Psychiatric Treatment in Plain English

an antidote to euphemistic jargonese

Mental healthcare has a euphemism problem. Generally, the thing we pay for when we want someone to get better is referred to as ‘treatment’ or ‘care’ or maybe ‘services’. It is rarely clear from the language used what that involves, what it is aimed at doing, and how we know if it worked, to an almost farcical degree. Entire healthcare conferences carry on and hold hours-long panels about psychiatric treatment in which not one of these strategies is described in a straightforward way.

So, I wrote a description of every major psychiatric treatment type I could find, along with some broad discussion of their possible risks and benefits.

Some general principles—pretty much every treatment type works better when:

• The provider is better at it (e.g. they are ranked highly as a practitioner in their field)

• The patient and those closest to them trust it and are motivated to participate

• It doesn’t involve a lot of waiting or delays

• The provider is well-rested, not burnt out, and is able to pay good attention

• There isn’t a lot of time pressure while the treatment is happening

These factors can be so influential that it’s possible that an ‘ineffective treatment’ (as defined by, say, the scientific literature) where all these factors are present is better than an ‘effective treatment’ where they are absent.

Things not included in this list—how much each thing costs, how widely available they are, and how commonly they are available together from the same provider. Some of these you can do without a professional and some you can’t because of practical or legal limitations.

This list just aims to answer the question “what do we mean when we say ‘mental health treatment’?”.

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Types of psychiatric treatment

Prescribe psychiatric medication

This can only legally be done by a doctor or a licensed nurse practitioner. Most current psychiatric medications directly counteract distressing symptoms, and don’t resolve the cause of the symptoms. Some work immediately, and some take a few weeks to begin to work properly. Many medications come with side effects, and in some cases you need to taper off over a few weeks or months when you want to stop taking them. It can sometimes take trying a few medications to find one that counteracts the symptoms the way you want but doesn’t have intolerable side effects. Some people find taking medication eases their suffering or dysfunction enough that they can make other changes that help them recover.

Offer emotional support

Many kinds of overwhelming distress become more bearable if we can share them and feel accepted and understood by someone else. Most emotional support provided as a formal mental health service is provided by strangers or by professionals with whom you build a relationship gradually over time. Some people find it easier to get emotional support from strangers or professionals who must keep issues secret and aren’t connected with their daily lives, while others find it hard to open up to strangers who they don’t have an existing relationship with. Services that provide emotional support include suicide crisis hotlines, support groups, some peer support specialists, and some therapists.

Work through issues in therapy

Some kinds of therapy help us reflect on how we live our life, investigate patterns that might be causing us distress, and figure out how to change those patterns within ourselves. Sometimes it is helpful to do this with a therapist who can pay attention to our blindspots, encourage us, act as a role model or someone to practice a healthier kind of relationship with. This is mostly done with therapists one-on-one in regular appointments, although it may be done in group therapy, with support groups, in intensive workshops, or alone with the help of a book or other recorded guide. Rarely, it can involve working through issues as they involve the body, such as in somatic experiencing, or while under the influence of a substance, but most commonly it is done entirely through talking.

Do an assessment to decide what treatment to do

When a person seeks treatment for the first time, or for the first time with a new provider, the provider needs to gather information and make a judgement about whether treatment is needed and if so, what kind. Also, after doing some treatment, sometimes a provider will do assessments in order to figure out how effective the treatment was and what to do next. This can involve administering tests, using evaluation checklists, interviewing the person and possibly their loved ones to learn more about the situation and their history, and observing them or ruling out medical problems. This may also involve deciding on a diagnosis, even if the provider has only just met the person, because a diagnosis is often required before treatment is begun in order for insurance or the government to agree to pay for it. Assessments are usually done by mobile crisis teams, emergency responders like paramedics, emergency room doctors and psychiatrists, therapists and psychiatrists in the initial sessions, and intake people for social services programs. Some people find assessments invasive or get frustrated at how long they take, particularly when they are acutely distressed. 

Teach psychological skills

There are psychological skills that help us better avoid getting into distressed or dysfunctional states, or handle it better if we do get into such a state. These include skills at getting calm, regulating emotions, untangling unhelpful beliefs, solving problems, and getting motivated. You can learn these skills one-on-one from a therapist or teacher, in a class or workshop, or from a book, app or course. Many people find it hard to stick to training when learning alone, and find some kind of social support, encouragement and accountability helpful to learn successfully.

Hold someone in a high-security environment

If someone is in such a distressed or intense state that they seem like they are about to hurt or kill themselves or someone else, sometimes to prevent those bad outcomes we hold them in an environment that makes hurting themselves or others very difficult. In these environments potentially dangerous items like pens, shoelaces, knives, and musical instruments are banned, and there are security features that make it difficult to impossible to escape. Sometimes the person agrees to go there, and sometimes a doctor decides to hold them there against their will if the doctor thinks the risk is high enough. These environments can be bleak, stifling, distressing or depressing, and most patients and doctors agree it is better to only use them as a last resort.

