Brain Wave

There is a sea change occurring in psychotherapy. Multiple discoveries in neuroscience and developments in a variety of fields are converging and making it possible to transform how we conceptualise therapy and how we practice it.

One major era is ending in psychotherapy and a new one is beginning. Thirty years ago, Prozac, the DSM-III and “evidenced-based” therapies all came into being within a few years of each other. These innovations promoted a coherent way of thinking about, classifying and treating mental conditions, and became institutionalised in a model we refer to as the pax medica. Two thousand years ago, the Emperor Augustus ended a series of destructive civil and foreign wars, and instituted an enduring period of relative harmony under the rule of law. Commerce thrived. As the Pax Romana made possible a suspension of hostilities under the rule of an emperor, the pax medica brought relative peace to the warring fields of mental health, under the hegemony of the medical model. The pax medica era medicalised psychotherapy procedurally and influenced psychotherapists down to the very words we use in describing our work.

In this article we argue that the pax medica is being replaced by a dynamic new understanding of how psychotherapy works. Based on neuroscience, developmental psychology, psychotherapy research, complexity theory and a reconceptualisation of existing psychological theories, we call this new model brain-based therapy (Arden & Linford, 2009a; Arden & Linford, 2009b; Linford & Arden, 2009). Brain-based therapy sheds new light on a question that has beguiled psychotherapy from its beginning: How can a simple conversation—or, as Freud called it, the “talking cure” change the brain?

To understand where we’ve been and what the future offers it is useful to understand pax medica within a historical context. By the mid 20th century critics were beginning to ask if psychotherapy actually helped. Up until then psychotherapy was steeped in psychoanalytic lore. From the time of Freud through the 60s, some form of psychoanalytic/ psychodynamic psychotherapy was just about the only game in town. If you had a problem, you did some version of laying down on a couch to talk to an analyst who maintained a posture of neutrality. Except for draconian treatments for severe mental illness, (electroshock, lobotomy, ice baths) stranglehold had a lock on psychotherapeutic practice. The physical brain seemed not to have existed at all; what mattered were drives, conflicts, repressions, and transference dynamics.

One eminent psychologist, writing in the 1950s, answered the question: “Does therapy help?” Quite simply: “It doesn’t.” In a review of the existing outcome literature, the formidable Hans Eysenck (1952) stated that psychotherapy was no more effective “than the mere passage of time.” Timothy Leary (before his psychedelic period and when he worked for Kaiser Permanente), compared therapy patients to those on waiting lists, and found that being on the waiting list appeared to be about as effective as therapy. The study went largely unnoticed. At about the same time that Eysenck’s critique was published, the first tricyclic antidepressant appeared, thereby putting into the hands of psychiatrists what they assumed to be a powerful alternative to the talking cure. Isolated from the biological sciences and averse to empirical inquiry, psychotherapy seemed about to be relegated to the niche of second-rate “alternative” treatments for psychological disorders.

During this period of upheaval, Carl Rogers introduced client- centred counseling approaches. He offered an alternative to psychoanalytic therapy that removed metapsychology from therapy and added in its place a strong dose of humanism. Soon thereafter, a wide variety of other schools of psychotherapy burst onto the scene, including variants of behavioural, gestalt, narrative, and cognitive therapy. Instead of fruitful dialogue and integration of the concepts from these schools of therapy, under pax medica these became a mere sideshow.

The Pax Medica

While the first tricyclics were found to be mildly successful in treating depression, it was the advent of Prozac in 1974 that changed everything (Wong, et al., 1974). Prozac shifted psychiatry away from a preoccupation with meaning and towards a fascination with the effects of various medications. Part of Prozac’s success was based on the enticing notion that it corrected “chemical imbalances” in the brain, and at first glance it appeared that controlled trials proved the theory might be plausible. Even today, more than 30 years after its advent, Prozac remains hugely popular around the world. In the U.S. alone, millions of prescriptions annually are written for the drug’s generic version and two newer generation antidepressants are even more widely prescribed. In the U.S., 1 in 20 men and almost 1 woman in 10 uses an antidepressant (Barber, 2008). By contrast, about 1 in 20 adult Americans sees a psychologist, psychiatrist, or social worker for psychotherapy. The number of patients treated for depression with psychotherapy actually declined between 1987 and 1997, a decade during which prescriptions for antidepressants doubled (Barber, 2008).

