Let’s say you’ve got a new idea to improve peoples’ mental health. Well, tough luck, since in 2025, we are sold a million ways to do this.
My social media feeds are full of 440 Hz frequency tones that help you focus, hypnosis courses that reprogram your subconscious, and a headset that retrains your brain waves to reduce stress.
Now, this feed curation might (probably) be affected by my work at a neuroscience startup trying to research markers of depression - but still, there are thousands to millions of users using these products! Moreover, they report substantial rates of symptom improvement for users, cite peer-reviewed scientific literature, and even have evangelising clinicians.
A question that always pops into my mind when I see these ads is: How do I tell when something is helpful, or hogwash?
Who is Overton, and why does he have a Window?
I think that the baseline of how we judge ‘hogwash’ comes from the dominant beliefs in our particular time period - the cultural zeitgeist. When you see the above ideas, you probably judge each of them as either ‘reasonable’, ‘weird but acceptable’ or ‘absolutely bonkers’.
I’ve always framed this concept as the Overton Window, referring to the range of ideas which are acceptable to a population at a given time period, on a spectrum from unthinkable to popular.
Going along with what is popular is helpful for cognitive outsourcing, as it’s hard to critically analyse everything. But of course, just because something is unpopular, doesn’t mean it’s untrue - some of the greatest ideas start off as Unthinkable. For instance, in the early 1500s, it was a commonly held belief that the Sun revolved around the Earth (Geocentrism). Copernicus instead proposed a model where the Earth revolved around the Sun (Heliocentrism), which when popularised by Galileo was not well-received by the Romans. But gradually, over time, Geocentrism was upturned and Heliocentrism became the accepted norm in the Overton window. This is now known as the Copernican Revolution.
This example demonstrates how expertise comes into play; they enable shifts in the mainstream Overton window. Crucially, these experts also have their own Overton windows, which enable these shifts! For instance, a treatment like electroconvulsive therapy would probably be around Radical-Acceptable for the mainstream public, but fits more into Sensible-Popular amongst psychiatrists, given that they consider it the gold standard for severe depression!
However, in mental health, “expert” doesn’t cleanly point to one group. In fact, there’s a meta-Overton window of who the right experts are! Institutions recognise psychiatrists and psychologists, grassroot movements have empowered lived experience advocates, and now waves of alternative medicine, wellness ideologies, and neuroscientists have come into vogue, all with their own philosophies and beliefs. Not to even mention the whole world or art - books, music, films, can be intensely healing, after all (2).
Deciding which expert to believe in requires understanding how each expert field creates and maintains their Overton windows; since these govern how new ideas are filtered through and considered by the community as acceptable.
Understanding this, well, you are basically god understand how to move ideas from hogwash to helpful.
So, you wanna make a new psychiatric treatment?
I’m woefully unqualified to understand what governs the Overton window of Spiritual Healing - but as an overly keen medical student, I can certainly spout on theories about Psychiatry! Let’s go to the story of Transcranial Magnetic Stimulation (TMS), one of the modern psychiatric success stories.
TMS is a bizarre treatment to the uninitiated - a year ago, I participated in a study exploring brain current activity (EEG) changes with TMS, where as a research participant I had brief TMS bursts applied to my noggin’ (see below). It’s a machine with a magnet, accompanied by a robotic whizzing sound when it’s running - it doesn’t feel like much, although some people get headaches. It’s currently indicated to treat depression that antidepressants haven’t worked on.
I recently went to a psychiatry conference, where around a thousand psychiatrists gathered to learn about new developments in the field. There was a section on electrostimulation, and a series of lectures which described the current practice of TMS and its medical justification.
TMS began in 1985, where Barker and Colleagues in England developed the first TMS coil - with the intuition that using a magnetic field could enable electrical changes in the deeper part of the cortex, in turn affecting neuronal activity and firing patterns. (Remember Faradays’ law in highschool? Who told you Physics wasn’t useful).
The conference speaker described how unlike a good chunk of psychiatry, where although medications were discovered serendipitously, TMS was hypothesis-led. fMRI studies demonstrated that the left dorsolateral prefrontal cortex (a mouthful, I know) seemed to be hypoactive in depression - and so, they decided this would be the first target for TMS. (Naturally, the true story gets a lot more complicated, but that warrants another essay).
