Evaluating Popular Therapies in Psychology

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As you may know, I am not only a patient with autism/ADHD/bipolar disorder, but I am a researcher with a PhD in Psychology from UCLA. My training has included exposure to various therapies, particularly including ABA, CBT, and DBT (check out my first-author paper on DBT). This post is a quick guide to different kinds of therapies, starting with behaviorism and then evolving over time to include second and third wave therapies. I’m evaluating them based primarily on my subjective understanding as a patient, but also with regards to the scientific literature.

Behaviorism (First Wave Therapies)

These therapies are based on the basic principles of behaviorism (Pavlov, for instance) and concern themselves with observable behaviors.

ABA: The controversial modality which usually dictates early intervention for autism is basically straight behaviorism. First, a behavior plan will be drawn up which includes antecedents (triggers), behavior, and consequences (which may or may not reinforce a behavior). ABA basically involves changing the consequences to change the behavior. Desired behaviors are reinforced using a small reward (like an M&M, although caution should be taken about using food rewards). Unfortunately, sometimes, punishment can also be used to change an undesired behavior. I don’t personally find this appropriate, and I think if you see this being done you should change interventionists. It is harmful to target innate autistic behaviors or intense interests with an extinction plan.

Exposure: Although extinction (for example, to treat a phobia by systematically exposing the patient to the thing they fear until their level of distress declines) is extremely effective, typically, the therapy causes distress — thus, patients often find it unacceptable. Starting with a different kind of therapy may help. A variant of pure exposure called Exposure & Response Prevention (ERP) is effective at treating some patients with OCD. In ERP, the patient is exposed to a trigger and prevented from performing the compulsive behavior that is aimed at neutralizing the obsession (which is caused by the trigger).

Second Wave Therapies

These therapies evolved from behaviorism to include thoughts, feelings, and other internal stimuli.

CBT: This modality is common in the wild, but it is often low quality. When you do find high quality CBT, it may be particularly helpful for people with severe mental illness (bipolar or schizo spectrum) who have anosognosia (low insight) to increase understanding of their illness. As a person with high levels of insight, I did not find it particularly helpful most of the time.

Third Wave Therapies

These therapies, like second wave therapies before them, evolved from CBT to emphasize mindfulness and acceptance of unwanted thoughts or feelings.

Acceptance and Commitment Therapy (ACT): Unwanted thoughts and feelings often cause distress. However, if you do not fight against the unwanted thoughts or feelings, and instead accept them and move forward with your life, you can reduce the suffering those thoughts or feelings cause you. This is the central observation of ACT.

Dialectical Behavior Therapy (DBT): Marsha Linehan developed DBT to help people who met the profile of Borderline Personality Disorder (BPD), especially those at high risk for suicide. However, watered-down versions of the DBT model are common, for example, in inpatient hospital settings. The full DBT model involves a weekly skills group, weekly individual therapy, and phone coaching. It is expensive and often these programs do not accept insurance. However, this approach is what started me on a different life path.

Non-Evidence Based Therapies

Psychoanalysis or Psychodynamic: I had a psychodynamic therapist briefly. I’d be interested to try it again, since I’ve tried everything else.

Eye Movement Desensitization and Reprocessing (EMDR): Some people swear by EMDR, but it is not considered an evidence-based treatment. That doesn’t mean it’s not worth a try, though.

10 Ways to Reduce Stress and Prevent Burnout

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Recently, someone on another website reached out to me and asked what they could do to reduce stress, and in turn reduce their chance of burning out and relapsing in mental illness and substance use. This is what I wrote back.

What works for one person won’t necessarily work for everyone. I will say that I learned some useful stuff from DBT skills group (but not everything was useful for me — I took what worked), so you could look for a DBT program in your area. Unfortunately, DBT programs tend to not take insurance, so it can be expensive.