Actually, the concept of medical treatment for psychological problems has wide support in popular culture. Te obvious appeal of a simple pill to “fix” one’s depression seems preferable to endless therapy. The idea that a medical doctor could tweak a “chemical imbalance” to help patients become free of depression is irresistible. Medicinal cures for psychological problems is a quintessentially American solution—fast, easy, simple, efficient, and new. Psychodynamic psychotherapy, by contrast, appeared quaint, slow and old-fashioned, a bit European.

CBT and the DSM

Post-Prozac psychotherapy had to change in order to survive. Addressing the mounting skepticism about psychotherapy’s effectiveness became imperative. The psychiatrist Aaron Beck led one effort to establish “indisputable evidence” of psychotherapy’s effectiveness (1972; Beck et al., 1979) and its worthiness for inclusion in the armamentarium of effective medical treatments. Whereas many therapists were disdainful of the social-science research paradigm underlying psychotherapy outcome research, Beck saw this paradigm as an opportunity to build scientific credibility for his own approach, cognitive behavioural therapy (CBT). Somewhat after the fact, in a 2007 APA convention talk, Beck joked about his almost total lack of familiarity with psychological research. He ignored the brain and made only parsimonious assumptions about how the mind worked; but even more than Freud, Beck championed the view that technique is what matters. Like Freud, Beck was a physician who viewed psychotherapy as a mental health treatment.

Beck’s work dovetailed seamlessly with a new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, American Psychiatric Association, 1980). The editor of DSM III, the psychiatrist Robert Spitzer, identified what were to become some of psychiatry’s “greatest hits”: panic disorder, ADHD, and major depression. In a field fraught with complexity and ambiguity—and in a world where enormous amounts of money were at stake—Spitzer offered mental health professionals some peace, simplicity, and the comfort of a renewed faith in authority. His time rapidly became the “bible of psychiatry” for insurance companies, the disability and criminal justice systems, and researchers seeking government approval for new drugs.

The collective influences of Spitzer, Beck, and the pharmaceuticals resulted in a compromise in the mental health treatment community that has worked reasonably well since the late 1970s. This pax medica stipulates that in psychotherapy, as in dermatology, diagnosis is vital to planning treatment for and evaluating a patient. Treatment should target the patient’s symptoms. Thus, the new language made provision for clinicians, who formulate treatment plans for their patients to ameliorate symptoms associated with specific diagnoses in line with medical necessity.

As an indication of how thoroughly the medical model had penetrated the mainstream psychology, in the mid-1990s the Society of Clinical Psychology of The American Psychological Association (APA) established a task force on “empirically validated treatments” (Norcross, 2002). To earn the designation “empirically validated”, a treatment had to be shown superior to placebo or comparable treatment in two separate randomised clinical trials. The intervention had to be reducible to a clear and teachable manual. Eighteen DSM-III disorders were seen as candidates for this process; almost all the methods that initially qualified as “evidence-based” were CBT. It seemed that Beck’s coronation as the king of evidence based treatments was imminent and psychotherapy had found a secure place within the pax medica.

There were also potent market forces at work in the pax. Major clients of the mental health establishment—insurance companies, the courts, the disbility industry—needed an extensive, categorically distinct list of discrete diagnostic entities, and assurances that they were getting something effective for the dollars spent on psychotherapy. The DSM gave payors, such as insurance companies and managed care, a procedural way of making decisions about reimbursements: treatments would be reimbursed only for particular diagnoses and only if they were tackled with “evidenced-based” treatments.

Cracks in the Castle Walls

Some outcome researchers and neuroscientists remained skeptical, however. Just four years after the publication of the DSM-III, three little-known academics turned the spotlight of social science research methodology on the question of psychotherapeutic benefit. Smith, Glass, and Miller, in The Benefits of Psychotherapy (1980), by aggregating many smaller well-designed studies, reached two important conclusions: Psychotherapy was robustly effective; and (against the spirit of the times) the methods employed by therapists seemed to have no significant effect on outcome. Between 80 and 90 percent of research in psychotherapy since Smith et al. has continued to examine the efficacy of specific methods for specific disorders (Bohart, 2000). Gradually, however, skepticism about the singular importance of methods and diagnoses has come to be taken more seriously. The alleged superiority of CBT has attracted the scrutiny of increasing numbers of dissidents within the APA and elsewhere.

The critics argue that the core processes of psychotherapy differ only slightly across methods. For example, gestalt therapy was using the term safe emergency for the type of intervention CBT therapists call exposure (Perls, et al., 1951). Similarly, psychoanalysts also believe that working through and integrating repressed troubling thoughts and feelings is an important ingredient in recovery. We agree with Lou Cozolino that “all forms of successful therapy strive to create these safe emergencies in one form or another” (2002, p. 32).

