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.

The Impact of Bipolar Disorder on Physical Health

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Those of us with bipolar disorder can bear a heavy burden when it comes to co-occurring conditions, medication side effects, and we are at higher risk for many diseases. Some of these effects are ameliorated by efforts at early screening and detection. We hope (perhaps naively) to catch tardive dyskinesia before it becomes permanent and Stevens-Johnson Syndrome before it becomes fatal. Likewise, in the US we have a federal registry for clozapine patients that aims to detect agranulocytosis (destruction of white blood cells, which disables the immune system) with rigorous blood testing.

Other medications may take a more nefarious route to affecting our health. Lithium is able to cross membranes and take up residence inside your body’s cells, where it stubbornly resists removal by hemodialysis. Years down the road, it can lead to kidney failure, not to mention destroying your thyroid gland.

But there’s more than meets the eye to the interface of bipolar disorder in medical care.

Bipolar disorder is widely stigmatized by medical professionals

I once presented at the ER for an abscess the size of a tennis ball erupting from my thigh (a consequence of my then-undiagnosed hidradenitis). I showed the triage nurse; she documented it. Then she asked for my phone and my shoes.

“The psychiatrist is going to see you,” an aide informed me.

“What? Why? I have an abscess!”

They didn’t care to listen to me. Two hours later, a psychiatry resident showed up at my bedside. He took a look at my abscess.

“I don’t know why they sent you over here,” he said, sighing. Another two hours passed before a “medical” MD came to take a look and determine (within minutes) that we were going to drain my abscess. It was extremely painful. Surely, anyone would be a touch irritable or agitated in such circumstances. But I’ve been told that having bipolar disorder in my history was good enough reason to detain me, independent of any other facts. You know what that’s called: discrimination. I hadn’t complained of any suicidal planning or expressed a desire to be admitted. In my place, someone without those two words in their file — “bipolar disorder” — would have been seen by a medicine doctor hours earlier.

But, to be fair, it’s not just bipolar disorder that is stigmatized. I was once being detained in the psych area of the ER, when an aide mentioned to another aide that she had PTSD. I was in a fairly good mood, and I joked, “You’re one of us!”

“I’m nothing like you,” she said, frowning coldly. “PTSD is not a mental illness.”

I was taken aback by her confidence and we started to argue when the charge nurse walked in. We both told our side of the story and the charge nurse decided to move the aide to a different part of the ER. She did not look happy, let me tell you.

Bipolar disorder can affect how drugs work in your body

Whether from drug-drug interactions or simply unusual metabolism of certain medications, prescribing medicine for physical health reasons is a tricky business when you have bipolar disorder. The most commonplace medications can be problematic: antibiotics (can cause mania), ibuprofen or most other NSAIDs (interacts with lithium and can raise lithium levels to toxic, resulting in profuse vomiting — try telling that to an overworked nurse who thinks you’re seeking pain meds!), prednisone or other steroids (can cause mania), Sudafed (stimulant — may cause mania)… the list goes on.

This is what I’ve found with alternatives. This only represents my own experience and should not be taken as an endorsement of research in this area (probably because there isn’t much).

Antibiotics: Doxycycline should be avoided, but amoxicillin is okay.
Ibuprofen/NSAIDs: The exception to this rule is old-fashioned aspirin, which is safe if you’re on lithium!
Prednisone/steroids: Unfortunately I haven’t found an effective alternative. You just gotta play the odds. Being manic is better than being dead.
Sudafed: I recommend diphenhydramine (Benadryl) which is effective, safe for bipolar disorder, and cheap.

Having bipolar disorder can increase your odds of having another disease

Some diseases and risk factors for diseases, including metabolic syndrome, obesity, diabetes mellitus (type 2), and diabetes inspidus (if you’re on lithium) appear to clearly be linked to certain medications people might take to treat their bipolar disorder. But others are less clear. Headaches are associated with bipolar disorder, especially migraines and cluster headaches (less commonly chronic tension headaches). Genetic evidence has aligned to connect epilepsy and bipolar disorder (such as the SP4 gene, which was published about in September 2024) and this is concordant with the longstanding clinical observation that bipolar disorder often responds to cocktails including anticonvulsant medications such as Lamictal (lamotrigine), Depakote (valproate), even Topamax (topiramate). Large studies have also shown that people with bipolar disorder are more likely to develop Parkinson’s Disease, independently of cases that are likely drug-induced.