Here are some things that work for me:

  1. Distractions: it may not be super useful at work, but when I get stressed I watch something on TV — either something that will get my attention, or something that I’ve seen before (Star Trek and Pokémon series are good ones for me) just to take my mind off of whatever is bothering me. Video games are good too. It comes down to personal preference.
  2. Sudoku: When I really need something that commands my whole attention (to take my mind off something), I sometimes play Sudoku. I usually play on easy and strive to make no mistakes. If I’m playing on paper, I use a pen so that I can’t erase my mistakes. Maybe for some people playing with a timer is better. You could also try some other puzzles, like KenKen. I play Sudoku because it’s easy to get paper booklets. But you can also readily get apps on your phone. Experiment with it.
  3. Pets: If you have any animals in your life, it may be helpful to consult them when you are feeling stressed. I have a cat and she definitely keeps me alive sometimes.
  4. Creativity: When I need to let off some steam, I sometimes do something creative. For me, I’d choose painting or writing/journaling. But there’s tons of options here that could work. The ideal hobby would not make you feel competitive and thus add to your stress. I’ve found that since I write professionally, it’s less useful as a distraction. But, painting takes a bit of setup, so if I plan to do that it helps to set up a day or so in advance. I keep a folder of inspiration/references that I can use when the mood strikes. Ideally, you’d get a feeling of accomplishment from your creative works, as well as distracting your mind.
  5. Medication: I have medication that I use for severe agitation or anxiety. I also use THC, but I don’t recommend that for everyone, especially people on the schizo spectrum because it can make things worse. Since you said you’re schizoaffective, I’d steer clear of non-prescription medications, but you can definitely ask your psychiatrist about something to use PRN/in emergencies. Benzodiazepines are definitely helpful but they may not want to prescribe those to someone with substance use history. Strong antipsychotics are also good, though, and they should definitely be willing to talk about that. Olanzapine/Zyprexa is great since its main side effect is weight gain and that shouldn’t happen with a PRN (something you don’t take every day). Haloperidol/Haldol is also very effective and the main side effect is movement disorder, which can be at least somewhat alleviated by a medication called benztropine.
  6. Self-care: Eat right (whatever that means to you), exercise if you can, practice good hygiene, and treat physical health problems. These things will make you more resilient to stress. They are boring, but effective.
  7. Comfort items: I have certain plushies that bring me comfort in times of stress. Some big ones I like to sleep with, and I also have small ones that I can carry around with me.
  8. Socializing: While it may be the last thing you feel like doing when you are very stressed, talking to friends or family to let off some steam can really help. It may be a time to practice the DBT skill “opposite action”, which (for example) dictates that when you feel like isolating, you should seek out social interactions.
  9. Cold water: This is part of the DBT skill “TIP” (Temperature, Intense exercise, Paced breathing) — it’s the part that works best for me. Technically, you’re supposed to submerge your face in ice water and hold your breath for as long as possible to trigger the mammalian dive reflex, which lowers heart rate and anxiety. For me, that’s too many steps, so I use a cold shower.
  10. Music: I’ve heard from people who hear voices that white noise can be very triggering. If you have to be around white noise, try playing music through headphones. I would actually avoid active noise canceling since it uses white noise.

Anxiety and mania

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Recently, The Mighty published an article about the differences between anxiety and hypomania. However, I wanted to complicate the discussion by bringing up something that breaks the juxtaposition of anxiety and mania: primarily anxious mania, which is most likely a mixed episode associated with bipolar type 1.

The author describes how her anxiety leaves her “immobilized”. This can actually happen in mania, too — but usually not in hypomania. Hypomania is often very productive. Full mania is no longer productive — it’s frantic, potentially confused, and may be characterized by manic stupor. Emil Kraepelin used this term to describe a flight of ideas and elevated mood (not necessarily happy, but revved-up) combined with psychomotor slowness or immobility. I’ve been in this state, and I experienced it subjectively as intense feelings of anxiety paralyzing my every move. This might also be referred to nowadays as catatonia, and something similar can occur in severe depressive states; however, the catatonia that coincides with mania is likely excited catatonia (characterized by purposeless movements rather than being completely still).

Hypomania isn’t rare, exotic, or exciting to me. It’s just part of my life, and I take advantage of it when it comes around — which it will, no matter what. But, to me, full mania is to be avoided. Anxiety is also a daily part of my life, but the anxiety and paranoia I experience during a manic episode is even more excruciating than it usually is. Juxtaposing them as discrete, separate states can only take you so far in understanding what mania is and how it affects people.