Championed by the estimable John Norcross and Michael Lambert (Lambert & Ogles, 2004), opponents of the specific methods schools of psychotherapy have wondered why the “evidence-based” research all but ignores anything but diagnosis and methods (Norcross, 2002). Why omit factors such as the client’s functional impairment, strength of resistance, treatment expectations, or stage of change? Lambert’s work in particular has undermined some of the fundamentals of the Pax Medica. He demonstrated that diagnosis is not a significant factor in outcome and that the contributions of specific methods are relatively minor. According to Lambert, who the client is and what he or she brings to the therapy are the best predictors of success (Lambert & Ogles, 2004). So-called common factors the warmth, confidentiality and support found in virtually all psychotherapeutic approaches are the next most powerful elements in the outcome of treatment.

Based on decades of psychotherapy research, Lambert has offered the following conclusions:

• Psychotherapy is as effective as many common medical treatments
• It works well due to the common factors that underlie different schools
• The “best practice” in individual psychotherapy is to ask the client how things are going in the therapy on a regular basis (preferably during each visit)
• Generating “treatment-based evidence” for therapists about therapeutic progress and the patient’s view of the state of the alliance minimises failure and significantly enhances overall outcomes (Lambert, 2006).

SSRIs Redux

If psychotherapy research has eroded the conviction that there is only “one method” for conducting successful psychotherapy, the social science research paradigm has, like a river overflowing its banks, engulfed the simplistic “one-factor” theory of antidepressant action (Arden & Linford, 2009a). Like so much of American society, where the marketplace taints beliefs, the pharmaceutical companies have promoted the idea that a “chemical imbalance” is the cause of depression, and massive marketing has convinced millions of patients that by manipulating their neurotransmitters they can cure their depression. Tis “one-factor”, linear model underlies the dramatic success in marketing serotonin reuptake inhibitors (SSRIs). What it omits is the fact that the brain is different from the liver or other organs in the body. The brain is a non-linear, complex system that changes itself through experience, especially experiences of interpersonal connection that rewire the brain from birth onwards.

Recent events bolster our impression that the pax medica, and with it the one-factor theory of antidepressant action, are in their waning years. Researchers at the Oregon Health and Science University (Turner, et al., 2008) subpoenaed the FDA to release all the studies on antidepressant effectiveness in its archives. Because science journals prefer positive findings over negative ones, Turner and his colleagues were unsurprised to find unpublished studies concluding that SSRIs are no more effective than placebo. What was a surprise was the number of such studies. Research reporting positive effects for antidepressants was 12 times more likely to be published than studies reporting negative results. Turner et al. concluded that publication bias had inflated the common impression of the effectiveness of SSRIs by about a third overall; and for some medications, the figure was twice as high (Turner, et al., 2008). Post Turner estimates of the effectiveness of antidepressants have dropped to a level close to that of placebos.

Indeed, the early, widely touted success of SSRIs was based on an overly simplistic methodology and selected reporting of results. Large-scale reanalysis of the studies of efficacy of SSRIs indicates that these agents are effective between 56 to 60% of the time (Taylor, et al, 2006). A recent meta-analysis shows that between 42 and 47% of subjects respond to a placebo (Arroll, et al, 2005). An effect 10% greater than placebo does not quite justify the psychiatric and popular confidence in SSRIs as the first-line treatment for one of the most common mental disorders.

In addition to the reexamination of the efficacy literature, the one-factor theory of SSRI action has been subjected to neuroscientific scrutiny. Since there is no way to measure the amount of serotonin in a person’s brain, some researchers have opted to measure a means for the production of serotonin. Neurotransmitters are synthesised from amino acids. In the case of serotonin, the amino acid is tryptophan. Researchers at the University of Arizona recruited subjects to tryptophan-free diet, which should theoretically reduce their serotonin levels. The intervention appeared to have no effect on healthy people with no family history of depression; but a third of the healthy subjects who did have a family history of depression became depressed. What about the 66% of the sample that remained depression free? These results strongly suggest that more is involved in depression than just a “chemical imbalance,” and too little serotonin (Delgado, 2000). What is most striking is that two-thirds of people being treated with anti-depressants at the time relapsed with depression after five hours. Serotonergic antidepressants usually take up to four weeks to be effective. Yet, this effect occurred in merely five hours! This finding seems to suggest that the SSRIs do indeed effect serotonergic systems, but how? Another study, from a completely different angle, showed that the European drug called Tianeptine reduces depression. Tianeptine acts to reduce serotonin (Fuchs, et al, 2002).