Importantly though, you don’t have a clinical conference without some good ol’ evidence. And boy, TMS has certainly built its case - but hold on, I’m getting ahead of myself.
What is evidence in medicine? In medical school, we get taught the ‘evidence pyramid’, which (abridged) goes from anecdotal case studies, to Randomised Controlled Trials (RCT), and finally, Meta-analyses. RCTs are studies which randomly assign a group of people to a treatment or a placebo condition, hold everything else constant (as much as possible), and then compare the resultant change. Since one study can have protocol flaws or not enough people, Meta-analyses then group the results of multiple RCTs to come to a conclusion.
And how does TMS fare? The Royal Australian and New Zealand College of Psychiatry cites 5 meta analyses in TMS and depression in their guidelines, which they consider sufficient evidence to recommend TMS for treatment. The largest meta-analysis cited includes 81 RCTs, with a total of 4233 patients, and all of the selected meta-analyses indicate a reduction in depression symptomatology following TMS compared with placebo.
There are two parts to this TMS story I wanted to highlight:
Medical Theory-Based Justification. TMS was able to align neuroscientific theory, cellular-based models of brain function, and physics-based principles to justify its intervention. Medicine necessitates an underlying dogma of belief to be accepted by the community; although it can at times come post-hoc, as in the case with many antidepressants.
Clinical Evidence & Protocolisation. TMS underwent the evidence collection process as most medical procedures undergo - a time-intensive and costly process. Unlike drugs, TMS is a procedure with a wide range of variables; where you place the coil, the frequency of the bursts, the duration of the treatment… But they’ve constrained these to specific protocols amenable to the RCT paradigm.
These two points create both a story for clinicians to explain to patients, and an institutionally recognised evidence-base necessary to justify treatment. These are examples of key forces (4) which govern the Psychiatric Overton window. You can’t move from Unthinkable to Policy without them.
And what are the fruits of this labour? Now that TMS has gone into the Policy realm of Psychiatry, we see it being entrenched into the institution - the most clear marker being regulatory approval and reimbursement in public healthcare systems. TMS has FDA clearance in the US, and public reimbursement for severe forms of depression in the UK, Australia, and Singapore to name a few.
But just like Geocentrism, the Overton window is dynamic and can shift if the regulating forces deem it so. A more recent 2024 re-analysis of TMS meta-analyses calls into question the methodological validity of these conclusions, whereas another 2023 meta-analysis questions whether the TMS effect is more placebo than real.
TMS still faces challenges in separation of commercial incentives, scaling its commercial model, and convenience for patients, but it marks an achievement from neuroscience, psychiatry, and engineering.
More than you needed to know about Neurofeedback
TMS shows what Psychiatry filters in, but what does it filter out?
Let’s go to an example of an intervention which hasn’t (yet) broken into the Psychiatric Overton window, called Neurofeedback (NF). In this intervention, you monitor a patient’s brain waves - typically EEG (3), the same tool used in the research study I was in - and administer positive or negative feedback based on whether the brain waves fit within a defined range. This feedback can be given in the form of a game, or audio (think of an alarm sound when you get out of range), or visual.
On first glance, you might feel this seems similar - It also relies on neuroscientific-based theories, seems initially unnerving to patients, and reports to do weird stuff with my brain?! The psychiatrist’s verdict? Negative. Neurofeedback is currently still on the fringe within the medical community, and placed squarely into the Radical-Acceptable camp.
Why is this? Let’s consider the same two Psychiatric Overton window forces, which enabled TMS.
Medical Theory-Based Justification
NF’s story originated in the 1930s, where two French researchers, Durup and Fessard, observed that brain activity could be voluntarily controlled with feedback. This declined in the 1980s and 90s due to poor signal reliability, but renewed interest in the 2000s.
The premise of neurofeedback is similar to TMS, in that it targets specific brain regions implicated in depression, such as the dorsolateral prefrontal cortex. But instead of stimulating the brain directly, its mode of action is based on operant conditioning: reinforcing good brain activity when it appears, and enabling the brain to subconsciously favor those patterns.