Enforce daily routine

In many away-from-home psychiatric environments the staff enforce routines like regular sleep and meal times, regular activities, and limited stimulation from things like phones or the internet. This can help a person get calm and return to ordinary physiological rhythms. Some methods used to enforce routine can feel controlling, alienating, or humiliating to some people, and some people get distressed at the loss of autonomy they experience.

Provide role models

When someone is experiencing a lot of mental health problems or a new, surprising mental health problem, it’s easy to feel hopeless about things getting better, or to pay attention to negative societal judgments and stories about people with mental health problems. Role models who have gone through similar things and are now living good lives can help people feel optimistic about getting better themselves, which can make them feel more motivated and capable. These role models are most often peer workers, although this can also be filled by reading books or watching movies or other media about people who have gone through mental health challenges and recovered successfully.

Create calming experiences

Sometimes acute crises happen when someone is overwhelmingly agitated or triggered by something. Calming experiences can help them relax and make it easier to manage whatever problem happened. Services that do this include massage, spa treatments, art therapy, relaxing retreats in nature, or guided relaxation meditations. This is different from meditation training, which aims to teach a skill, and somatic therapy, which aims to explore an issue—the relaxation itself is the treatment.

Help find resources like housing, benefits, and work

Mental health challenges can be compounded by stress, and not having money or a place to live is very stressful! These services help a person find those things. This help often comes from social workers, case managers, supportive employment programs, or directly from government social services agencies.

Provide support, encouragement and accountability to make changes

Changing distressing or dysfunctional patterns is difficult and staying motivated is often hard. Having someone to encourage you, offer advice, celebrate wins and struggle through challenges with you can make it easier. This service is usually provided by coaches, 12-step programs, support groups, and people with titles like ‘recovery and addiction specialist’.

Provide a calm environment to stay in

Crises can be triggered by stressful life situations; calm environments help someone relax and deal with their psychological situation with more breathing room. In these environments often someone else looks after major life responsibilities like cooking, cleaning and finances, although sometimes they take more responsibility for it over time. Calm environments include residential treatment centres and peer respites. 

Relentlessly, resourcefully provide treatments

When someone is experiencing intense mental health challenges it’s common for them to feel ambivalent about participating in treatments or taking medications, or to lack the motivation to do it. Some services explicitly involve providers being so persistent in following up with their clients that they are able to find them and check in on them anywhere even if the person’s life is very unpredictable. This can make it easier for the person to participate in treatments and take medication, which makes those things more effective. However, some people may consider the persistence of such providers to be overwhelming or distressing in and of itself, or may find it threatening. Services that work this way include assertive community treatment teams, intensive case management, and some suicide crisis centers.

Enforce treatments with the threat of locking someone up

If someone has been prescribed treatments such as medication, therapy or an intensive case management program and they refuse to do it, and their mental health gets worse or continues to be extremely bad, doctors may get a court order to say they must do the treatment that has been prescribed for them, or else they will be brought to hospital to be involuntarily committed. This is rare and most often used for people who have already stayed in a psych hospital multiple times. Some people say it violates their autonomy and is an extremely distressing experience itself; some people say that it is unfortunately necessary for making sure a person can get treatments at all if mental health services are hard to get, because service providers legally have to help them get it. This is called involuntary outpatient treatment, involuntary outpatient commitment, community treatment orders, or assisted outpatient treatment.

Help resolve conflicts and strengthen relationships

Challenges in close relationships can be a big source of stress and potential triggers, and also makes it harder for loved ones to be supportive when someone is trying to handle a mental health challenge. Some providers help mediate conflicts, teach conflict resolution skills, and build rapport with a person’s family. This service might be provided by a marriage and family therapist, a family specialist, a social worker, or informally by different providers if a problem comes up.

Teach skills to their loved ones

If someone’s mental health challenges involve acting in ways that impact the people around them, then it can be helpful to teach their loved ones strategies for responding that will encourage helpful changes, and prevent crises. This is particularly true if the person with the challenges is a child and their parent has a lot of control over the rules, rewards and punishments of their social environments. This kind of family training can be provided in extensive outpatient programs, specialist psychosis programs, and family-specific classes.

Do direct brain stimulation

It is possible to change someone’s mood or mental state by stimulating their brain directly, using electricity or magnetism. This can ‘jolt’ their mental state into a different, more tolerable one. Such treatments are rare; some people find they are helpful when all other treatments are not, while others consider them too risky, and potentially permanently damaging.

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This is the whole list! I don’t claim to say any of these are entirely good or bad, even the controversial ones; the aim is simply to list them out, today. What do you think? Did I miss any major ones?