In another event signalling the beginning of the end of pax medica, three enterprising psychologists (McKay, Zac, & Wampold, 2006) obtained and reanalysed data from the medication segment of the NIMH’s Treatment of Depression Collaborative Research Program (Elkin et al., 1989). McKay et al.’s results bear eloquent testimony to the power of the prescribing relationship. The original NIMH study did not include the relationship as a study variable, but focused instead on comparing the effects of the antidepressant imipramine with a placebo. Published results heralded the power of the pill. In the study reanalysis, however, it became apparent that the most effective psychiatrist actually got better results with placebos than the worst-performing psychiatrist got with antidepressants (McKay, Zac, Wampold, 2006).

In an article in Scientific American aptly entitled “Antidepressants: Good drugs or good marketing?” it was reported that, due in part to the power of simplistic model of what causes depression, only half of all drug trials over the past century were published or reported (Dobbs, 2006)—another shock to the walls of pax medica.

Brain-Based Therapy

The re-introduction of the complete brain into our understanding of psychotherapy is an indispensable part of the sea change about to occur in our field. In contrast to the one-factor model of pax medica, which envisions chemical imbalances and specific methods targeted to the symptoms as the crux of “treatment,” brain-based therapy provides an integrated model that fits together pieces of the puzzle, which include evidence-based practice, alliance/outcome management research, psychological theory, and neuroscience.

Brain-based therapy is not a reductionist perspective. It sifts through psychological and research to discover common denominators relevant to how the brain operates. Some methods and concepts have utility, others less so, and others are blind alleys at best and counter-therapeutic at worst.

We discuss the new developments in neuroscience and evidence-based practices with our clients to give them a tangible idea of what had gone wrong and what they can do to get out of the emotional rut in which they find themselves. Overall these developments include:

• Neuroplasticity
• Neurogenesis
• Affect asymmetry
• Social brain networks
• Nutritional neuroscience
• Implicit and explicit memory differences.

The first two have been highlighted in several television and radio programs. Neuroplasticity is a phenomena that illustrates beautifully how brains can change, given the right conditions, such as effective therapy. Through the establishment of new synaptic connections, new habits can be formed and exchanged for bad habits such as depression and/or anxiety. We teach clients to use the mantra of neuroplasticity, “Cells that fire together wire together,” to keep them on course and practising the new thoughts and behaviours learned in therapy.

We tell clients that when neurons fire together often, they fire together at a quicker rate and without as much effort. For example, when learning to ride a bicycle, we use more muscles and neurons than will be necessary once we have learned to ride efficiently. Most of us wobble when we make our first attempt at bicycle riding. Later, our precision necessitates less effort, cognitively and physically, to keep ourselves upright. Similarly, when clients practice new skills learned in therapy, it becomes that much easier to do them out of habit - a new habit.

It was not long ago that we were taught that each of us was born with as many neurons as we will ever have and that it was all downhill from there. If you wanted to accelerate that loss, all that was required was a head injury or indulgence in drink or drugs. The discovery that new neurons can develop in the hippocampus is nothing short of revolutionary. What relevance does this have for therapy, you might ask. Considering discovery that depression often blocks neurogenesis, that excessive cortisol is damaging to the hippocampus, and that up to 19 percent of chronically depressed people incur atrophy in the hippocampus, the concept of neurogenesis is of critical importance. Neurogenesis is spurred by a substance called Brain Derived Neurotropic Factor (BDNF). Sometimes simply called “Miracle Grow,” BDNF is most effectively produced by exercise. This fact alone can be used to encourage clients to exercise. We encourage all our clients to exercise at least 30 minutes a day by using these facts.

We use this information to encourage clients to meet challenges. We describe how a balance between too much and too little activation is the optimum for learning and memory. This balance between too much and too little stress is referred to as the inverted "U"—(or, technically, the Yerkes- Dobson curve). The inverted "U" means that moderate activation keeps their brain alert, generating the correct neurochemistry to allow their brain to thrive and promote neuroplasticity and neurogenesis.

