many) and learn useful concepts, techniques and schemas that you can then apply to your own life

Psychedelic-Assisted Psychotherapy— A & D

This is perhaps one of the more fringe treatments in the list but personally, the one showing the most promise. It’s a bit of a hybrid of A & D, but often has the result of impacting C & B. I feel like I could easily write something 10 times the length of this post just on this treatment modality, so I’ll try to keep it brief. I could go into a long backstory about psychedelics, their history and relationship with governments but we can save that for another time. First, let me paint a picture of what this treatment broadly is, and then I’ll run through some mental models that hopefully help to explain, how and why it works.

We’ve already read what Psychotherapy is above, so hopefully we have that covered. The Psychedelic component in this treatment is a dose of a psychedelic drug taken between therapy sessions. Typically this would look like:

• Day 1, building trust with patient, therapists (and group if applicable)
• Day 2, psychedelic dosing. It’s absolutely imperative that this is done in the right “Set & Setting” where “set” is the mindset you come to the session with (Day 1 helps in this) and “setting” is the physical and emotional environment of the dosing experience. I really can’t emphasise enough, how important set & setting are. You will not have the same psychological benefits trying to replicate this at a party with friends
• Day 3, integration (this is more therapy where one works with the therapist to try to understand/make sense of/integrate the psychedelic experience

The above can be repeated and extending in time but critically, integration follows dosing.

How it works, some useful mental models and analogies:

1. The goal of more traditional psychoanalytic psychotherapies is to help you uncover the things in your past that are causing you to feel and behave the way you are. Uncovering these causes can take many years, very often decades. In a normal psychoanalytic environment (i.e. not fueled with psychedelic insight) this is where things start to get very expensive. Psychedelics seem to be uniquely gifted at zeroing in on what it is/was that was causing the trauma, if it’s something very very suppressed. Nobody seems to know (yet) how psychedelics are able to so accurately zero in on the causes, but the consequence is, they often do. As a result, within a day or to you have lots and lots of “material” to work with, both on your own and with a therapist. Many have equated psychedelic assisted psychotherapy as being like 20 years of therapy in 20 hours
2. The snow globe. Just like when you shake a snow globe, and then leave the snow to settle, the landscape of the snow globe changes as the snow resettles. This is (loosely) analogous to what neuroscientists currently think is happening to our brains, post psychedelic trip. One of the truly strange things that happens post trip is the change in mood one experiences, doesn’t just last while the compounds are in our body (2–18 hours depending on compound and dose) but rather can last weeks, months or even years. Some have described this as the psychedelics creating a “window of plasticity” in your brain, where your brain is highly open to change within the window the compounds are in your body.
3. The above ads weight to the REBUS (RElaxed Beliefs Under pSychedelics) hypothesis. The brain is essentially a very highly tuned prediction engine with much of its evolution targeted toward making better predictions of the future with less and less energy. One pathological consequence of this is that our brains significantly over-index predictions over sensory input (i.e. your brain will filter out sensory input that doesn’t match with it’s predications). This turns into a pathology when our brains (especially the Default Mode Network) rely far too much on these learned predications and we end up ruminating on things, completely disabled from breaking the cyclical thinking. Psychedelics (with the snow globe and window of plasticity analogy) seems to allow our brains to see things a little more clearly (or at least differently) and then settle into a new way of thinking, no longer so doggedly tied to our pre-psychedelic, maladaptive ruminations.

e.g. you spend time with a therapist building trust, then have a mind alerting and potentially confusing psychedelic experience, and then start to integrate your experience with your therapist taking valuable learnings (the learnings existing not just at the intellectual level but at the phenomenological level)

A good book to start with on this subject: How to Change Your Mind by Michael Pollan

Closing Thoughts

The above largely paints a dualistic view of the mind and body. As though they are two separate (albeit interlinked) systems. There seems to be a growing interest within various suffering-amelioration fields that we lose something when thinking of them (the mind and body) as separate entities. To use my own analogy, it’s totally unintuitive that (in our universe at least) the properties of space and time are not two separate entities, but one, Spacetime. It’s not possible to have a unit of space without the corresponding time component. It’s highly unintuitive to us, but those appear to be the facts. This seems similar with mind-body. They aren’t two separate entities that work with one another, it’s the same entity. As a consequence, viewing treatments by only looking at one component of the mind-body may very well be missing a trick.

For all of you suffering, I wish you luck, love and compassion as you undergo the journey of self discovery. Speaking personally, I feel like on the hedonic set-point, I sat at about +7 for most of my 20s, cruised at around -8 for the latter part of my 30s, and now at 40, I feel like at a relatively stable +3. While +3 doesn’t sound that sexy or inspiring, it beats the fuck out of -8, so there is hope!