This is speculative, but I suspect this story isn’t as convincing as the magnet story in medicine - and perhaps this is because medicine has wired clinicians to desire a more biological mechanism of action. It calls upon neuroscientific theory, but the final story relies on psychology, which most doctors aren’t typically trained in, and thus fits less cleanly into the Psychiatric schools of thought.
Clinical Evidence & Protocolisation
Using the same yardsticks as TMS, how has NF fared in depression treatment (5)?
On first glance, one might consider NF on a similar path as TMS, with two recent meta-analyses both finding 22 studies related to NF as an intervention for depression, and concluding an overall improvement in depression symptoms.
But here comes the expert nuance - some of the biggest criticisms of the field challenge the lack of control groups, especially of earlier NF studies, leading to placebo effects. The authors of the first meta-analysis acknowledge the lack of RCTs as a limitation, and conclude that further high quality research is necessary for the field to advance.
Another critique involves the heterogeneity of protocols. There are many ways to deliver NF: amplitude training, LORETA-based, Infraslow, signal-to-noise ratio, alpha training - all jargon-istic terms which refer to different brain signals you train on, none of which have found conclusive efficacy over others. This suggests to me NF is in an earlier stage than TMS, where a field proliferates with different protocols but eventually converges via clinical evidence.
NF has many parallels to TMS as an intervention, but struggled to break into the Overton window due to issues in framing and insufficient clinical evidence. This is a reflection of the regulating mechanisms of the Psychiatric Overton window; even if NF is a promising treatment (which many clinicians report it to be), it needs to pass these barriers to receive widespread acceptance and thus adoption.
The Mental Health Dilemma
How does all this fit your mental health innovation into the helpful vs hogwash debate?
To recap, in syllogistic IQ test-question style:
Whether an idea is hogwash or helpful is an opinion usually based on a mainstream Overton window
Expert fields can influence mainstream Overton windows
Expert fields are based on different Overton windows to mainstream ones, and are regulated internally by different dynamics
Psychiatry is an example of an Expert field, and it self-regulates the Psychiatric Overton window by factors like biological justifiability and clinical evidence, as indicated by anecdotes of TMS and NF
Easy right? So we’re happy that all mental health innovation should do clinical trials and base foundational beliefs on biological premises, and mental health will be cured?
Hmm…
Alright, time to fess up - I’ve done a cheeky sleight-of-hand throughout this. I’ve implied the only expertise which governs mental health is psychiatry, where all the 100s of different disciplines have likely been reading this with clenched teeth and strong detestations at a range of the above ideas.
Trusting medical opinion implicitly means believing that biomedical justification and evidence-based medicine are the necessary regulatory forces to find mental disorder interventions.
Many thinkers, including psychiatrists, believe in a more pluralistic approach, which takes into account a biopsychosocial model (6). But it remains that each Expert field has their prevailing ideologies and regulatory mechanisms, and each has their own regulatory forces which enable your idea to move into the gilded spot of Policy. I’ve gone through some of the mechanics of Psychiatry, but there are plenty more to explore in other Expert fields.
So, dear innovator, which Overton window do you want to shift?
(1) The overton window is typically extended to have a spectrum of Leftist vs Rightist political opinions, but for the purposes of this article I’ll focus on a single half.
(2) I’m reminded of when I started to go watch plays at the beginning of my medical degree, and thought astutely: Actors understand the psychology of the everyday human condition more viscerally than any clinician. The general spectrum of mental health included.
(3) Recent studies are also more excited about fMRI-based NF, like this 2024 FDA approval for PTSD treatment, but I’ll stick with EEG for clarity.
(4) I’ve chosen depression as a clear comparison to TMS to demonstrate NF’s relative lack of evidence; it should be noted that NF is more established in ADHD, and with emerging interest in PTSD.
(5) There are of course, other forces which influence the window - such as commercial incentives - but I consider these two as unique hallmarks of Psychiatry/Medicine.
(6) See Aftab (2024) for an interesting discussion on Pluralism, which seeks to unify many perspectives into mental health