The efficient way to deal with stress is to strive toward a moderate path. With a moderate degree of stress (that is, at the high side of the inverted U) the major stress neurochemicals of cortisol, CRF, and norepinephrine bind to cell receptors that boost the excitatory neurotransmitter glutamate. By moderately increasing the glutamate activity in the hippocampus, there is an increase in the flow of information and the associated dynamics at the synapses that are critical for neuroplasticity. Each time the message is sent along the same pathways it will fire the same signals more easily and use less glutamate—making cells fire together so that they can wire together. The take-home point here is that clients ought not to want to run from stress and anxiety; they want to manage it. And by managing it, they will promote a healthy, thriving brain that promotes neuroplasticity.

We describe how the amygdala and hippocampus are involved in two different types of memory: Implicit and explicit memory. Explicit memory is used when clients try to remember what they had for dinner last night or when they have that dental appointment, or the name of that familiar-looking woman standing next to the water cooler. These are facts, dates, words, and they are pieces of information. It is this type of memory that people often complain that they are losing when depressed or overwhelmed by anxiety.

The amygdala is involved in a different type of memory, referred to as implicit memory. This type of memory is often thought of as unconscious memory. It reacts to the emotional intensity of events and situations. When the situation is potentially dangerous, it activates the fear system in the body. This is colloquially referred to as the fight or flight response.

This alarm system is automatic; that is, it happens before we have time to think about it. We invite clients to think of how our ancestors, thousands of years ago, encountered a predatory animal like a lion. It was best to react immediately and not stand around thinking about the lion, admiring his mane, or wondering why he is bothering them instead of tracking down some tasty antelope. Thus, the fast track to the amygdala and then onto the hypothalamic pituitary adrenal (HPA) axis kept our ancestors alive.

We help clients understand how the panic button can be mistakenly triggered and that there are two principle ways to activate their amygdala: through either the fast track or the slow track. The slow track goes through the cortex. This means that they can think about things before they become fearful. This is both good and bad. It’s good because they can remind themselves that there is nothing to fear. It’s bad if they develop irrational fears. The fast track to activate their amygdala can trigger their sympathetic nervous system into action; it can potentially cause anxiety and/or panic. Tier amygdala can sound the alarm before their cortex knows what's happening. This means that they can feel anxious before they are thinking about something that makes them anxious.

We describe how the orbital frontal cortex and other parts of their brain comprise what has been called the “social brain.” This system of neurons thrives on social interaction. When they are activated effectively, people tend to experience fewer psychological problems and better mental health. We stress the many benefits of social medicine made possible by their social brain networks.

We describe how, from our first few minutes of life, the bonding experiences we have with our parents affect our social brain. Our later relationships modify these neural connections. Positive relationships enhance our sense of well-being, while negative relationships leave us with unpleasant feelings.

We know that neurochemicals such as oxytocin are not only involved in childbirth and bonding, but also later in life they activate intimate relationships. Higher oxytocin levels help blunt pain and make us feel comforted by other people. For this reason, oxytocin is referred to as the “cuddling hormone”. It is effective in activating the vagus nerve system and therefore the parasympathetic nervous system.

The recent discovery of “mirror neurons” has shown how parts of our brain are acutely sensitive to the movements and intentions of others. They are called “mirror neurons” because they allow us to mirror the other person—or feel what they feel. Mirror neurons help us feel what others are feeling without thinking about it. The bottom line here is that the brain thrives on social medicine and that our clients can gain by understanding that pushing themselves to have social contact when they don’t feel like it will produce psychological gains.

The phenomenon referred to as affective asymmetry can be used to encourage depressed and anxious clients to understand that the areas of the brain involved in particular emotional states suggest particular psychological interventions. Negative affect is associated with over-activation of the right frontal lobes; positive affect with activity on the left. This phenomenon is called affect asymmetry. People with an anxious attachment style and/ or a shy temperament over-activate their right frontal lobe relative to their left frontal lobe (Kagen,1998). Therapeutic approaches that activate the left prefrontal cortex and can help alleviate these problems encourage the client to take action more often in respect of the dilemmas that they face.

Studies have shown that hemispheric asymmetry is correlated with particular affective traits. For example, several studies support the idea that depressive symptoms are associated with an imbalance in hemispheric activation, specifically with increased activation of the right frontal lobe and an inhibition of activity in the left frontal lobe (Davidson, 2000; Baxter, et al., 1985, 1989). Generally, the right hemisphere is associated with negative emotions, and the left hemisphere with positive feelings. Also, the right hemisphere is associated with withdrawal behaviour, and the left with approach behaviours. These characteristics can be considered affective traits and are particularly relevant to the therapeutic approach taken. In other words, withdrawing while developing “insight” can be counter-therapeutic.