Surprisingly, when COVID-19 first swept the world, some research suggested that people with bipolar disorder were more likely to have a severe or life-threatening COVID-19 disease course even when controlling for factors such as obesity. Taken together with available evidence, this may lend support to the idea that alterations in the body’s inflammatory pathways may be causal to bipolar disorder. It has long been recognized that influenza infection can precipitate manic or psychotic episodes. In January 2018 I had the flu and I became preoccupied with the fact that I (definitely) had AIDS and I began writing long goodbye letters to my friends. Luckily, the flu was better in about 3 days.

Drugs (use, abuse, and misuse) cause problems

As I mentioned, certain medications can have severe side effects…
Neuroleptics (such as Haldol/haloperidol): Neuroleptic Malignant Syndrome, Tardive Dyskinesia, Movement Disorder
Atypical Antipsychotics (such as Zyprexa/olanzapine, Risperdal/risperidone, Abilify/aripiprazole, and clozapine): Agranulocytosis (Clozapine specifically); Akathisia and movement disorder (particularly Abilify and Vraylar)
Anticonvulsants: Stevens-Johnson Syndrome (especially lamotrigine — and keep in mind that risk for SJS increases whenever you start or stop taking the medication suddenly, and if you do this multiple times your risk climbs higher and higher)
Antidepressants and other serotonergic drugs, such as stimulants and street drugs like MDMA: Serotonin Syndrome

Bipolar people are famous for resisting taking medications that could help them, which can make the above side effects more likely. Not taking your meds can also make bipolar disorder worse, and make you more at risk for accidental deaths such as a car crash, while also making you more at risk for intentional death (suicide). Lithium has uniquely shown a capacity to lower the risk of suicide.

Not only that, but it will always be assumed that you are “drug seeking” especially when you try to explain the bit about why you’re too good for the ibuprofen that everyone else takes. But no fear, the nurse has your back and will get you some IV lorazepam (Ativan) while they process your discharge.

Showering is too much. What can I do?

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I won’t lie to you; there are many days where showering just seems like too much. This post is just a list of things that might be helpful if you struggle with showering every day. I am not an Amazon affiliate; I do not earn anything from recommending certain products, it’s simply a matter of my personal taste.

Face: It’s very important to me that my face stays blemish-free because I have skin-picking issues. First, I cleanse my face at least once a day with a makeup remover wipe. Any of these wipes should do the trick, my favorites right now are Burt’s Bees Micellar (I prefer the rose water one) and Neutrogena Hydro Boost Wipes.

After cleansing, I use Pixi Glow Tonic (an exfoliating toner that helps shed dead skin cells). I prefer the “to go” variety with pre-saturated pads. I wouldn’t start using exfoliating toner every day; start by using it every 2 or 3 days and let your skin get used to it.

Finally, since I just used a toner with glycolic acid, I definitely want to finish up with something that has SPF and moisturizing. My skin tends to be a little bit red and this step definitely helps. There are many products you could choose, but I go with something easy: Neutrogena City Shield Water Gel. It absorbs rapidly into my skin, reducing redness and protecting my skin from sunburn.

Body: Unfortunately it’s hard to compare to a real shower, but you can get by on baby wipes. Always freshen up your deodorant of choice every day. I use Dr. Squatch aluminum-free deodorant in the cooler months where I don’t sweat as much. During the summer, I use Old Spice Wilderness Antiperspirant and Deodorant.

I’ve tried Lume deodorant and it doesn’t play well with my skin condition (hidradenitis) but that or another “whole body” deodorant might be helpful.

Hair: Advice on how to keep hair fresh varies by hair type. If you have Type 1 or Type 2 hair (straight or slightly wavy) most likely a conventional dry shampoo will work best for you. You spray it in your hair, it absorbs grease, and you comb it out. I have Type 3 hair (curly), which means I avoid combing my hair like the plague. Instead, foam shampoo — like this one from Not Your Mother’s — works great for me.

I’ve also used foam shampoos meant for pets and that works as well if you’re on a budget! I’ll admit I’m not sure what the best products are for Type 4 hair, but please drop any recommendations in the comments!