01 Oct Clinic of the Future Part VI: The Potential of Combined Therapies

This this post was originally posted here

Over the last few months, we’ve been exploring the hypothetical clinic of the future, focusing on how emerging treatment modalities like psychedelics, transcranial-focused ultrasound, metabolic therapies, and relational practices can synergistically improve mental health care.

We’ve proposed four categories for these innovative approaches:

• Relational: Emphasizing the therapeutic relationship between clinicians, therapists, and patients, fostering social connections and community support.

• Experiential: Utilizing interventions that induce altered states of consciousness, such as psychedelic-assisted therapy, to facilitate profound personal shifts as well as sensory stimulation from programmatic light, sound, and haptic technologies.

• Energetic: Neuromodulation tools like transcranial-focused ultrasound stimulate neural tissue and optimize brain activity directly.

• Metabolic: Leveraging the connection between metabolic processes and mental well-being, such as through ketogenic diets, to address the physiological roots of mental health conditions.

Our central thesis is that the pinnacle of care will be a multimodal, collaborative, and holistic combination of two or more categories.

Today, I want to explore two ways these things can be combined and close out this series with some thoughts on a potential failure mode of “holistic” care.

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The Potential of Combined Therapies

It is unlikely that providers and clinics will specialize in all of these specific approaches, and future clinics might specialize in particular combinations of these modalities.

For example, Greenbrook TMS delivers transcranial magnetic stimulation (TMS) and Spravato (esketamine) at more than one hundred clinics around North America.

Future clinics will deliver many permutations of the emergent treatment technologies; below are a few hypotheticals.

Relational-Experiential-Metabolic

The ketogenic diet is an intervention that shows incredible promise for severe mental illnesses.

In May, researchers published a case series titled Complete Remission of Depression and Anxiety using a ketogenic diet: case series. The authors note:

“Complete remission of major depression and generalized anxiety disorder occurred within 7–12 weeks of therapeutic nutritional ketosis during treatment with a personalized animal-based ketogenic diet in adults with complex comorbid depression and anxiety engaged in a specialized metabolic psychiatry program.”

However, adopting a ketogenic diet can be challenging due to its significant departure from conventional eating habits and the emotional complexities surrounding food. This is where the synergy of multiple therapeutic modalities can be transformative.

Imagine a patient embarking on the following journey:

• Experiential: They begin with a course of psychedelic-assisted somatic psychotherapy. This experience allows them to explore their relationship with food, their body, and the underlying emotional patterns driving their dietary choices.

• Relational: Following psychedelic therapy, they join a professionally led integration group, connecting with others who share similar goals. This supportive environment fosters accountability and encourages the development of new, healthier habits.

• Metabolic: Empowered by the insights from the psychedelic experience and supported by their peers, they adopt a ketogenic diet under professional guidance. The integration group provides ongoing support and encouragement, facilitating long-term adherence to the dietary changes.

This integrated approach addresses the multifaceted nature of mental health, combining the transformative potential of psychedelic therapy with the supportive power of group dynamics and the physiological benefits of a ketogenic diet.

By weaving together experiential, relational, and metabolic interventions, we can create a synergistic pathway towards healing and reducing suffering. 

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Multimodal Sensory Simulation

One of the most exciting—and simplest—recent findings in neuroscience and psychology concerns the importance of sensory processing in mental health and the role of programmatic sensory stimulation, such as light, sound, haptics, and thermal stress, in enhancing this neural process.

Sensory processing refers to the nervous system’s ability to reliably receive, interpret, and respond to sensory information from both the external and internal environment.

And as we noted in Part I, “Nearly all of the difficult-to-treat mental health conditions are predicated on disruption or miscalibration of the nervous system’s ability to perceive and assign threat value to incoming sensory information.”

In response to early life trauma and prolonged periods of stress, it is common for the brain to shunt metabolic energy away from the sensory pathways as an adaptive survival response because so much emotional sensation from these periods is too overwhelming.

As a result, trauma and prolonged stress lead to a disconnected or disembodied state.

This diminished capacity to feel sets the stage for depression, anxiety, addiction, and compulsive behavior.

In their book Better in Every Sense, University of Toronto researchers Norman Farb and Zindel Siegel describe it this way:

“…despite how plausible it seems that blocking out sensation would reduce sadness, the participants who blocked out sensation did not report feeling less sad in the moment—it’s just that their sadness had become a type of expectation, concept, or thing, rather than a living, embodied experience….

Our most depressed participants had somehow learned to regulate their feelings away, an understandable reaction to being continually exposed to stress, loss, and harsh internal judgments. Yet because physical sensations are the building blocks of emotion, the more a person shut out the feeling of what was happening in their bodies, the less they could experience any emotion.”

Emerging research supports the use of programmatic light, sound, haptic stimulation, and even thermal stimuli for strengthening sensory pathways.

In a paper titled An Active Inference Approach to Interoceptive Psychopathology, the authors posit:

If the body is the nexus by which therapies can directly alter interoceptive states, then it follows that body-based therapies should provide a more direct entry point by which to manipulate the interoceptive system and correct somatic error. 

Again from Norman Farb and Zindel Siegal:

This is precisely why rebuilding sensory pathways is so transformative. Because attention is a limited resource, a powerful way to break down a dominant narrative or worldview is to starve it of those attentional resources. A simple way to do this is to attend to elements of experience that are not already bound up in this worldview—every moment of attending to a sensation that is not obviously relevant is a moment of taking resources away from the story we tell and re-engaging with the unknown. 

In other words, the body not only keeps the score but also calls the shots that keep us locked in rumination, worry, and pain patterns.

Sensory stimulation through light, sound, haptics, or thermal stimuli can help re-engage these pathways, leading to a more accurate perception of the present moment and promoting a sense of embodiment.

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Kitchen Sink vs. Silver Bullet 

Finally, while these emerging technologies and innovations portend an exciting and promising departure from the current paradigm, they are not without potential pitfalls and points of failure.

A particular failure mode for this kind of holistic thinking I refer to as the ‘Kitchen Sink’ problem and it has plagued integrative/holistic health practices for as long they have existed. 

Let’s imagine a future clinic replete with infrastructure, staff, and treatments we’ve been discussing: psychedelic-assisted therapy, transcranial-focused ultrasound, closed-loop multimodal neurofeedback, metabolic therapy, etc. 

How do we direct patients to the most optimal treatment for them?

Throwing the proverbial ‘kitchen sink’ at each patient is neither feasible nor good practice.

Not everyone will respond to these treatments; they may pose risks for some. For each individual, there will be an optimal “entry point” that will vary depending on their current situation, preferences, medical history, etc.

To my mind, the role of the clinic of the future then is not only to offer these treatments but to elucidate a method for identifying the optimal treatment path for each person.

With this advent of innovation, distinguishing between patients who would benefit from experiential interventions (e.g., psychedelic-assisted therapy) versus those who might need metabolic therapies or neuromodulation will be crucial.

Developing robust assessment tools that can identify the most appropriate therapeutic entry point for each patient through evaluation of the patient’s physical, psychological, and social history is crucial to tailoring a treatment plan.

Of course, any personalized assessment will rely on technologies based on patient-specific biomarkers, genetic information, symptom patterns, and even lifestyle factors. This data-centric approach can guide clinicians in avoiding the overuse of therapies, thus minimizing the ‘kitchen sink’ approach.