With respect to developments in nutritional neuroscience, we teach clients that their diet is critical to their ability to maintain affect stability and to develop the conditions for neuroplasticity. The biochemistry of your brain is dependent on obtaining specific nutrients from your diet. Specific amino acids are the crucial building blocks for your neurotransmitters, which are produced when your body synthesises these specific amino acids from the food that you eat. For example, L-Glutamine is an amino acid found in foods such as almonds and peaches and when digested your body uses it to synthesise into the neurotransmitter called GABA. GABA helps you stay calm. Tyrosine is manufactured by your body from amino acid phenylamine. Tyrosine is a building block for the neurotransmitters epinephrine, norepinephrine, and dopamine. It is also an important building block of the thyroid hormone, thyroxin.

Choline serves as the raw material for the manufacture of the neurotransmitter acetylcholine. Choline is found in large quantities in egg yolks. Long ago, Richard Wurtman of MIT noted that inadequate choline causes the brain to cannibalise phosphatidylcholine from its own neural membrane to obtain enough choline to make acetylcholine (Wurtman & Zeisel, 1982). Because inadequate acetylcholine has been associated with memory problems and Alzheimer’s disease some researchers have targeted choline with various types of medications.

Like the Ecsher drawing of the hand drawing a hand, brain-based therapy incorporates the concept of mutually influencing determinants in psychotherapy. Therapeutic interaction changes the brain of both client and therapist. Therapeutic encouragement to confront “emergencies” within the safety of the therapeutic alliance helps the client’s brain rewire itself. The therapist's efforts to encourage self-organising transformation are paramount. It is through these safe emergencies that a client can be encouraged to leap to a higher level of organisation—self-organisation.

Therapy offers the client a chance to experience states associated with strong anxiety, or “emergencies,” safely, with strong (but not too strong) levels of arousal, and to do so again and again, until the neurodynamic underpinnings of a new way of responding are firmly in place.

One of the principles of brain-based therapy is that a moderate degree of anxiety is critical to the facilitation of the rewiring of the client’s brain. It requires a more skillful blend of timing, challenge, support, attunement, and knowledge of theoretical principles and neurodynamics than will ever fit between the pages of a treatment manual. The attunement and bidirectional regulation that goes on between client and therapist is key and, in our view, the most important of the common factors described earlier in this article (Lambert, 2004).

The effects of a new state induced in therapy, if practiced enough, influence the development of a new trait or set point. These properties allow us and our clients to be created and to create ourselves like Escher’s drawing of the hands.

Expansion of psychotherapy’s scope suggests that we are moving beyond the era of the pax medica to a more complex understanding of how people change—and a more accurate view of how psychotherapy helps us do it. At heart we help clients change by enhancing neuroplasticity. Our brains are extraordinarily complex systems that are exquisitely adapted to changing in response to the attuned and compassionate interest of another human being. Attunement helps our clients face that safe emergency, and as that happens, both their brains and ours are changed. We help the process along by educating clients about how their behaviour affects their brains and how that in turn changes how they feel. A promising new era is opening for psychotherapists. We can make the most of it by being mindful of the fact that the brain needs someone to listen to it and encourage change just as much as it needs sleep, good food and exercise to thrive.

About the authors

JOHN ARDEN Ph.D. is a previous Director of Training in Mental Health for Kaiser Permanente in Northern California. He oversees training in twenty-four medical centers, where over 130 postdoctoral residents and interns are trained each year. He is the author and co-author of 13 books, including Brain-Based Therapy with Adults and Brain-Based Therapy with Children and Adolescents (with Lloyd Linford), Improving Your Memory for Dummies, Conquering Post Traumatic Stress Disorder (with Victoria Beckner), Consciousness, Dreams and Self: a Transdisciplinary Approach, The Brain-Based Anxiety Workbook, The Brain-Based OCD Workbook, Rewire Your Brain, and his most recent The Brain Bible.

LLOYD LINFORD Ph.D. is the co-author of the Brain-Based Therapy books and the editor of more than 30 other books on various scientific topics. Dr. Linford served as Chief Psychologist and the Chair of the Chiefs of Psychology and Social Work for Kaiser Permanente in Northern California. He previously served the Chair of Kaiser's Annual Psychiatry and Chemical Dependency Conference and the Director of Psychiatry Best Practices, which develops evidenced-based programs for twenty-four medical centers in Northern California.

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